Introducing a nurse practitioner into an urban Canadian emergency department

ED Administration

CJEM 2008;10(4):355-363

Abstract

Résumé

Introduction

There is growing interest in the introduction of nurse practitioners (NPs) to emergency departments (EDs), and published research suggests that NPs can provide care that is comparable to resident physicians, who provide the bulk of emergency care in some systems.1,2 The current standard of care is different in urban Canadian EDs, where emergency physicians (EPs) provide 24 × 7 care and where resident-level physicians are not allowed to function on an unsupervised basis. When considering how NPs might be incorporated into multidisciplinary ED teams, it is important to determine whether they should have an autonomous scope of practice or whether they should work with EPs in a more collaborative model.

In some US, UK and Australian EDs, NPs with or without emergency care training function as an adjunct to or in lieu of EPs;1-13 although NP education and scope of practice vary widely.14 In the United States, NP designation requires a 2-year master's level graduate degree in an area of specialization,15 while in the United Kingdom, national guidelines for training and minimal education standards do not exist.8,10,16 UK NPs autonomously diagnose and treat low-acuity patients such as those with extremity bone and soft tissue injuries, simple burns, soft tissue infections, and eye, and ear, nose and throat complaints.17 In the United States, NP scope of practice may extend beyond the low-acuity patient population,15 but in Canada, nationally accredited NP training programs in emergency care, certifications and standardized scope of practice do not exist.18,19 There is no published literature comparing the care provided by NPs and EPs.14,20 The 2006 Canadian Nurse Practitioner Initiative (CNPI) released national educational, practice and legislative recommendations for the implementation of the primary care NP role but did not mention the area of emergency care.19 For all of these reasons, the potential ED role and scope of practice for Canadian NPs remains unclear.

In 2003, the Alberta Ministry of Health provided a grant for the introduction of an NP into our Edmonton ED. The objective of this report is to compare the quality of medical care provided by a carefully selected NP with that provided by EPs, and to identify the types of patient presentations most appropriate for autonomous care by the NP.

Methods

Setting and patients

The Northeast Community Health Centre (NECHC) is a community primary health care centre attached to a 24-hour free-standing ED that provides emergency care to about 46 000 individuals each year (Table 1). Despite managing patients in all 5 Canadian Emergency Department Triage and Acuity Scale (CTAS) levels,21 the NECHC does not have inpatient beds, admitting physicians or onsite consultant support. Patients requiring hospitalization or diagnostic imaging beyond radiographs and basic ultrasound are referred to acute care hospitals. The ED does not routinely accept ambulance patients, and all EMS requests are screened by the EP and nurse in charge. EPs working at the NECHC also provide emergency care at a tertiary care teaching institution and trauma centre.

Project mandate and guiding principles in developing scope of practice

The NECHC EPs acquired a Medical Services Development and Innovation Fund (MSDIF) grant "to create an emergency service delivery model that optimizes the use of emergency physicians" by adding NP to the multidisciplinary ED team. The NP would help "identify, develop and utilize alternatives to emergency physician care for appropriate clinical presentations." Our approach in developing the NP scope of practice differed from that taken in other countries where NPs in the ED are restricted to specific patients. Our hypothesis was that the NP had a role — either completely autonomous, collaborative or both — in the provision of care to all types of ED patients. Our expectation was to broaden the scope of practice beyond the boundaries set elsewhere.

NP candidate selection

The Alberta Association of Registered Nurses (AARN) requires that NPs have a baccalaureate degree and complete a specified educational program approved by the AARN.22,23 The Capital Health Region requires a master's degree in nursing.24 In addition to these qualifications, we specified that NP applicants must have Advanced Life Support (ALS) certification, a minimum of 3 years ED nursing experience and a license to practise in Alberta. Certification in ED nursing, Trauma Nurse Core Course (TNCC), Emergency Nurse Pediatric Course (ENCP), Pediatric Advanced Life Support (PALS) and the Course in Advanced Trauma Nursing (CAATN) were preferred. The NP selection committee included 3 Capital Health administrators and 2 physician leaders who developed criteria for ranking applicants, assessed candidates' clinical competencies and developed an entry level scope of practice for the NP in the ED.

