Attitude of emergency department patients with minor problems to being treated by a nurse practitioner

EM Advances

CJEM 2004;6(4):246-252

Abstract

Résumé

Introduction

Nurse practitioners (NPs) have provided independent care to many North American rural communities since the 1960s.¹ From the early 1990s, the integration of NPs into the acute care setting has become more common.² Although a universal definition of what constitutes an NP is elusive, there are 2 specific groups commonly referred to as NPs: acute care/specialty NPs, and extended class NPs.³

There are growing pressures to change the delivery of acute care in Canada. The Romanow Report suggested there is a need to break down barriers between health care workers and have greater teamwork and interdisciplinary collaboration;⁴ therefore an increased deployment of NPs in the Canadian health care system seems likely.

Although the potential of a role for NPs in primary care delivery in Canadian emergency departments (EDs) has been identified, this role remains undefined and controversial.³ High levels of patient satisfaction with NP care have been reported,⁵ but no studies have prospectively assessed patient willingness to be treated by NPs in urban tertiary care settings. The purpose of this study was to assess the stated willingness of adult tertiary care ED patients with minor problems to be treated by an NP, and to determine the characteristics of this population.

Methods

Design and setting

This prospective descriptive study was conducted in the ED of Vancouver General Hospital, Vancouver, BC. This tertiary trauma centre has an annual ED census of 53 000 patients, 56% of who are triaged to the treatment (non-acute) area.

Ethics and approval

The Behavioural Research Ethics Board of the University of British Columbia and Vancouver Hospital and Health Sciences Centre approved the study. Completion and return of the survey implied the patient's consent to participate in the study.

Study setting and population

From April 10, 2000, to July 13, 2000, consecutive patients over age 16 who were triaged to the ED treatment area on weekdays between 8 am and 4 pm were eligible if they had 1 of the following 18 complaints: minor abrasions or lacerations, minor bites, minor burns, minor extremity trauma, cast check, earache, superficial foreign body, lice or pinworms, morning-after pill request, needlestick injury or body-fluid exposure, prescription refill, puncture wound, sore throat, subconjunctival hemorrhage, suture removal or wound check, tetanus immunization request, toothache, or urinary tract infection (women). These specific complaints were developed by an interdisciplinary committee of emergency physicians and nurses for a potential ED fast-track program prior to the genesis of this study. Patients were excluded if they were unable to provide informed consent, unable to read or understand questions due to language or comprehension difficulties, unable to complete the survey due to pain severity, or if the emergency physician had already assessed them.

Sampling

Convenience sampling was chosen to maximize patient enrolment during times of high ED volume when research personnel were available. Based on projecting sufficiently narrow confidence intervals (CIs) for the proportion of subjects hypothetically willing to see an NP, we established a priori that our minimum sample size requirement was 200 patients.

Protocol and data collection

The study training program included one-on-one in-servicing of all triage nurses, distribution of a pocket card study summary prior to study commencement, and daily briefings to triage nurses during study enrolment.

On-duty triage nurses invited eligible patients to participate in the study and gave them a cover letter (Flesch-Kincaid Readability Grade 11.5), a survey (Flesch-Kincaid Readability Grade 5.2) and a pen. The cover letter (Appendix 1) explained the purpose of the study and the survey procedure. To maximize response consistency, the cover letter defined "nurse practitioner" as a registered nurse with advanced knowledge and decision-making skills in assessment, diagnosis and health care management; and defined "emergency physician" as a doctor with specialist training and certification in emergency medicine. The cover letter also indicated that NPs assess and discharge some patients without direct physician involvement, but that, during the study, all patients were assessed and discharged by an emergency physician. The one-page survey (Appendix 2) took approximately 5 minutes to complete and included the following: 5 closed-ended demographic questions, 1 open-ended question to clarify the presenting problem, and one 3-part, closed-ended question regarding hypothetical willingness to have an NP treat this problem (assuming availability). Patients were informed that completion and return of the survey to a dedicated study box in the treatment area waiting room prior to physician assessment implied consent to participate. To maintain consistency, triage nurses directed all patient questions to the on-call research nurse who was available by pager during the study period.

To determine the true denominator of eligible patients, 1 of 2 dedicated research nurses regularly reviewed the ED charts and computer tracking system for eligible patients each day during the study period. Every day at 8 am, research nurses gave triage nurses batches of 20 sequentially numbered surveys. At 4 pm they collected and documented all unused surveys at triage and all completed surveys in the study box. Research nurses also confirmed patient eligibility, checked completed surveys, and noted any reasons for exclusion. All survey responses were transferred to a computer database for analysis.

