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Emergency nurse practitioners’ perceptions of their role and scope of practice: Is it advanced practice?
International Emergency Nursing (2013) 21, 76– 83
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Emergency nurse practitioners’ perceptions of their role and scope of practice: Is it advanced practice? Donna McConnell RGN, BSc, MSc (Lecturer in Nursing) a,*, Oliver D. Slevin RGN, BA, MA, PhD (Lecturer in Nursing) a, Sonja J. McIlfatrick RGN, BSc, MSc, PhD (Reader/Head of Research) a b
a,b
Ulster University, Jordanstown Campus, Newtownabbey BT37 0QB, United Kingdom All Ireland Institute of Hospice & Palliative Care (AIIHPC), Ireland
Received 2 February 2012; received in revised form 13 March 2012; accepted 22 March 2012
KEYWORDS Advanced nursing practice; Advanced Nurse Practitioner; Accident and Emergency; Emergency nurse practitioner; Nursing
Abstract There are multiple interpretations of the nurse practitioner role which appear to be shaped by discourses within and outside the profession and its regulatory body. This study aimed to explore and clarify the role and scope of practice of emergency nurse practitioners in a region in the United Kingdom and determine if they fulfil the proposed criteria for Advanced Nurse Practitioners. A survey approach using questionnaires (n = 42) was adopted. The sample included all emergency nurse practitioners working in Accident and Emergency Departments and Minor Injury Units in the region. Statistical data was analysed using SPSS for Windows and qualitative data was content analysed for themes. Results revealed a variation in education. Investigation of role typology and scope of practice revealed a relatively homogenous group where the clinical aspect of the role dominated. The scope of practice was perceived to be influenced by internal factors such as competence; however protocol use, referral rights and prescribing authority could be considered ways that nursing management and medical staff indirectly control the role. Findings suggested that emergency nurse practitioners were working at a level significantly beyond registration, yet do not fulfil the Nursing and Midwifery Council proposed criteria for Advanced Nurse Practitioner.
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Corresponding author. Tel.: +44 (0) 2890368581; fax: +44 (0) 2890 368 202. E-mail address: [email protected] (D. McConnell). 1755-599X/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2012.03.004
Emergency nurse practitioners’ perceptions of their role and scope of practice
Introduction Advanced practice roles have increased significantly in many countries over the last years. Titles, scope of practice, levels of autonomy, registration or licensing and education however differ greatly (Griffin and Melby, 2006). This leads to confusion over what exactly comprises ‘‘advanced practice’’ and which roles could be considered ‘‘advanced’’. The emergency nurse practitioner (ENP) delivers care beyond the remit of the ‘‘traditional nurse’’, although whether this constitutes advanced practice remains a contentious issue. In the United Kingdom (UK), the Nursing and Midwifery Council (NMC) regulatory body made proposals for role definition, competencies and education for advanced practice (NMC, 2005). The proposal includes plans to regulate a single standard of proficiency for a clinical level of practice beyond registration with the title ‘‘Advanced Nurse Practitioner’’ (ANP) (NMC, 2005). Subsequent papers (DH, 2007, 2011; Council for Healthcare Regulatory Excellence, 2009) however have meant regulation of advanced practice is still uncertain. The Department of Health published a statement defining the nature of advanced practice ( DH, 2010a), while a review of nursing and midwifery recommended the regulation of advanced practice (DH, 2010b). More recently the government issued a paper calling for a balanced cost–effective approach to regulation ( DH, 2011). The NMC remain concerned about safeguarding the public ( NMC, 2009) and recognise they will have to provide a strong case for further regulatory action that would be considered appropriate and proportionate to risk.
Background While no one single definition of advanced practice exists, there is consensus that it extends the traditional scope of practice, maximises the use of nursing knowledge, contributes to the development of the profession ( NMC, 2005; Callaghan, 2008) and is distinguished by a high degree of autonomy, authority and accountability (Barton, 2006). The literature reveals conflicting views of advanced practice. Some consider clinical posts at the nursing–medicine interface, such as the nurse practitioner (NP) role, as advanced practice ( Knowles, 2006). In contrast, Manley (1997) and Mantzoukas and Watkinson (2006) support the multidimensional role of advanced practice incorporating the sub roles of expert practitioner, educator, researcher and consultant with clear differentiation between nursing and medical roles and values. These diverse views need not be regarded as mutually exclusive ( Manley, 1997; Barton, 2006), rather both have the potential to be considered advanced. The Advanced Practice Toolkit (Scottish Government, 2008), developed under the auspices of the UK Modernising Nursing Careers initiative (DH, 2006), incorporated UK and international work on advanced practice. It adopted Level 7 of the Career Framework for Health (Skills for Health, 2006) to benchmark advanced practice, and took an overarching view of it as a level of practice rather than a role or title. The Toolkit considers
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the contextual nature of the skills required in both clinical and non-clinical roles, while maintaining the underpinning principles of advanced practice. Skills include the level of autonomy, critical thinking, decision-making and problemsolving which are common to all. The current NMC definition of advanced practice articulates the clinical ANP role within the UK context, but does not consider the non-clinical advanced practitioner role. Within the UK Scotland, Wales and Northern Ireland (NI) have their own devolved parliaments and assemblies responsible for healthcare policy. In the absence of regulation, Scotland (Scottish Government, 2010) and Wales (NHS Wales, 2010) have used the Toolkit as a foundation to develop processes for guidance and governance arrangements around advanced practice posts. NI have developed a Nursing Strategy document for 2010–2015 (Department of Health, Social Services and Public Safety, 2010) which makes reference to reviewing new ways of working, however they have not developed any advanced practice guidance. Evidence from the UK indicates that the ENP role is determined largely by key stakeholder’s needs (Lloyd Jones, 2005). According to Tye and Ross (2000) the vision of the role and scope of practice appear to be largely shaped by a ‘‘fit for purpose’’ ethos, with role enlargement being seen as having potential benefit for the organisation. Fotheringham et al. (2011) carried out a survey of ENP roles in Scotland. They found a role that had developed in response to local need with a range of job titles, protocol use, pay bands and education. Significant themes from the literature were protocol use, relationships with other stakeholders (Tye and Ross, 2000) and educational preparation for the nurse practitioner role. Literature concerning knowledge for Accident and Emergency (A&E) practice focused on the acquisition of clinical skills or ‘‘know-how’’ (Ryle, 1949) as the most significant aspect for the role (Duffield et al., 2010). Norris and Melby’s (2006) study into attitudes towards the Acute Care NP role in A&E found 96.9% of nurses and doctors rated clinical aspects of the role as most important, with mentorship, management and research not considered important. Purposive sampling however within a small geographical area means the study lacks generalisation. Only one A&E study (Griffin and Melby, 2006) identified the need for ENPs to possess broader theoretical knowledge or ‘‘know-that’’ ( Ryle, 1949). In contrast, international literature on advanced nursing roles in general, places emphasis on the need for integration of knowledge in all the arenas of knowing as the framework underpinning effective advanced practice (Carper, 1978; Mantzoukas and Watkinson, 2006). See Fig. 1. Multiple roles and levels of practice shaped by the context in which the ENP is employed, apparent diversity of practice, and the deliberation over prospective regulation of advanced practice make it timely that the role and scope of practice of ENPs is researched and benchmarked.