Given the lack of published benchmarks for hiring NPs for ED practice, the physician leaders developed, by consensus, a standardized 3-part selection process and criteria to identify the applicant with the best training, a superior track record as a registered nurse in urban ED and the most suitable personal attributes for this pioneer role. The selection committee reviewed the process and tools and approved them unanimously. To be short listed, NP applicants had to attain a score of 75 on the part 1 selection criteria listed in Appendix 1. Short-listed candidates went through an interview (part 2) and a clinical review (part 3). The clinical review used standardized, common clinical scenarios to measure the depth of knowledge, level of decision-making and personal attributes. The final ranking was composed of (35%) part 1, (25%) part 2 and (40%) part 3. Final placement also required a minimum score of 75 on the interview and a clinical review free of actions that would put the patient at risk. Three out of 12 applicants were short listed, but 1 withdrew. Based on the unanimous recommendation of the selection committee, the highest ranked applicant was hired in October 2004. The content relevance of our selection process and tools to ED practice is good, and the volume and variety of information about applicants, collected through the use of multiple assessment methods, is significant. This, and the high concordance between measurements by different raters, gives us confidence that we have selected the best possible applicant. Subsequent interactions with the NP further confirm this conclusion.

Because the clinical review process suggested a likely disparity of practice (relative to EP care), we made the completion of a comprehensive proficiency assessment prerequisite to the development of any autonomous NP clinical practice. This prospective, performance-based assessment of NP and EP clinical skills was conducted between Nov. 1, 2004, and Apr. 30, 2005.

Shift procedures and NP assessment

Capital Health Region's 37.5 hour/week NP job description consists of 80% clinical work and 20% dedicated to teaching, leadership, personal professional development and research. For the NP, this represented 3 or 4 eight-hour clinical shifts per week — mostly the higher volume day and evening shifts starting at 7 am, 10 am, 3 pm or 6 pm. For each shift, the NP was paired with an experienced volunteer EP preceptor prospectively taught how to apply the standardized assessment process and measurement tool (Appendix 2).

To assure the inclusion of a wide variety of acuity and patient presentations, the NP saw patients in order of triage priority. All NP decisions needed sanctioning by the preceptor. For every patient encounter, the NP and preceptor prepared a blinded, individual diagnostic and management approach. Preceptors then reviewed the NP's plan. Standard of care was defined as EP practice. The NP's plan was followed if all the intermediary and final steps in patient care, such as assessment, investigation, treatment, disposition, were equivalent to the preceptor's plan (not leading to different patient outcomes). Preceptors also recorded total time spent on teaching and the specific learning domain: knowledge, skills, behaviours, patient assessment or patient management. For each shift, a data form was completed (Appendix 2) and returned to a secure location. Physician leaders reviewed all data forms and provided global formative feedback to the NP on a weekly basis.

Data analysis

Emergency care is based on patient presentations and in order to develop a starting scope of practice for the NP, we aimed for relatively homogenous presentation categories. Patient presentations were stratified into 23 categories based on the individual's presenting complaint. When patients had multiple complaints, the first 2 were categorized. This was done to further differentiate heterogeneous patients presenting with identical first complaints. In each category, shift forms were reviewed to determine the proportion of encounters where steps in the NP care plan (patient assessment, investigation, treatment and disposition) were "all equivalent to EP care" (AEEPC). We assumed that in order to approve a patient presentation group (e.g., abdominal pain) for autonomous NP practice, at least 50% of NP patient encounters in that group should be AEEPC. In light of the fact that decision-making by residents, including those in emergency medicine, is not perfect,1,2,25 we postulated that a stringent definition of AEEPC blended with a reasonable minimum number of patient presentations (50%) would assure quality of patient care and allow for the development of a realistic scope of practice. Descriptive data, including patient counts, means, medians and proportions, were provided for NP case mix and AEEPC rates for each presentation category. Teaching domains and time were recoded and compared using 6 consecutive months. Primary care nursing skills were identified by the preceptors on the assessment sheets, but they were not tabulated as they were not the focus of this review.

