An exploration of the perceptions of Emergency Physicians and Trainees, towards Emergency Nurse Practitioners in Australia

Australasian Emergency Nursing Journal (2013) 16, 73—80

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

An exploration of the perceptions of Emergency Physicians and Trainees, towards Emergency Nurse Practitioners in Australia Mark Jones, BN, GDip CritCare, MNSc a,∗ Luke Christoffis, BN, GCert Emerg, MNSc a Stuart Smith, MSc, BSc (Hons), Dip HE a Nicolette Hodyl b a b

Lyell McEwin Hospital, Emergency Department, Elizabeth Vale, South Australia 5112, Australia Robinson Institute, Lyell McEwin Hospital, Elizabeth Vale, South Australia 5112, Australia

Received 14 October 2012; received in revised form 19 February 2013; accepted 19 February 2013

KEYWORDS Emergency Nurse Practitioner; Emergency Physicians perceptions

Summary Objective: To explore Emergency Physicians perceptions towards the Emergency Nurse Practitioner role, specifically, examining their support, its perceived benefits, difficulties, impact in the clinical environment and proposed scope of practice. Methods: A survey was distributed to all members of the Australasian College of Emergency Medicine via Survey Monkey between August and November 2009. Statistical analysis of the data was performed using the SPSS package. Results: A total of 50.8% (n = 315) responded positively to supporting the Emergency Nurse Practitioner role whilst 20% (n = 124) responded negatively. When comparing those who have worked with Emergency Nurse Practitioners vs those who have not, 59.8% (n = 307) of those who have worked with Emergency Nurse Practitioners were positively identified as supporting the role, compared to 7.5% (n = 8) of those who had not. In those who had not worked with Emergency Nurse Practitioners 53.3% (n = 57) neither agreed nor disagreed in supporting the role. With respect to the benefits and the proposed scope of practice, a response trend of greater significance was found in those who had previously worked with Emergency Nurse Practitioners. Conclusion: Emergency healthcare is evolving in line with increasing demands. Worldwide, the Emergency Nurse Practitioner role has been researched and critiqued at length. This paper provides evidence of Emergency Physicians positive perceptions and recognition of benefits of

∗ Corresponding author at: The Emergency Department, The Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia 5112, Australia. Tel.: +61 8182 9470; fax: +61 8182 9276. E-mail addresses: [email protected], [email protected] (M. Jones).

1574-6267/$ — see front matter © 2013 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.aenj.2013.02.002

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M. Jones et al. the Emergency Nurse Practitioner role within Australia. This was especially apparent amongst clinicians that have previously worked alongside them. Despite this, concerns were expressed with regard on-going medical training, medico-legal implications and training of Emergency Nurse Practitioners. © 2013 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

What is known • Whilst there are numerous international and local studies examining patient perceptions of the role, safety and clinical effectiveness, there is scant evidence which specifically focuses on Emergency Physicians and Trainees perceptions of the ENP role in Australia. What this paper adds • Our data indicates that those practitioners with direct experience of working with an ENP are more favourable towards supporting the ENP role. There is a large percentage of respondents with no experience working with ENP’s indifferent towards supporting the role 53.3% (n = 57). • The evidence of this study supports the notion that there is consensus on the ENP’s scope of practice amongst Physicians and Trainees.

Introduction The role of the emergency nurse and emergency service delivery has been changing in response to increasing demands on Australian emergency departments.1 Some of these specific demands identified are increasing patient presentations, extended waiting times, access block, longer average lengths of stay (LOS) and time-based performance targets. As a result, the traditional role of the Emergency Nurse has been re-evaluated and where there have been service deficits, roles such as the nurse practitioner have been explored and developed.2 Following the implementation of The Emergency Nurse Practitioner (ENP) in the UK and USA, the ENP role has become one of the most widely implemented NP roles throughout Australia. At the time of writing there are 81 authorised ENPs and 122 Nurses with Emergency listed as a specialty with the Australian College of Nurse Practitioners.3