Aim The aim of this study was to determine the role and scope of ENPs’ practice in NI and establish the extent to which they could fulfil the criteria for an ANP.
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D. McConnell et al.
Fig. 1
Carper’s Framework (1978) and how it relates to knowledge required for the Advanced Nurse Practitioner role.
Objectives To examine the education and/or training undertaken in preparation for an ENP role. To explore the current roles and scope of practice of ENPs and the factors which determine this. To determine the extent to which ENPs fulfil the current proposed competencies of the ANP.
Method This study adopted a survey approach using a self-reported questionnaire. The population (n = 60) included all ENPs working in the 16 A&E departments and the 4 Minor Injury Units (MIUs) in NI, which is a devolved healthcare region within the UK. To ensure content validity questions were constructed following a critique of the literature, previous studies and the framework for ANPs (NMC, 2005). Questions included a range of open and closed ended questions, focusing on sections on education, current role activities and scope of practice within and outside the employing organisation, and factors which ENPs perceived as impacting on their role and scope of practice. The questionnaire was piloted with six ENPs who were not included in the final survey, resulting in minimal change to the wording of some questions.
A total of 60 anonymous questionnaires were sent to ENPs for voluntary completion during August 2008, along with a pre-paid addressed envelope and suggested date of return. One reminder for completion was sent to each department.
Ethical considerations Following ethical approval from Office for Research Ethics Committees Northern Ireland, permission was obtained from each trust. Ethical considerations of voluntary participation and anonymity were respected.
Analysis Quantitative data was analysed using SPSS version 11.5. Themes were identified from the open ended questions. Descriptive statistics were used to report frequencies and mean values. The ENPs reported scope of practice was assessed against the ANP framework for achievement of the competencies.
Results Response Following one postal reminder a total of 42 questionnaires were returned giving a response rate of 70%.
Emergency nurse practitioners’ perceptions of their role and scope of practice
Education for the role Preparation for the role varied with 35.7% (n = 15) having undertaken primary degree level preparation, and 26.2% (n = 11) post graduate study. A total of 31% (n = 13) undertook short courses or stand-alone modules with one of these ENPs having already studied to primary degree level prior to undertaking preparation for the role. A small number (7.1%, n = 3) received in-house training or study days only in preparation for the role.
Pay band The ENPs were employed between Agenda for Change Bands 5 and 7. 71.4% (n = 30) were employed at band 7, 14.3% (n = 6) at band 6 and 14.3% (n = 6) at band 5. Of the eighteen ENPs working in MIUs, 66.7% (n = 12) were at band 7, and 33.3% (n = 6) at band 5. No band 5 ENPs worked in A&E departments.
Role and scope of practice The ENPs perceived their scope of practice to be determined internally by their own competence (71.4%) and externally to varying degrees by the patient’s wishes (45.2%), protocols (69%), age restrictions (35.7%), wishes of medical staff (23.8%), nursing management (21.4%), referral rights to other healthcare professionals (26.2%), X-ray referral rights (40.5%) and prescribing authority (31.0%). Themes that emerged as being perceived as the greatest obstacles to autonomy were lack of role progression, control of the role by others and the domination of clinical workload (Table 1). All but one ENP (97.6%) worked within protocols at least some of the time, with the majority (64.3%, n = 27) reporting always working within protocols. Of those who used protocols 56.1% (n = 23) felt they restricted their practice. One ENP stated ‘‘[protocols] restrict as can only treat patients within the rigid criteria.’’ A small percentage (9.8%, n = 4)
Table 1
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felt they increased their practice. Approximately one quarter (24.4%, n = 10) felt they neither increased nor restricted their scope of practice, and 2.4% (n = 1) felt they had the potential to both restrict and increase scope with different patients. Those that reported sometimes working outside protocols (33.3%, n = 14), did so as they gained experience in the role, and when patients presented with conditions not covered by the protocols. One ENP reported ‘‘protocols are in place but we are not expected to work within themthey provide guidance at start of role’’. All but one ENP referred to X-ray (97.6%, n = 41), with 92.9% (n = 39) also interpreting them. This study found 78.6% (n = 33) reported strong support for their role from radiography staff, with only 4.8% (n = 2) citing them as the greatest obstacle to their autonomy. Over half (54.8%, n = 23) of the ENPs reported their role incorporated additional duties, such as staff nurse duties 47.8% (n = 11), being in charge of their shift 30.4% (n = 7) and ward manager duties 21.7% (n = 5). ENPs were asked to estimate the percentage of time spent in the sub-roles of clinical workload, education, research, audit, leadership, management and expert resource, which are competencies to be met within the ANP framework (NMC, 2005). In all cases the clinical role dominated (mean 81.3%) with one ENP reporting spending 100% of the time in this role. Education and training (mean 5.7%) and expert resource (mean 4.8%) were the next highest followed by audit (mean 3.1%) leadership and management (mean 2.6%) and finally research (mean 2.5%). See Fig. 2. A total of 85.7% (n = 36) reported that they were not involved in any advanced practice outside their own organisation. None reported involvement in any organisational decision-making, legislative or policy making activities, which are also competencies to be met within the ANP framework (NMC, 2005). Table 2 shows the results of ENPs participation in a list of clinical activities derived from Domain 1 (assessment and management of patient/health/illness) of the Advanced Practice Competencies (NMC, 2005). The results indicate that many ENPs can demonstrate achievement of these clinical competencies.
