[The authors respond]

Letters

CJEM 2008;10(6):508

We thank Mr. Tapper for acknowledging the timeliness of this work for Canada. The article1 is specific to nurse practitioner (NP) "expanded"2 emergency clinical care roles in the setting of an urban Canadian emergency department (ED) and we refrain from discussing NPs in other clinical settings or countries.

We agree with colleagues,2-4 as indicated in our methods section,1 that adding any new type of health providers must be on a "value added," goal- related strategy basis and should not be used to replace current care providers.

From the start, similar to others,3 we faced challenges arising from systemic problems. The grant for a new advanced practice nursing (APN) role was provided because of a perceived specific need and lacked the recommended analysis of health system's requirements.2,3 Evidence about the quality of emergency clinical care provided by NPs potentially working in "expanded," autonomous roles was also lacking. Furthermore, validated educational benchmarks for this type of urban emergency practice in Canada did not exist.1

Mr. Tapper seems to suggest that our process of developing a starting scope of an NP "expanded" clinical practice is not valid because it is in contrast with existing nursing education and is inconsistent with the College and Association of Registered Nurses of Alberta (CARNA) mandate. He states that the selected NP was prevented from collaborating with the health care team during the evaluation period and the progress of NP from novice to expert was not assessed. We disagree.

In the points below, we provide our comments for clarification:

• The essential goal of all ED health care providers is to deliver the best patient care.
• Mr. Tapper seems to suggest that we are in breach of nursing educational approach and CARNA's right to self-regulate. The references he quotes, however, do not pertain to an "expanded" clinical role in emergency care by NPs in Canada. Nationally accepted educational guidelines or regulations specific to the specialty of emergency care for NPs do not exist.5 Therefore, the development of a scope of practice for the purpose of diagnosing, investigating and treating undifferentiated patients in the ED becomes a collaborative effort between physicians, nurses and the ED administration, reaching beyond the exclusive domain of nursing. This is not a "turf" issue; rather, it is a "best patient care" issue.
• Published standards or tools to help create an NP "expanded" emergency clinical practice do not exist. We used the Canadian emergency physician (EP) as the current (imperfect) standard of care. We chose the benchmark of NP care to be "equivalent care to the EP" to determine a starting scope of clinical practice. We believe that this comparison is valid, because in the current system EPs diagnose and treat patients. In keeping with "best patient care" goal, NP autonomous practice must meet this benchmark until more valid and reliable benchmarks are developed.
• Data on the feedback provided to our NP and the clinical improvement over time was reported. We strongly believe in the physician-NP collaboration to facilitate clinical growth.

Publications clearly identify "lack of knowledge and skills" as the major barriers for overall NP implementation.3,6 We believe this is the same for the area of emergency care. To date, the development of educational curricula for "expanded" emergency care for NPs seems to be taking place in isolation. Our perception is that faculties of nursing and medicine work without significant interdisciplinary communication and collaboration. Given that both faculties fit the role of "stakeholders" required for the development of NP,3 we strongly encourage input from both. The need to include all stakeholders has since been validated by updated national recommendations targeting primary care NPs.5

Any future consideration for developing national, provincial or territorial plans for APN with "expanded" emergency clinical practice requires, at a minimum, systematic needs analysis, input from all stakeholders and outcome indicators that demonstrate a significant potential health benefit to the Canadian public.

Ivan P. Steiner, MD,

Darren N. Nichols, MD

Departments of Family Medicine and Emergency Medicine

University of Alberta

Edmonton, Alta.

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. Bryant-Lukosius D, DiCenso A, Browne G, et al. Advanced practice nursing roles: developments, implementation and evaluation. J Adv Nurs 2004;48:519-29.
3. Bryant-Lukosius D, DiCenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs 2004;48:530-40.
4. Drummond A. Nurse practitioners in Canadian emergency departments: An idea worthy of attention or diverting our attention? CJEM 2007;9:297-9.
5. 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 Oct 1).
6. DiCenso A, Auffrey L, Bryant-Lukosius D, et al. Primary health care practitioner in Canada. Contemp Nurse 2007; 26:104-15.