Background The ENP role has become widely researched with literature analyzing and critiquing the role dating back to the late 1970s.4 There is evidence that ENPs are at least as clinically effective as their medical colleagues within a defined scope of practice,5—7 can safely interpret X-rays,8,9 can reduce waiting times in the ED,10 decrease ED LOS and assist EDs to meet time based ED LOS targets.11 Further, patients and fellow nursing and medical staff report being satisfied with

the care provided by ENPs.12,13 A recent detailed Cochrane Collaboration which reviewed 4253 papers suggested patient care outcomes when managed by a NP were similar when compared to physicians in primary care.14 There is no documented evidence to dispute the high level of clinical care provided by ENPs within a defined scope of practice. With the establishment of Medical Benefits Schedule and Pharmaceutical Benefits Scheme access for NPs,15 patients will have greater accessibility and equity to medications and healthcare. Despite evidence supporting the clinical role of the ENP, there remains some reservation about the implementation, level of autonomy, clinical responsibility and the impact to medical staff training opportunities. In a study by Bradford16 it was found that many older physicians still felt that the main role of nurses was to carry out the orders of a physician. The Australian Medical Association (AMA)17 stated that ‘‘other countries have attempted to substitute doctors with other health care providers. These are best described as brave experiments — based on little or no evidence. Studies that have attempted to evaluate these experiments have relied on patient experience and have not attempted to evaluate clinical outcomes.’’ These comments, however, appear unsubstantiated and without reference to rigorous evidence. Task substitution has also been discussed by various bodies including the AMA17 who have stated that ‘‘The AMA supports appropriate delegation of tasks or referral of tasks to other types of health practitioner where it can be demonstrated that there is an improvement in the access and delivery while maintaining the quality patient care.’’ Whilst there are numerous international and local studies examining patient perceptions of the role, safety and clinical effectiveness, there is scant evidence which specifically focuses on Emergency Physicians and Trainees perceptions of the ENP role in Australia. The importance of local research is necessitated by the regulatory process in becoming an ENP varying greatly internationally. The objective of the current research was to evaluate the perceptions of Emergency Physicians and Trainees towards the ENP role, within Australian ED’s. This study aimed to provide recommendations that will help Australian ENPs, Emergency Physicians and Trainees better understand the benefits and limitations of the role in Australia.

Methodology Study design The survey content was designed collaboratively by an Senior Emergency Registrar, 2 authorised ENPs and one ENP candidate. The survey was developed in consideration of

An exploration of the perceptions of Emergency Physicians and Trainee the survey designers own current scope of practice, experience and knowledge of other Emergency Nurse Practitioner services and knowledge of previous research regarding the Emergency Nurse Practitioner role. Both quantitative and qualitative data were obtained. The survey included questions regarding demographics, past experience of working with ENPs, perceptions of the ENPs role and their scope of practice within the ED. Responses related to opinions were identified on a Likert scale from 1 to 5, strongly disagree to strongly agree, 3 was a neutral response. An opportunity for open ended comment in all questions other than demographic questions was offered. Data of both the scope and the difficulties of the ENP role were obtained by providing multiple check box options, where respondents could select multiple choices.

Ethics Ethics approval was gained through the Central Northern Adelaide Health Service Ethics of Human Research Committee. The survey was also authorised by the Australasian College for Emergency Medicine Scientific Committee.

Sample/data collection Through the Australasian College for Emergency Medicine (ACEM) email list, the survey was distributed to all Trainees and Emergency Physicians of the ACEM. A link was provided for respondents to reply via an online survey tool (SurveyMonkeyTM ) Data collection commenced in August 2009 and ceased in November 2009. A reminder invitation was sent through the ACEM, in October2009. A total of 2868 emails were sent with the survey link, 1698 trainees and 1200 Fellows.