ENP’s perception of which factors are the greatest obstacle to their autonomy.
Themes
What is the greatest obstacle to your autonomy?
%
Nos.
Lack of role progression
62.4%
Lack of knowledge and education to expand role Lack of infrastructure in place to support role development Lack of prescribing power Protocols (only able to treat certain conditions)
14.3 7.2 26.2 14.3
6 3 11 6
Control of role by others
50.4%
Dr. acceptance/opposition/control Refusal to accept referrals from ENP Senior Nurse Managers controlling role and off duty X-ray staff opposition Staff nurses opposition
21.4 19.2 4.8 4.8 4.8
9 8 2 2 2
Domination of clinical workload
19.2%
Due to – Staff shortage – Excessive clinical workload – Being used for other duties outside ENP role
7.2 7.2 4.8 4.8
3 3 2 2
None
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D. McConnell et al. Expert resource Leadership & mgt Audit Research Education/training
Clinical
Fig. 2
Mean percentage estimation of time spent in sub-roles.
A total of 9.5% (n = 4) did not prescribe medication at all. The 90.5% (n = 38) who did, reported using a variety of methods to suit different situations. 78.6%, (n = 33) used Patient Group Directions, 19.0%, (n = 8) used non-medical prescribing and (7.1%, n = 3) asked doctors to sign their prescriptions on different occasions. In total 33.4% (n = 14) had completed the Non-Medical Prescribing programme, however just over half (57.1%, n = 8) reported using this to prescribe medication.
Discussion Education for the role This study found no standardisation of educational preparation, with education ranging from in-house training to post-graduate degrees. This is supported by UK literature, highlighting a variety of local and in-house programmes (Currie et al., 2007). Walsh (2000) found that short-term educational solutions undermine the concept of advanced practice and the more limited the training the more limited the role. Currie et al. (2007) suggest that the absence of formal regulation in the UK may have caused emphasis on clinical experience and clinical competence, in preference to academia. According to Lloyd Jones (2005) the debate around educational preparation only appears to be an issue in the UK. This is in stark contrast to the USA, where education for the nurse practitioner role is undertaken at masters-degree level and there is national consensus on minimum standards for education (Hoskins, 2011).
Pay band The majority of ENPs were employed at band 7. Despite Agenda for Change (NHS Employers, 2005) being devised to match posts to pay bands, variations still exist in this region. The only band 5 ENPs were employed in MIUs, which appears to be a paradox since it could be anticipated these
ENPs would be more likely to be working in autonomous roles without medical support. Fotheringham et al’s. study (2011) found ENPs in Scotland employed at band 5–8a, although they also reported a wide variation in roles which does not appear to be a feature in this study.
Role and scope of practice Factors which appeared to be influential in shaping the ENP role and scope of practice were interrelated, to varying extents, with those that the ENPs perceived as significant in determining the degree of autonomy in their role. In this study the ENP’s perceived their own capacity to treat the presenting conditions as the strongest factor in determining their scope of practice, while only a small percentage cited lack of knowledge and education to expand their role as an obstacle to their autonomy. This indicates that the ENPs felt they had control over their role by virtue of their knowledge and skills. However factors such as protocols, imposed age restrictions, prescribing and referral ability, wishes of medical and nursing staff and domination of the clinical workload were all referred to as factors influencing the role and obstacles to autonomy. This indicates a role which is largely shaped by external factors beyond the ENPs control. In contrast to the literature this study found that only 21.4% (n = 9) stated senior nurse managers wishes strongly determined the range of patients they treated. The majority felt managers strongly supported them in their role with few perceiving them as an obstacle to their autonomy. Slightly higher numbers felt the wishes of medical staff strongly determined their role, and found them the greatest obstacle to their autonomy. As in this study, the literature cites lack of infrastructure to support the role (Lloyd Jones, 2005), the requirement to use protocols (Scholes and Vaughan, 2002) and staff shortage forcing ENPs to take on other roles (Tye and Ross, 2000) as factors impacting on the role. Whilst not immediately apparent, it could be considered that these factors could be ways in which senior
Emergency nurse practitioners’ perceptions of their role and scope of practice Table 2
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Role features of current ENP role.