Health review ethics board evaluation was requested and the need for review was waved by the panel.

Results

During the 6-month evaluation period, the NP worked 83 shifts comprising 47 day, 34 evening and 2 night shifts. Table 1 shows that there were a total of 711 NP-patient encounters (median 8 per shift) and that NP patients were similar to the overall ED patient profile. Twenty-one preceptors participated in the project; 4 of these supervised 50% of NP shifts, 8 supervised 70% and 15 supervised 90% of shifts. Table 2 summarizes the breakdown of NP cases by presenting complaint and shows the proportion of cases in each group for which NP assessment, investigation, management and disposition were deemed AEEPC.

These data show that 42.9% of all encounters and 33.4% of new visits were considered AEEPC. There were no significant differences in AEEPC rates for pediatric versus adult encounters (37.7% v. 44.3%) or for male versus female encounters (42.6% v. 43.2%). Patient encounters with the highest AEEPC rates were those in the follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). Lacerations (63.6%) and isolated sore throats (53%) also met the 50% benchmark. Table 3 shows that the rate of AEEPC encounters increased from time period 1 to 6.

ED physician preceptors recorded 88.3 hours of NP teaching time during the evaluation period, a mean of 1 hour per shift. Recorded domains relate NP knowledge (41.9%), patient management (29.5%), patient assessment (23.4%), NP skills (10.0%) and NP behaviours (2.0%).

Daily entries in multiple teaching categories account for the 106.8% total.

Discussion

There is interest in introducing NPs into Canadian EDs. Our data shows that, in this free-standing ED with a high proportion of less urgent (CTAS IV and V) patients, care provided by a carefully selected NP differs substantially from that provided by EPs, except in limited domains. Practice was most similar in the areas of patient follow-up visits and microbiology results or diagnostic imaging related follow-up phone calls, simple lacerations and isolated sore throats; hence, these areas were used as starting points for autonomous NP practice at the NECHC. (Appendix 3). The autonomous component of the job description incorporates practice limitations, including limitations on specialty consultations.

This comparative assessment is a first step in addressing the question of equivalence of EP and NP practice.12,18 Research from other jurisdictions suggests that NPs can provide a level of care similar to residents,1,2 but there are no data showing that NP care is equivalent to EP care, which is the current standard in Canada.

NP training and knowledge base

Despite the fact that in our free-standing ED we had a large "non urgent" patient population, transfer rate to acute care hospitals was nearly 5% (Table 1). This highlights the requirement for broad-based knowledge and skill sets for anyone considering practising autonomous emergency care in EDs. Patients with potential life, limb or function threatening entities need to be diagnosed and managed appropriately, even if they present with ubiquitous symptoms in fast track.

During our selection process, the short-listed applicants, both experienced ED nurses, were tested using standardized, common clinical scenarios to measure depth of knowledge and level of decision-making. These assessments, along with the relatively low AEEPC rates seen during real patient encounters, suggest there are significant differences between NP and EP decision processes and knowledge base. We believe these differences reflect systemic educational problems rather than individual shortcomings. This credence is further backed up by the fact that with teaching, the NP's performance improved over the review period (Table 3).

A recent Canadian national review by the CNPI recommends at least 2 years nursing experience prior to entering primary care NP training programs, a master's degree in nursing and a 6-month "internship" period, as well as the adoption of national core competencies for NPs (by 2010).17 This would allow each province and regional health authority to tailor the NP role to local needs while maintaining national practice standards. While CNPI initiatives are very positive, focusing on educational improvement, core competencies and standardization of NPs in primary care, the CNPI neither commented on the role of NPs in emergency care nor addressed educational requirements in this domain. Consequently, variability in this area will likely persist for some time.