Data analysis Analysis of the qualitative data was considered using thematic analysis and Nvivo software, this was considered to be too expansive for the authors to appropriately analyse and therefore was omitted from further analysis in this paper. The quantitative data was transferred from SurveyMonkey into an excel document and coded. Once coded the data was transferred into the SPSS package to allow statistical analysis. The survey design allowed respondents to skip questions before answering the next question, therefore the total respondents for each question was variable accordingly. Due to being able to skip questions and proceed with the survey there were respondents who responded towards attitudes towards the role, however had not identified their demographic details. Where it was unknown to which demographic group the data belonged to the data was omitted from inclusion in the analysis. There were 6 Likert scale questions which in retrospect were considered double barrelled. 5 of these were omitted from analysis. The double barrel question ‘‘I work with ENP’s and support their role’’, was included in the analysis as determining Emergency Physicians or Trainees support for ENPs was one of the major concerns of the survey and

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determined to still be of value despite the nature of the question. In analysis of the Likert scale questions, agree or strongly agree were collapsed and coded together as positive responses and disagree or strongly disagree were collapsed and coded together as negative responses. Neither disagree or agree responses were determined as neutral. Chi-square analyses of the following variables was used with p < 0.05 indicating statistical significance. The variables examined using Chi Square analysis were the attitudes of Emergency Physicians vs Trainees, those who had worked with ENPs vs those who had not and the variable years of experience of working in emergency departments. The multiple check box questions were analysed via determining frequencies and percentages of each independent check box in relation to the total number of respondents to the entire question.

Results Demographics Of the 2868 questionnaires distributed a total of 703 questionnaires were returned giving an overall minimum response rate of 25%. Of the respondents, 47.5% (n = 329) were Emergency Physicians and 52.5% (n = 364) were Trainees. Looking at the experience of the respondents 55.9% (n = 383) had 1—5 years ED experience, 20.6% (n = 141) had 6—9 years, 12.1% (n = 83) had 10—14 years, 7.0% (n = 48) had 15—19 years and 4.4% (n = 30) had greater than 20 years ED experience. A large number of the Physicians and Trainees had experience previously working with ENPs 79.9% (n = 560) and 55.5% (n = 388) currently had an ENP employed in their ED.

Support for the ENP role When asked about support for the ENP role, 50.8% (n = 315) of respondents were positive, 29.2% (n = 181) were neutral and 20% (n = 124) were negative. The support of the ENP role was further analysed by Emergency Physician vs Trainees, years of experience and previous experience of working with an ENP. Of those who had worked with an ENP previously, significantly greater number of respondents (59.8%, n = 307) supported the role compared to those who had never previously worked with an ENP (7.5%, n = 8; p < 0.001). Of those respondents who had never worked with an ENP before, 53.3% (n = 57) were inconclusive in their support. Those having no experience of working with an ENP significantly reported more negative responses (39.3%, n = 42), compared to those who had worked with ENPs (16%, n = 82; p < 0.001).

The benefits of the ENP role Respondents were given eight options of benefits of the ENP role to which they could agree to more than one option (Table 1). Of the eight benefits to the ENP role explored six were shown to have a significantly greater response in those respondents who had previously worked with ENPs (p < 0.05).

76 Table 1

M. Jones et al. Pereceived benefit of the ENP role.

Reduced waiting times Allows appropriate health care professionals to manage patients within a defined scope of practice Allows doctors to manage more critically ill patients Provides a clear clinical career pathway for nurses in ED Reduced did not waits Cost effectiveness Reduction in complaints Continuity of care

Frequency

Number

73.3% 63.1%

429 369

61.9%

362

48.9%

286

48.7% 34.7% 14.5% 12.6%

285 203 85 74

The only two benefits where there was not a significant difference when comparing those who have and have not worked with ENPs were continuity of care and reduced numbers of did not wait’s. When benefits of the ENP role were identified by Trainee and Emergency Physician responses, only reduction in waiting times was significantly different, Trainees 64.8% (n = 236) and Emergency Physicians 57.4% (n = 189), p = 0.046.

Difficulties of the ENP role Respondents were given twelve options of perceived difficulties of the ENP role to which they could agree to more than one option (Table 2). Over half the respondents saw clinical responsibility issues, identification of scope of practice and accountability of scope of practice as difficulties of the role. Funding was determined to be a significantly greater issue by Physicians 30.7% (n = 101) than Trainees 21.4% (n = 78; p = 0.05). Conversely two difficulties were determined to be more

significant in the trainee group, these were patient’s acceptance of the role, 23.1% (n = 84) compared to Physicians (15.8%, n = 52; p = 0.016), and reported safety for patients 30.5% (n = 111) compared to 18.2% (n = 60, p < 0.001). Respondents who had never previously worked with an ENP regarded patient safety 40.4% (n = 57) as an greater issue than those who had worked previously with an ENP, 20.7% (n = 116, p = 0.010). Similarly inadequate preparation of the role was more frequently identified by those who had never worked with ENPs (31.2%, n = 44) compared to those who had (23.3%, n = 130; p = 0.05). Analysing doctors becoming deskilled showed a significant increased response in those who have worked with ENPs (40%, n = 224), compared to those who have not (29.8%, n = 42; p = 0.026).