Order medication Order X-rays Interpret X-rays Accept referrals from other health care providers Triage patients by telephone See clients with undifferentiated and undiagnosed problems Undertake health history assessment of patients Carry out physical examination of patients Recognise emergencies and refer appropriately Request laboratory tests Interpret laboratory tests Make diagnoses Screen patients for signs of illness Health promotion and health education Review patients to evaluate effectiveness of treatment plan Discharge patients Refer patients to other health care providers
management and medical staff surreptitiously control the role which has not been recognised by the ENPs. The high percentage of ENPs in this study reporting working within protocols (97.6%) is in contrast to the USA (Marsden, 2003), but mirrors the rest of the UK ( Walsh, 2000; Fotheringham et al., 2011). Marsden et al. (2003) link the use of protocols to the negative effects of inadequate or ineffective educational preparation for the role. While 69% of respondents felt protocols strongly determined their scope of practice just over half of those using them felt they restricted it. One ENP raised the issue of protocols limiting their ability to respond to the client individually. This raises questions around quality of care and whether this perceived inflexibility impacts on individualised treatment options. The fact that just under half the respondents did not find protocols restrictive may be due to the fact that one third of respondents reported the flexibility to work outside them when they needed to or as they gained experience. Ethical knowing involves making moment-to-moment judgments about what ought to be done and what is right and responsible (Carper, 1978). Lack of flexibility which prevents this raises a potential ethical dilemma for the ENP. Walsh (2000) speaks of the need to have freedom to work as an accountable practitioner, which means there may be a need to expand and diverge from previously defined boundaries. Autonomous decision-making is not about strict adherence to protocols, rather it is discretionary decision making that is fundamental to autonomous practice (Benner, 1984; Wade, 1999). Dreyfus and Dreyfus (2005) describe how rule-based performance and failure to take risks leads to rigidity rather than the flexibility associated with expertise. Benner (1984) describes how experts can suffer and performance deteriorate through strict adherence to parameters of practice set for less experienced nurses, and suggests that nurses can only become truly proficient by stepping outside the rules. Fotheringham et al. (2011) advise that ENP roles developed to reflect the level of advanced nursing practice will result in a broader complexity of the role evidenced in advanced decision-mak-
%
n
90.5 97.6 92.9 100 66.7 100 100 100 100 69.0 61.9 95.2 47.6 100 95.2 97.6 97.6
38 41 39 42 28 42 42 42 42 29 26 40 20 42 40 41 41
ing skills, rather than adherence to protocol limited care which may not be synonymous with advanced practice. The clinical activities undertaken by the ENPs in this study indicate that many can demonstrate achievement of the ANP clinical competencies ( NMC, 2005) (Table 2). According to Currie et al. (2007) in the UK although some diversity in practice exists between departments, the role remains clinically focused concentrating on common illnesses and injuries. The majority of ENPs reported ‘‘prescribing’’ medication through using Patient Group Directions. Despite one third of the respondents having undertaken their Non-Medical Prescribing course, just over half reported using this as a means of prescribing. This was also reported in the rest of the UK by Marsden et al. (2003) who found that even when ENPs had undertaken a Non-Medical Prescribing course, they were constrained in what they could prescribe by a limited formulary. Since then the formulary has been significantly extended (Currie et al., 2007), however this study still found prescribing rights not being fully utilised, with one ENP stating they were a ‘‘qualified prescriber but trust policy not in place’’. It would appear that in NI trusts often failed to develop local policies to allow qualified nonmedical prescribers to prescribe in the clinical areas. Even when ENPs possess the necessary knowledge and qualifications, outdated infrastructures and controls do not allow them the authority to practise autonomously. X-ray referral and interpretation are a significant aspect of these ENPs role. Meek et al. (1995) and Norris and Melby (2006) found resistance from radiography staff a major obstacle to practice. However this was not confirmed in this study, rather it was found that there was mostly strong support from radiography staff. Possible reasons for the change in opposition may be acclimatisation to the ENP role, as one of these studies was undertaken over a decade ago, and the publication of guidelines permitting selected nurses to refer patients for X-ray (RCN 2006). The requirement for ENPs to be involved in other roles impacted on their ability to carry out their own role. When staff sickness was high the ENP service was ‘axed’ and ENPs diverted to other roles. This finding is supported by Tye and
82 Ross (2000) who found that even when ENPs were employed in a dedicated role, they were forced to relinquish it to fill gaps due to nursing staff shortages on a regular basis. As well as adversely affecting the numbers of patients managed by the ENP service, this led to confusion amongst medical staff who did not know which mode of work the ENP was working in. Fotheringham et al. (2011) also reported ENPs working in dual roles, however their study did not include how this impacted on each role. This study found the clinical aspect of the role dominated to the detriment of other advanced practice subroles. The NMC domains and competencies for advanced practice (NMC, 2005) demonstrate a multidimensional focus of the role. Therefore while ANPs must possess advanced clinical skills, they must also demonstrate a wider scope of practice than merely advanced clinical practice.
Limitations A potential limitation was that the tool was developed for this study and has not been fully pilot studied. However it was informed from the literature, fitted the aims of the study, and was pilot tested before use. Self-reporting of information is open to the possibility of social desirability bias where respondents answer in a manner they perceive will be viewed favourably. According to Bowling (2005) this is less likely with postal questionnaires than face-to-face methods, especially when anonymous. The population size for this study was small (n = 60), however since this represents the total number of ENPs in emergency care within NI, this was unavoidable. A 70% response rate (n = 42) is reasonable, however due to the small numbers it is difficult to obtain any significant statistical analysis from which generalisations could be made.
Conclusion and relevance to clinical practice The ENP role and scope of practice in NI appears to have developed in a relatively homogeneous fashion with high degrees of concurrence in role activities. Most care delivered remains protocol-led signifying little autonomy, although some flexibility has been noted. Standardisation of education, role and scope of practice could reduce the need for protocol led care leading to a more autonomous role. This study indicated that ENPs perceive they have substantial control of their role in considering their own capacity to treat patients as the main determinant of their role. While the wishes of medical staff and nursing management are rated as considerably lower determinants, closer inspection reveals protocols, age restrictions, referral and prescribing ability as significant factors which could be interpreted as covert methods of control, not apparent to the ENP. Based on the results of the study there is primacy of the clinical role in ENP practice to the detriment of other subroles of advanced practice. There was little or no activity reported in various aspects of advanced practice domains such as those in Domain 5: Managing and Negotiating Health Care Delivery Systems ( NMC, 2005). This study found that it is doubtful whether many ENPs could fulfil the NMC criteria within their existing role and scope of
D. McConnell et al. practice. However scrutiny of the NMC criteria indicates it aligns more closely with the Consultant Nurse role (Health Service Circular, 1999) than the ENP role. The ENP role appears to correspond more closely to the Level 6, Specialist Practitioner tier of the Career Framework for Health (Skills for Health, 2006). The findings of this study however demonstrated that ENPs are working at a level significantly beyond registration in direct patient care roles. Currently the NMC propose to regulate only one level of practice beyond registration – that of advanced practice (NMC, 2005) which appears to exclude ENPs. ENPs will, in all probability, continue as before to provide an expanded role with an unregulated title, practice and inconsistent educational preparation, fulfilling a fitness for purpose function for the organisation. It would appear that the opportunity for regulation of a significant level of practice has been missed. Perhaps it is timely for the NMC to consider what they hope to achieve through the regulation of advanced practice, and whether current proposals will achieve this. To address this, the current regulatory criteria could be modified to allow inclusion of roles such as those undertaken by ENPs. Alternatively, they could consider the regulation of an additional level of practice to include those who do not undertake all aspects of the proposed advanced practice role, yet work in significantly expanded clinical roles.