In Alberta, the Health Professions Act, revised in 2005, mandates the College and Association of Registered Nurses (CARNA) as the sole professional body responsible for evaluating NP competency, licensing and quality of practice.26 The act provides legal title protection for the term "Nurse Practitioner" but does not mention educational requirements for emergency NP practice and it does not discuss autonomous ED practice.

Educational concerns are not exclusive to Canada. In the Unites States, only 15% of NPs have dedicated emergency education, while 70% have family practice NP training backgrounds.13 Studies from the United Kingdom indicate that over 10% of NPs have no emergency training at all and fewer than 10% possess master's level education in emergency nursing. Most have on-the-job training that is supplemented with local skill development courses.6,8,14

Given the absence of standardized core training in emergency care, the absence of evidence that NP and EP care are equivalent, and a lack of clarity around the areas of emergency care in which NPs can practise safely, it is difficult to recommend a common, nationwide role for NPs in widely variable types of EDs, and it is equally difficult to endorse the use of NPs as alternative, autonomous ED staffing options. This does not preclude the use of NPs in a collaborative care role with EPs — a concept that is not contentious in our ED.

Drummond suggests that NPs be introduced to EDs on a value-added (to existing service) basis, rather than substituting for existing service providers.27 We believe that NPs are a potentially valuable resource who can fulfill diverse roles depending on site-specific need. Our findings failed to support our a priori hypothesis in which we stipulated that the NP has a role in the provision of autonomous care to all types of ED patients; however, while areas for starting autonomous practice are limited, we anticipate that a collaborative NP model will help us address the needs of patients that are more complex and time-consuming. We are currently evaluating the impact of the NP on patient care in the ED.

Hiring an NP

Validated tools and selection processes for hiring NPs for ED practice do not exist and consequently ED administrators can develop their own or adopt and customize the model described here. Significant experience in ED nursing is essential as it identifies individuals who "fit" the profile required for the job (Appendix 1). We believe that a formal assessment process (Appendix 1) and training period are important because the NP knowledge base and skill set will be variable until the recommended CNPI national reform has been implemented and validated.17 Potential employers should recognize that the resources required to select the right person and educate them to EP level of care will be significant. Lastly, those considering an autonomous part to the scope of practice will need to understand that the job description will be site- and individual-specific and likely not transferable.

Limitations

Several limitations need to be acknowledged. MSDIF funds were provided for program development and implementation and not for evaluation or research. Consequently, lack of resources precluded pilot testing of selection and assessment tools and limited our data collection capability. Although we hired an excellent NP candidate who fulfilled all of the desired requirements, our data reflects the practice of a single NP and this limits the generalizability of our conclusions. The relatively low AEEPC rates documented in this study suggest that there are substantial differences between EP and NP practice; however, different care is not necessarily unsafe care, and our review does not show that patient outcomes are at risk. Finally, we looked at NP management of a wide spectrum of ED patients; it did not address the potential utility of an NP in more circumscribed ED roles, including clinical decision unit management, pathway management, community linking, case management support and discharge planning. We invite others to further verify NP and EP equivalence in other jurisdictions.

Conclusion

With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience or training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for NPs should focus on a model of collaborative practice with EPs.