Scope of practice Respondents were asked to tick one or more differential diagnoses which could be included within a ENPs scope of practice (Table 3). The proposed scope of practice list was evaluated comparing those supportive and unsupportive of the ENP role. In 16 of the 19 diagnosis there was a significantly greater response from those supportive of ENPs compared to those unsupportive (p ≤ 0.05 in each instance. In the remaining 3 diagnoses (headache, neurological complaints and the unwell or febrile child), no significant differences were observed between those supportive and unsupportive of the role. For each diagnosis, responses of Trainees and Emergency Physicians were compared. In 11 out of the 19 diagnoses, the response rate was significantly greater in the Physician group compared to the Trainee group, p ≤ 0.05 in each instance. Responses from those who have and have not previously worked with ENPs were also compared. In 11 of these there was a significantly greater response in those that have worked with ENPs previously, p ≤ 0.05 in each instance.

Discussion Table 2

Difficulties of the ENP role.

Clinical responsibility issues Identifying specific scope of clinical practice Accountability of practice Doctors becoming de-skilled in the management of patients now seen by an ENP Resistance from medical staff Access to MBS & PBS Funding Inadequate preparation for the role Safety for patients Doctors feel their role is threatened Patients acceptance of the role Resistance from nursing staff

Frequency

Number

63.5% 55.9%

395 348

52.7% 42.8%

328 266

31.5% 30.9% 28.9% 28.0%

196 192 180 174

27.8% 25.2%

173 157

22.0% 19.3%

137 120

This study has provided evidence of the perceptions of Emergency Physicians and Trainees to the role of the ENP in Australia. There is no other study of this magnitude that has been undertaken in Australia. It could be argued that the study population represents the perceptions of Emergency Physicians and Trainees in Australia and in fact there is evidence of support for the role particularly with those that have worked with ENP’s (59.8%). It is also interesting to note that those whom have not worked with an ENP (53.3%) neither, disagree and agree with the concept of support for the role, therefore indicating an open mindedness to their usefulness, a move from the stereotypical perception of the role. Like Mauksh and Campbell18 our data also indicates that those practitioners with direct experience of working with an ENP are more favourable towards supporting the ENP role. Mauksh and Campbell also found that those who lacked direct experience of working with an ENP, based their rejection of the role on stereotypes. The notion that Physicians or Trainees are negative towards supporting the

An exploration of the perceptions of Emergency Physicians and Trainee Table 3

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Diagnosis that should be included in an ENP’s scope of practice.

Suture/staple check/removal Plaster applications/evaluations Minor Burns Abrasions/puncture wounds/lacerations Morning after pill Soft tissue injuries of joints Fracture of extremity ENT presentations such as ear aches, tonsillitis Cellulitis Opthalmic presentation such as corneal abrasion, conjunctivitis Role in resuscitation Vaginal bleeding, dysmenorrhea, STD’s Urinary complaints including UTI or renal calculi Common respiratory complaints, including asthma exacerbation, URTI, pneumonia Nausea/vomiting Gastroenterology complaints such as gastroenteritis, haemorrhoids, abdominal pain The unwell/febrile child Headache Neurological complaints like vertigo, migraines, Bell’s Palsy