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Available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/aaen
Emergency nurse practitioners’ perceptions of their role and scope of practice: Is it advanced practice? Donna McConnell RGN, BSc, MSc (Lecturer in Nursing) a,*, Oliver D. Slevin RGN, BA, MA, PhD (Lecturer in Nursing) a, Sonja J. McIlfatrick RGN, BSc, MSc, PhD (Reader/Head of Research) a b
a,b
Ulster University, Jordanstown Campus, Newtownabbey BT37 0QB, United Kingdom All Ireland Institute of Hospice & Palliative Care (AIIHPC), Ireland
Received 2 February 2012; received in revised form 13 March 2012; accepted 22 March 2012
KEYWORDS Advanced nursing practice; Advanced Nurse Practitioner; Accident and Emergency; Emergency nurse practitioner; Nursing
Abstract There are multiple interpretations of the nurse practitioner role which appear to be shaped by discourses within and outside the profession and its regulatory body. This study aimed to explore and clarify the role and scope of practice of emergency nurse practitioners in a region in the United Kingdom and determine if they fulfil the proposed criteria for Advanced Nurse Practitioners. A survey approach using questionnaires (n = 42) was adopted. The sample included all emergency nurse practitioners working in Accident and Emergency Departments and Minor Injury Units in the region. Statistical data was analysed using SPSS for Windows and qualitative data was content analysed for themes. Results revealed a variation in education. Investigation of role typology and scope of practice revealed a relatively homogenous group where the clinical aspect of the role dominated. The scope of practice was perceived to be influenced by internal factors such as competence; however protocol use, referral rights and prescribing authority could be considered ways that nursing management and medical staff indirectly control the role. Findings suggested that emergency nurse practitioners were working at a level significantly beyond registration, yet do not fulfil the Nursing and Midwifery Council proposed criteria for Advanced Nurse Practitioner.
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Corresponding author. Tel.: +44 (0) 2890368581; fax: +44 (0) 2890 368 202. E-mail address: [email protected] (D. McConnell). 1755-599X/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2012.03.004
Emergency nurse practitioners’ perceptions of their role and scope of practice
Introduction Advanced practice roles have increased significantly in many countries over the last years. Titles, scope of practice, levels of autonomy, registration or licensing and education however differ greatly (Griffin and Melby, 2006). This leads to confusion over what exactly comprises ‘‘advanced practice’’ and which roles could be considered ‘‘advanced’’. The emergency nurse practitioner (ENP) delivers care beyond the remit of the ‘‘traditional nurse’’, although whether this constitutes advanced practice remains a contentious issue. In the United Kingdom (UK), the Nursing and Midwifery Council (NMC) regulatory body made proposals for role definition, competencies and education for advanced practice (NMC, 2005). The proposal includes plans to regulate a single standard of proficiency for a clinical level of practice beyond registration with the title ‘‘Advanced Nurse Practitioner’’ (ANP) (NMC, 2005). Subsequent papers (DH, 2007, 2011; Council for Healthcare Regulatory Excellence, 2009) however have meant regulation of advanced practice is still uncertain. The Department of Health published a statement defining the nature of advanced practice ( DH, 2010a), while a review of nursing and midwifery recommended the regulation of advanced practice (DH, 2010b). More recently the government issued a paper calling for a balanced cost–effective approach to regulation ( DH, 2011). The NMC remain concerned about safeguarding the public ( NMC, 2009) and recognise they will have to provide a strong case for further regulatory action that would be considered appropriate and proportionate to risk.
Background While no one single definition of advanced practice exists, there is consensus that it extends the traditional scope of practice, maximises the use of nursing knowledge, contributes to the development of the profession ( NMC, 2005; Callaghan, 2008) and is distinguished by a high degree of autonomy, authority and accountability (Barton, 2006). The literature reveals conflicting views of advanced practice. Some consider clinical posts at the nursing–medicine interface, such as the nurse practitioner (NP) role, as advanced practice ( Knowles, 2006). In contrast, Manley (1997) and Mantzoukas and Watkinson (2006) support the multidimensional role of advanced practice incorporating the sub roles of expert practitioner, educator, researcher and consultant with clear differentiation between nursing and medical roles and values. These diverse views need not be regarded as mutually exclusive ( Manley, 1997; Barton, 2006), rather both have the potential to be considered advanced. The Advanced Practice Toolkit (Scottish Government, 2008), developed under the auspices of the UK Modernising Nursing Careers initiative (DH, 2006), incorporated UK and international work on advanced practice. It adopted Level 7 of the Career Framework for Health (Skills for Health, 2006) to benchmark advanced practice, and took an overarching view of it as a level of practice rather than a role or title. The Toolkit considers
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the contextual nature of the skills required in both clinical and non-clinical roles, while maintaining the underpinning principles of advanced practice. Skills include the level of autonomy, critical thinking, decision-making and problemsolving which are common to all. The current NMC definition of advanced practice articulates the clinical ANP role within the UK context, but does not consider the non-clinical advanced practitioner role. Within the UK Scotland, Wales and Northern Ireland (NI) have their own devolved parliaments and assemblies responsible for healthcare policy. In the absence of regulation, Scotland (Scottish Government, 2010) and Wales (NHS Wales, 2010) have used the Toolkit as a foundation to develop processes for guidance and governance arrangements around advanced practice posts. NI have developed a Nursing Strategy document for 2010–2015 (Department of Health, Social Services and Public Safety, 2010) which makes reference to reviewing new ways of working, however they have not developed any advanced practice guidance. Evidence from the UK indicates that the ENP role is determined largely by key stakeholder’s needs (Lloyd Jones, 2005). According to Tye and Ross (2000) the vision of the role and scope of practice appear to be largely shaped by a ‘‘fit for purpose’’ ethos, with role enlargement being seen as having potential benefit for the organisation. Fotheringham et al. (2011) carried out a survey of ENP roles in Scotland. They found a role that had developed in response to local need with a range of job titles, protocol use, pay bands and education. Significant themes from the literature were protocol use, relationships with other stakeholders (Tye and Ross, 2000) and educational preparation for the nurse practitioner role. Literature concerning knowledge for Accident and Emergency (A&E) practice focused on the acquisition of clinical skills or ‘‘know-how’’ (Ryle, 1949) as the most significant aspect for the role (Duffield et al., 2010). Norris and Melby’s (2006) study into attitudes towards the Acute Care NP role in A&E found 96.9% of nurses and doctors rated clinical aspects of the role as most important, with mentorship, management and research not considered important. Purposive sampling however within a small geographical area means the study lacks generalisation. Only one A&E study (Griffin and Melby, 2006) identified the need for ENPs to possess broader theoretical knowledge or ‘‘know-that’’ ( Ryle, 1949). In contrast, international literature on advanced nursing roles in general, places emphasis on the need for integration of knowledge in all the arenas of knowing as the framework underpinning effective advanced practice (Carper, 1978; Mantzoukas and Watkinson, 2006). See Fig. 1. Multiple roles and levels of practice shaped by the context in which the ENP is employed, apparent diversity of practice, and the deliberation over prospective regulation of advanced practice make it timely that the role and scope of practice of ENPs is researched and benchmarked.
