Nurse practitioners in the emergency department

Letters

CJEM 2008;10(6):508

To the editor: The recent article entitled "Introducing a nurse practitioner into an urban Canadian emergency department" by Steiner and colleagues1 compares the care provided by a nurse practitioner (NP) with that of an emergency physician working in an urban emergency department (ED). Steiner and coworkers provide timely insight regarding the potential role of a nurse practitioner in emergency care in Canada. However, the impact of developing an NP evaluation framework that is inconsistent with the existing nursing model for implementing the role of the NP in the Canadian health care system requires further clarification.

In Alberta, schedule 24 of the Health Professions Act (2005)2 identifies the College and Association of Registered Nurses of Alberta (CARNA) as the sole professional body responsible for licensing and regulating professional nursing practice. In the CARNA (2005) document "Nurse practitioner competencies," the core competencies for NP entry to practice are identified.3 Additionally, the role of the NP is defined as a provider and manager of health care services that is grounded in professional nursing values, knowledge, theories and practice. CARNA also defines the scope of practice for NPs as both autonomous and collaborative and indicates that NPs should not be considered role replacements for any other health care providers.3

The framework for graduate NP education in Alberta is built on the Health Professions Act (2000),2 CARNA's core competencies for NP practice,3 and Brenner's model of novice to expert4 master's education programs in Alberta support the assumption that graduate NPs are prepared as novice and progress to expert through continued exposure to the clinical practice environment. CARNA's continuing competency program for NPs also indicates the necessity for NPs to progress from novice to expert and requires that NPs evaluate and develop interventions to expand their professional practice annually. Additionally, validation of the NP's involvement in continuing education is required by CARNA.

The approach by Steiner and coworkers of developing, implementing and evaluating the role of the NP in the ED is in stark contrast with existing nursing theories and is inconsistent with CARNA's mandate for implementing the role of the nurse practitioners. The Steiner and colleagues' program development methodology compares the clinical competencies of an NP with those of an emergency physician. Moreover, this methodology prevents the NP from collaborating with the health care team during the evaluation period and evaluates NP competencies before the completion of a 6-month apprenticeship program. Thus the impact of a clinical orientation that allows the NP to progress from novice to expert is not assessed.

The recommendations identified in the preceding paragraphs are essential for evaluating the impact of the NP's role in individual, family and community health and wellness. Stakeholders are encouraged to review the work of Bryant-Lukosius and DiCenso5 and the Canadian Nurse Practitioner Initiative (2006),6 which provides further insight into the connection between nursing legislation, graduate nursing education and clinical practice. Furthermore, stakeholders who are considering implementing the role of the NP in the ED should critically evaluate Steiner and colleagues' recommendations for developing and implementing the role of the NP in the ED.

Persistent challenges to the NP scope of practice in the United States have recently resulted in the development of a Doctor of Nursing program that prepares NPs for entry to practice as specialists. By 2015, NPs in the United States will require a Doctor of Nursing for entry to practice. Nursing leaders in the United States anticipate that specialized NP programs will address obstacles preventing the full integration of NPs within the health care system and will improve individual, family and community access to care. If barriers to the NP scope of practice continue to exist in Canada, nursing scholars might want to consider a similar approach to NP education.

Lloyd Tapper, RN, BScN, MN, NP

References

1. Steiner IP, Blitz S, Nichols DN, et al. Introducing a nurse practitioner into an urban Canadian emergency department. CJEM 2008;10:355-63.
2. Government of Alberta. The health professions act. Edmonton (AB): Alberta Queen's Printer; 2005. Available: www.qp.gov.ab.ca/Documents/acts/H07.CFM (accessed 2008 Sept 23).
3. College and Association of Registered Nurses of Alberta. Nurse practitioner competencies. Edmonton (AB): The Association; 2005. Available: www.nurses.ab.ca/Carna/index.aspx?WebStructureID=3084 (accessed 2008 Sept 23).
4. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley; 1987.
5. Bryant-Lukosius D, DiCenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs 2004;45:530-40.
6. Canadian nurse practitioner initiative. Implementation and evaluation toolkit for nurse practitioners in Canada. Ottawa (ON): Canadian Nurses Association; 2006. Available: http://206.191.29.104/documents/pdf/Toolkit_Implementation_Evaluation_NP_e.pdf (accessed 2008 Sept 23).