Statistical analysis

SPSS (Version 6.1, Macintosh) was used to generate descriptive statistics and conduct logistic regression modeling. Bionomial 95% CIs for proportions, and tests of differences between proportions for exploratory purposes were calculated using Stata (Version 5.0, Macintosh). All statistical tests were two-tailed, and p ¾ 0.05 was considered statistically significant.

Results

Study population

During the study period and specified times, 5268 patients presented to the ED. Of these, 3201 were triaged to the non-urgent treatment area. Of 728 eligible patients, 246 (34%) were asked to participate in the study and 213 (87%) returned surveys. Six surveys were excluded due to incorrect completion and resultant coding errors (Fig. 1).

Fig. 1. Study population

Table 1 shows that patients ranged from 16 to 91 years of age, with a mean of 34.5. Fifty-eight percent of subjects were men. The highest level of subjects' completed schooling was a college diploma (38.2%). One percent had completed either a trade school or an English as a Second Language program. English was the primary language spoken at home for 93.2% of patients. Table 2 summarizes the number of patients enrolled in each pre-specified presenting complaint category and shows that the category could not be determined in 30 cases. These 30 completed surveys were included in the analysis on an intent-to-treat basis to reflect the reality of triage nurse assessment, complaint category assignment, and potential NP allocation.

Willingness to be treated by a nurse practitioner

Figure 2 shows that 150 of 207 subjects (72.5%; 95% CI, 65.8%-78.4%) indicated a hypothetical willingness to be treated by an NP for their presenting complaint. Of these, 67.3% said they would be comfortable being treated and discharged without direct emergency physician assessment, 21.3% said they would be comfortable only if they were also assessed by an emergency physician, 6.7% said they were uncertain how they felt about NP function, and 4.7% did not respond to the question. Of the 207 subjects surveyed, 25 (12.1%; 95% CI, 8.0%-17.3%) said they were unwilling to have an NP treat their presenting problem. In this group, 9 (36%) indicated they would never be comfortable being treated by an NP and 16 (64%) indicated they might be comfortable under the following conditions: if they had a different problem (n = 13; 81.3%), if NP treatment resulted in substantial cost savings to the health care system (n = 4; 25.0%), or if it resulted in shorter ED waiting times (n = 6; 37.5%). Note that multiple responses were permitted. Thirty-two of 207 subjects (15.5%; 95% CI, 10.8%-21.1%) were uncertain if they would be willing to have an NP treat their presenting problem. A logistic regression analysis showed that willingness to be treated by an NP was independent of age, gender or educational status.

Fig. 2. Survey responses, indicating respondents' willingness, or not, to be treated by an NP, reasons for their decisions and under what circumstances they would be willing. *Multiple answers were allowed. NP = nurse practitioner; CI = confidence interval; EP = emergency physician.

Discussion

We found that most adult tertiary care ED patients with minor problems indicated a willingness to be treated by an NP, often even if this meant being discharged without direct emergency physician assessment. Acceptability to patients is critical and, while there have been many studies on the use, the care spectrum and on patient acceptance of NP care,^1,2,3,5,6 no previous research has assessed patient acceptability in an urban tertiary care ED where nurse physicians do not currently practise.

Canadian emergency care is evolving, as suggested by a recent report from the Canadian Association of Emergency Physicians to the Romanow Commission.^7,8 If future research suggests that the introduction of NPs for non-urgent ED care will improve patient flow, increase staffing flexibility and provide high quality care at lower cost, then the data from this study suggest that most Canadians would be open to NPs providing non-urgent emergency care. A recent review outlined the numerous issues, controversies and challenges that must be addressed before deploying NPs in Canadian EDs, as well as the roles they might best fulfill if they are deployed.³ Interested readers are encouraged to refer to this well referenced discussion paper.³

Limitations

This was a study of stated willingness to be treated by an NP in a province that has yet to regulate and deploy NPs. It is conceivable that hypothetically stated willingness may not translate to true acceptance of such care, were it actually in place. Our study is also limited by the fact that triage nurses recruited only 34% of eligible patients, and it is possible that this selection was a non-random process. It is also conceivable that, because of triage workload, fewer eligible patients were invited to participate during high ED volume periods (making our study population less representative). These factors introduce uncertainty about the precision of our primary outcome; nevertheless the level of acceptance of NPs remains striking.

Conclusion

Most adult tertiary care ED patients with minor problems indicate a hypothetical willingness to be treated by an NP, often even if this involves treatment and discharge without direct emergency physician assessment. Several factors, including impact on ED staffing and patient flow, logistics, cost and quality of care should be evaluated before implementing such strategies.

We thank the emergency physicians and nurses of Vancouver General Hospital for their dedication to both excellence in patient care and research.

References

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