Aim The aim of this study was to determine the role and scope of ENPs’ practice in NI and establish the extent to which they could fulfil the criteria for an ANP.
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D. McConnell et al.
Fig. 1
Carper’s Framework (1978) and how it relates to knowledge required for the Advanced Nurse Practitioner role.
Objectives To examine the education and/or training undertaken in preparation for an ENP role. To explore the current roles and scope of practice of ENPs and the factors which determine this. To determine the extent to which ENPs fulfil the current proposed competencies of the ANP.
Method This study adopted a survey approach using a self-reported questionnaire. The population (n = 60) included all ENPs working in the 16 A&E departments and the 4 Minor Injury Units (MIUs) in NI, which is a devolved healthcare region within the UK. To ensure content validity questions were constructed following a critique of the literature, previous studies and the framework for ANPs (NMC, 2005). Questions included a range of open and closed ended questions, focusing on sections on education, current role activities and scope of practice within and outside the employing organisation, and factors which ENPs perceived as impacting on their role and scope of practice. The questionnaire was piloted with six ENPs who were not included in the final survey, resulting in minimal change to the wording of some questions.
A total of 60 anonymous questionnaires were sent to ENPs for voluntary completion during August 2008, along with a pre-paid addressed envelope and suggested date of return. One reminder for completion was sent to each department.
Ethical considerations Following ethical approval from Office for Research Ethics Committees Northern Ireland, permission was obtained from each trust. Ethical considerations of voluntary participation and anonymity were respected.
Analysis Quantitative data was analysed using SPSS version 11.5. Themes were identified from the open ended questions. Descriptive statistics were used to report frequencies and mean values. The ENPs reported scope of practice was assessed against the ANP framework for achievement of the competencies.
Results Response Following one postal reminder a total of 42 questionnaires were returned giving a response rate of 70%.
Emergency nurse practitioners’ perceptions of their role and scope of practice
Education for the role Preparation for the role varied with 35.7% (n = 15) having undertaken primary degree level preparation, and 26.2% (n = 11) post graduate study. A total of 31% (n = 13) undertook short courses or stand-alone modules with one of these ENPs having already studied to primary degree level prior to undertaking preparation for the role. A small number (7.1%, n = 3) received in-house training or study days only in preparation for the role.
Pay band The ENPs were employed between Agenda for Change Bands 5 and 7. 71.4% (n = 30) were employed at band 7, 14.3% (n = 6) at band 6 and 14.3% (n = 6) at band 5. Of the eighteen ENPs working in MIUs, 66.7% (n = 12) were at band 7, and 33.3% (n = 6) at band 5. No band 5 ENPs worked in A&E departments.
Role and scope of practice The ENPs perceived their scope of practice to be determined internally by their own competence (71.4%) and externally to varying degrees by the patient’s wishes (45.2%), protocols (69%), age restrictions (35.7%), wishes of medical staff (23.8%), nursing management (21.4%), referral rights to other healthcare professionals (26.2%), X-ray referral rights (40.5%) and prescribing authority (31.0%). Themes that emerged as being perceived as the greatest obstacles to autonomy were lack of role progression, control of the role by others and the domination of clinical workload (Table 1). All but one ENP (97.6%) worked within protocols at least some of the time, with the majority (64.3%, n = 27) reporting always working within protocols. Of those who used protocols 56.1% (n = 23) felt they restricted their practice. One ENP stated ‘‘[protocols] restrict as can only treat patients within the rigid criteria.’’ A small percentage (9.8%, n = 4)
Table 1
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felt they increased their practice. Approximately one quarter (24.4%, n = 10) felt they neither increased nor restricted their scope of practice, and 2.4% (n = 1) felt they had the potential to both restrict and increase scope with different patients. Those that reported sometimes working outside protocols (33.3%, n = 14), did so as they gained experience in the role, and when patients presented with conditions not covered by the protocols. One ENP reported ‘‘protocols are in place but we are not expected to work within themthey provide guidance at start of role’’. All but one ENP referred to X-ray (97.6%, n = 41), with 92.9% (n = 39) also interpreting them. This study found 78.6% (n = 33) reported strong support for their role from radiography staff, with only 4.8% (n = 2) citing them as the greatest obstacle to their autonomy. Over half (54.8%, n = 23) of the ENPs reported their role incorporated additional duties, such as staff nurse duties 47.8% (n = 11), being in charge of their shift 30.4% (n = 7) and ward manager duties 21.7% (n = 5). ENPs were asked to estimate the percentage of time spent in the sub-roles of clinical workload, education, research, audit, leadership, management and expert resource, which are competencies to be met within the ANP framework (NMC, 2005). In all cases the clinical role dominated (mean 81.3%) with one ENP reporting spending 100% of the time in this role. Education and training (mean 5.7%) and expert resource (mean 4.8%) were the next highest followed by audit (mean 3.1%) leadership and management (mean 2.6%) and finally research (mean 2.5%). See Fig. 2. A total of 85.7% (n = 36) reported that they were not involved in any advanced practice outside their own organisation. None reported involvement in any organisational decision-making, legislative or policy making activities, which are also competencies to be met within the ANP framework (NMC, 2005). Table 2 shows the results of ENPs participation in a list of clinical activities derived from Domain 1 (assessment and management of patient/health/illness) of the Advanced Practice Competencies (NMC, 2005). The results indicate that many ENPs can demonstrate achievement of these clinical competencies.