References

1. Sakr M, Angus J, Perrin J, et al. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomized controlled trial. Lancet 1999;345:1321-6.
2. Sakr M, Kendall R, Angus J, et al. Emergency nurse practitioners: a three part study in clinical and cost effectiveness. Emerg Med J 2003;20:158-63.
3. Geolot D, Alongi S, Edlich RF. Emergency nurse practitioner: an answer to an emergency care crisis in rural hospitals. JACEP 1977;6:355-7.
4. Stafford Hardy VG. The emergency nurse practitioner: the role and training of an emerging health professional. JACEP 1978;7:372-6.
5. Tye CC, Ross F, Kerry SM. Emergency nurse practitioner services in major accident and emergency departments: a United Kingdom postal survey. J Accid Emerg Med 1998;15:31-4.
6. Tye CC. The emergency nurse practitioner role in major accident and emergency departments: professional issues and the research agenda. J Adv Nurs 1997;26:364-70.
7. Neades BL. Expanding the role of the nurse in the accident and emergency department. Postgrad Med J 1997;73:17-22.
8. Meek SJ, Ruffles G, Anderson J, et al. Nurse practitioners in major accident and emergency departments: a national survey. J Accid Emerg Med 1995;12:177-81.
9. Saab M, Birkinshaw R, O'Gara P. Twenty-four hour nurse practitioner service in the accident and emergency department. Eur J Emerg Med 1997;4:25-8.
10. Cooper MA, Hair S, Ibbotson TR, et al. The extent and nature of emergency nurse practitioner services in Scotland. Accid Emerg Nurs 2001;9:123-9.
11. Cole FL, Ramirez E. A profile of nurse practitioners in emergency care settings. J Am Acad Nurse Pract 2002;14:180-4.
12. Hooker RS, McCaig L. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med 1996;14:245-9.
13. Chang E, Daly J, Hawkins A, et al. An evaluation of the nurse practitioner role in a major rural emergency department. J Adv Nurs 1999;30:260-8.
14. Nichols DN, Yoon PW, Steiner IP. Do emergency nurse practitioners provide safe patient care? ISRJEM 2006;6(1). Available: http://isrjem.org/IJEM_Jan06_NursePrac_Proof.Revised.pdf (accessed 2008 May 20).
15. Emergency Nurses Association. 2007 Position Statement on Advanced Practice in Emergency Medicine. Available: www.ena.org/about/position/PDFs/7FC38A8AEDA1457E9BC278D4C2A16F1E.pdf (accessed 2008 June 2).
16. Marsden J. Education preparation for ENP roles. Emerg Nurse 2003;10:26-31.
17. Dolan B, Dale J, Morley V. Nurse practitioners: the role in A&E and primary care. Nurs Stand 1997;11:33-8.
18. Drummond AJ, Bingley M. Nurse practitioners in the emergency department: a discussion paper. CJEM 2003;5:276-9.
19. Canadian Nurse Practitioner Initiative. (2006). Nurse practitioners: the time is now. Integrated report. Available: www.cnpi.ca/about_the_cnpi/np_final/index.asp?lang=e& (accessed 2007 Jan 28).
20. Carter AJE, Chochinov AH. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM 2007;9:286-95.
21. Beveridge R. CAEP issues. The Canadian Triage and Acuity Scale: a new and critical element in health care reform. Canadian Association of Emergency Physicians. J Emerg Med 1998;16:507-11.
22. Titanich K. Community nurse practitioners in Alberta: the story continues. In: Patterson C, editor. Nurse practitioners: the catalyst of change. Troy (ON): Newgrange Press; 2000. p. 135-62.
23. Alberta Association of Registered Nurses. Nurse practitioner: a vital member of the health-care team. 2003. Available: www.nurses.ab.ca/publications/NPpub.html (accessed 2006 Oct 30). [Since the time of writing, this article has been printed and is no longer available online. Print copies can be requested from the Alberta Association of Registered Nurses.]
24. Capital Health Careers in Nursing. Available: www.capitalhealth.ca/Careers/Nurses/default.htm (accessed 2006 Dec 20).
25. Sacchetti A, Carraccio C, Harris RH. Resident management of emergency department patients: Is closer attending supervision needed? Ann Emerg Med 1992;21:749-52.
26. Health Professions Act, 1999. Available: www.qp.gov.ab.ca/Documents/acts/H07.CFM (accessed 2008 May 21).
27. Drummond A. Nurse practitioners in Canadian emergency departments: an idea worthy of attention or diverting our attention. CJEM 2007;9:297-9.