ENP’s perception of which factors are the greatest obstacle to their autonomy.
Themes
What is the greatest obstacle to your autonomy?
%
Nos.
Lack of role progression
62.4%
Lack of knowledge and education to expand role Lack of infrastructure in place to support role development Lack of prescribing power Protocols (only able to treat certain conditions)
14.3 7.2 26.2 14.3
6 3 11 6
Control of role by others
50.4%
Dr. acceptance/opposition/control Refusal to accept referrals from ENP Senior Nurse Managers controlling role and off duty X-ray staff opposition Staff nurses opposition
21.4 19.2 4.8 4.8 4.8
9 8 2 2 2
Domination of clinical workload
19.2%
Due to – Staff shortage – Excessive clinical workload – Being used for other duties outside ENP role
7.2 7.2 4.8 4.8
3 3 2 2
None
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D. McConnell et al. Expert resource Leadership & mgt Audit Research Education/training
Clinical
Fig. 2
Mean percentage estimation of time spent in sub-roles.
A total of 9.5% (n = 4) did not prescribe medication at all. The 90.5% (n = 38) who did, reported using a variety of methods to suit different situations. 78.6%, (n = 33) used Patient Group Directions, 19.0%, (n = 8) used non-medical prescribing and (7.1%, n = 3) asked doctors to sign their prescriptions on different occasions. In total 33.4% (n = 14) had completed the Non-Medical Prescribing programme, however just over half (57.1%, n = 8) reported using this to prescribe medication.
Discussion Education for the role This study found no standardisation of educational preparation, with education ranging from in-house training to post-graduate degrees. This is supported by UK literature, highlighting a variety of local and in-house programmes (Currie et al., 2007). Walsh (2000) found that short-term educational solutions undermine the concept of advanced practice and the more limited the training the more limited the role. Currie et al. (2007) suggest that the absence of formal regulation in the UK may have caused emphasis on clinical experience and clinical competence, in preference to academia. According to Lloyd Jones (2005) the debate around educational preparation only appears to be an issue in the UK. This is in stark contrast to the USA, where education for the nurse practitioner role is undertaken at masters-degree level and there is national consensus on minimum standards for education (Hoskins, 2011).
Pay band The majority of ENPs were employed at band 7. Despite Agenda for Change (NHS Employers, 2005) being devised to match posts to pay bands, variations still exist in this region. The only band 5 ENPs were employed in MIUs, which appears to be a paradox since it could be anticipated these
ENPs would be more likely to be working in autonomous roles without medical support. Fotheringham et al’s. study (2011) found ENPs in Scotland employed at band 5–8a, although they also reported a wide variation in roles which does not appear to be a feature in this study.
Role and scope of practice Factors which appeared to be influential in shaping the ENP role and scope of practice were interrelated, to varying extents, with those that the ENPs perceived as significant in determining the degree of autonomy in their role. In this study the ENP’s perceived their own capacity to treat the presenting conditions as the strongest factor in determining their scope of practice, while only a small percentage cited lack of knowledge and education to expand their role as an obstacle to their autonomy. This indicates that the ENPs felt they had control over their role by virtue of their knowledge and skills. However factors such as protocols, imposed age restrictions, prescribing and referral ability, wishes of medical and nursing staff and domination of the clinical workload were all referred to as factors influencing the role and obstacles to autonomy. This indicates a role which is largely shaped by external factors beyond the ENPs control. In contrast to the literature this study found that only 21.4% (n = 9) stated senior nurse managers wishes strongly determined the range of patients they treated. The majority felt managers strongly supported them in their role with few perceiving them as an obstacle to their autonomy. Slightly higher numbers felt the wishes of medical staff strongly determined their role, and found them the greatest obstacle to their autonomy. As in this study, the literature cites lack of infrastructure to support the role (Lloyd Jones, 2005), the requirement to use protocols (Scholes and Vaughan, 2002) and staff shortage forcing ENPs to take on other roles (Tye and Ross, 2000) as factors impacting on the role. Whilst not immediately apparent, it could be considered that these factors could be ways in which senior
Emergency nurse practitioners’ perceptions of their role and scope of practice Table 2
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Role features of current ENP role.
Order medication Order X-rays Interpret X-rays Accept referrals from other health care providers Triage patients by telephone See clients with undifferentiated and undiagnosed problems Undertake health history assessment of patients Carry out physical examination of patients Recognise emergencies and refer appropriately Request laboratory tests Interpret laboratory tests Make diagnoses Screen patients for signs of illness Health promotion and health education Review patients to evaluate effectiveness of treatment plan Discharge patients Refer patients to other health care providers
management and medical staff surreptitiously control the role which has not been recognised by the ENPs. The high percentage of ENPs in this study reporting working within protocols (97.6%) is in contrast to the USA (Marsden, 2003), but mirrors the rest of the UK ( Walsh, 2000; Fotheringham et al., 2011). Marsden et al. (2003) link the use of protocols to the negative effects of inadequate or ineffective educational preparation for the role. While 69% of respondents felt protocols strongly determined their scope of practice just over half of those using them felt they restricted it. One ENP raised the issue of protocols limiting their ability to respond to the client individually. This raises questions around quality of care and whether this perceived inflexibility impacts on individualised treatment options. The fact that just under half the respondents did not find protocols restrictive may be due to the fact that one third of respondents reported the flexibility to work outside them when they needed to or as they gained experience. Ethical knowing involves making moment-to-moment judgments about what ought to be done and what is right and responsible (Carper, 1978). Lack of flexibility which prevents this raises a potential ethical dilemma for the ENP. Walsh (2000) speaks of the need to have freedom to work as an accountable practitioner, which means there may be a need to expand and diverge from previously defined boundaries. Autonomous decision-making is not about strict adherence to protocols, rather it is discretionary decision making that is fundamental to autonomous practice (Benner, 1984; Wade, 1999). Dreyfus and Dreyfus (2005) describe how rule-based performance and failure to take risks leads to rigidity rather than the flexibility associated with expertise. Benner (1984) describes how experts can suffer and performance deteriorate through strict adherence to parameters of practice set for less experienced nurses, and suggests that nurses can only become truly proficient by stepping outside the rules. Fotheringham et al. (2011) advise that ENP roles developed to reflect the level of advanced nursing practice will result in a broader complexity of the role evidenced in advanced decision-mak-
%
n
90.5 97.6 92.9 100 66.7 100 100 100 100 69.0 61.9 95.2 47.6 100 95.2 97.6 97.6
38 41 39 42 28 42 42 42 42 29 26 40 20 42 40 41 41
ing skills, rather than adherence to protocol limited care which may not be synonymous with advanced practice. The clinical activities undertaken by the ENPs in this study indicate that many can demonstrate achievement of the ANP clinical competencies ( NMC, 2005) (Table 2). According to Currie et al. (2007) in the UK although some diversity in practice exists between departments, the role remains clinically focused concentrating on common illnesses and injuries. The majority of ENPs reported ‘‘prescribing’’ medication through using Patient Group Directions. Despite one third of the respondents having undertaken their Non-Medical Prescribing course, just over half reported using this as a means of prescribing. This was also reported in the rest of the UK by Marsden et al. (2003) who found that even when ENPs had undertaken a Non-Medical Prescribing course, they were constrained in what they could prescribe by a limited formulary. Since then the formulary has been significantly extended (Currie et al., 2007), however this study still found prescribing rights not being fully utilised, with one ENP stating they were a ‘‘qualified prescriber but trust policy not in place’’. It would appear that in NI trusts often failed to develop local policies to allow qualified nonmedical prescribers to prescribe in the clinical areas. Even when ENPs possess the necessary knowledge and qualifications, outdated infrastructures and controls do not allow them the authority to practise autonomously. X-ray referral and interpretation are a significant aspect of these ENPs role. Meek et al. (1995) and Norris and Melby (2006) found resistance from radiography staff a major obstacle to practice. However this was not confirmed in this study, rather it was found that there was mostly strong support from radiography staff. Possible reasons for the change in opposition may be acclimatisation to the ENP role, as one of these studies was undertaken over a decade ago, and the publication of guidelines permitting selected nurses to refer patients for X-ray (RCN 2006). The requirement for ENPs to be involved in other roles impacted on their ability to carry out their own role. When staff sickness was high the ENP service was ‘axed’ and ENPs diverted to other roles. This finding is supported by Tye and
82 Ross (2000) who found that even when ENPs were employed in a dedicated role, they were forced to relinquish it to fill gaps due to nursing staff shortages on a regular basis. As well as adversely affecting the numbers of patients managed by the ENP service, this led to confusion amongst medical staff who did not know which mode of work the ENP was working in. Fotheringham et al. (2011) also reported ENPs working in dual roles, however their study did not include how this impacted on each role. This study found the clinical aspect of the role dominated to the detriment of other advanced practice subroles. The NMC domains and competencies for advanced practice (NMC, 2005) demonstrate a multidimensional focus of the role. Therefore while ANPs must possess advanced clinical skills, they must also demonstrate a wider scope of practice than merely advanced clinical practice.
Limitations A potential limitation was that the tool was developed for this study and has not been fully pilot studied. However it was informed from the literature, fitted the aims of the study, and was pilot tested before use. Self-reporting of information is open to the possibility of social desirability bias where respondents answer in a manner they perceive will be viewed favourably. According to Bowling (2005) this is less likely with postal questionnaires than face-to-face methods, especially when anonymous. The population size for this study was small (n = 60), however since this represents the total number of ENPs in emergency care within NI, this was unavoidable. A 70% response rate (n = 42) is reasonable, however due to the small numbers it is difficult to obtain any significant statistical analysis from which generalisations could be made.
Conclusion and relevance to clinical practice The ENP role and scope of practice in NI appears to have developed in a relatively homogeneous fashion with high degrees of concurrence in role activities. Most care delivered remains protocol-led signifying little autonomy, although some flexibility has been noted. Standardisation of education, role and scope of practice could reduce the need for protocol led care leading to a more autonomous role. This study indicated that ENPs perceive they have substantial control of their role in considering their own capacity to treat patients as the main determinant of their role. While the wishes of medical staff and nursing management are rated as considerably lower determinants, closer inspection reveals protocols, age restrictions, referral and prescribing ability as significant factors which could be interpreted as covert methods of control, not apparent to the ENP. Based on the results of the study there is primacy of the clinical role in ENP practice to the detriment of other subroles of advanced practice. There was little or no activity reported in various aspects of advanced practice domains such as those in Domain 5: Managing and Negotiating Health Care Delivery Systems ( NMC, 2005). This study found that it is doubtful whether many ENPs could fulfil the NMC criteria within their existing role and scope of
D. McConnell et al. practice. However scrutiny of the NMC criteria indicates it aligns more closely with the Consultant Nurse role (Health Service Circular, 1999) than the ENP role. The ENP role appears to correspond more closely to the Level 6, Specialist Practitioner tier of the Career Framework for Health (Skills for Health, 2006). The findings of this study however demonstrated that ENPs are working at a level significantly beyond registration in direct patient care roles. Currently the NMC propose to regulate only one level of practice beyond registration – that of advanced practice (NMC, 2005) which appears to exclude ENPs. ENPs will, in all probability, continue as before to provide an expanded role with an unregulated title, practice and inconsistent educational preparation, fulfilling a fitness for purpose function for the organisation. It would appear that the opportunity for regulation of a significant level of practice has been missed. Perhaps it is timely for the NMC to consider what they hope to achieve through the regulation of advanced practice, and whether current proposals will achieve this. To address this, the current regulatory criteria could be modified to allow inclusion of roles such as those undertaken by ENPs. Alternatively, they could consider the regulation of an additional level of practice to include those who do not undertake all aspects of the proposed advanced practice role, yet work in significantly expanded clinical roles.
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