Frequency

Number

p value Q2

p value Q4

p value Q11

93.8% 89.8% 88.6% 80.6% 77.1% 75.9% 72.7% 46.2%

561 537 530 482 461 454 435 276

.214 .031* .005* .626 .820 .098 .914 .653

.000* .000* .000* .000* .000* .000* .000* .000*

.000* .178 .004* .000* .000* .000* .000* .000*

45.8% 34.9%

274 209

.003* .012*

.000* .000*

.000* .000*

28.4% 27.4% 24.9%

170 164 149

.001* .021* .012*

.357 .000* .169

.000* .096 .010*

20.2%

121

.023*

.279

.000*

19.7% 11.0%

118 66

.169 .236

.491 .291

.018* .000*

8.4% 8.0% 5.2%

50 48 31

.008* .000* .004*

.451 .537 .306

.000* .000* .740

p value Q2: Chi squared analysis of Physician vs Trainee. p value Q4: Chi squared analysis of Worked with ENP’s vs Not Worked with ENP’s; p value Q11: Chi squared analysis of those supporting the role vs those NOT supporting the role. * Result < 0.05 = statistically siginificant.

ENP role due to their lack of experience of working with them and therefore developing a preconceived stereotype is not supported in our study as there is a large percentage of respondents with no experience working with ENP’s indifferent towards supporting the role 53.3% (n = 57). Through interviewing five doctors in one ED, Cairo19 examined Emergency Physicians attitudes towards the ENP role in the United States of America. Overall the physicians supported the ENP role on the premise that it be supervised in the traditional fashion by the physician. Cairo concluded that his data described a physician perceived model of ‘‘dependent collaboration’’ between NPs and physicians in the ED. Supporting the scepticism Cairo found, our survey showed the majority of Emergency Physicians and Trainees identifying accountability (52.7%, n = 328) and clinical responsibility (63.5%, n = 395) as difficulties of the ENP role. Cairo19 also found that all the Emergency Physicians interviewed, expressed concerns over legal liability. They concurred that that the use of ENPs would be a potential liability. The consensus was that ultimately the ENP is working ‘‘under the license’’ of a Physician. Despite this notion held by all the Emergency Physicians surveyed, ultimate medical doctor responsibility for the care delivered to patients by all professionals is unfounded.21 In both Australian and English law since the mid-20th century,

medical doctors have not been responsible for the care delivered by nurses including that of the Nurse Practitioner and ultimate clinical responsibility rests purely with the treating clinician. Despite this there is a remaining concern that doctors are responsible for nurse directed care. This concern continues to influence health service, state and federal health policy.20 There is, however, no evidence refuting the safety, clinical competence and patient acceptance of ENPs; such issues are purely anecdotal. Weiland et al.21 undertook a study on perceptions of NPs by 95 emergency doctors in Australia. They were asked whether NPs could replace interns in the ED, over half of the emergency doctors disagreed and 29.5% strongly agreed or agreed that NPs could replace interns. Such an analysis of the ENP role in relation to doctor replacement is thought to be unfair and inappropriate by the authors. The ENP role is a role which bridges an identified service gap, complements existing emergency care service, and by no means should be a replacement for medical staff.22 Weiland also identified negativity towards the ENP role. A quarter of the doctors interviewed felt that their role was threatened by ENPs and were also concerned about issues relating to becoming deskilled. This is thought to be a more appropriate analysis of the ENP role rather than assessing opinions of ENPs replacing Interns. The concerns regarding

78 doctors becoming deskilled and that their role is threatened are supported by our study, where 42.8% (n = 266) identified becoming deskilled as a difficulty of the ENP role. In regards to Emergency Physicians or Trainees feeling that their role is threatened 25.2% (n = 157), felt this was the case. It is hoped that this paper goes some way in alleviating these concerns through education that the ENP role is not one of doctor substitution. Despite Emergency Physicians and Trainees, having obvious concerns surrounding the ENP role in our study, there is also definite agreeance on benefits of the role. The majority of Emergency Physicians and Trainees agree that the role of the ENP allows doctors to manage more critically ill patients 61.9% (n = 362), allows appropriate health care professionals to manage a defined scope of patients 63.1% (n = 369), and reduces waiting times 73.3% (n = 429). The findings of Griffin and Melby23 supports this showing 94% respondents agreeing that an Advanced Nurse Practitioner (ANP) service would improve waiting times in the ED and would allow medical staff more time to deal with seriously ill patients. Another UK study by Norris and Melby24 interviewed ED doctors and nurses identifying perceived benefits as reduced waiting times, holistic care, increased patient satisfaction, safer practice and providing an alternative stream from emergency care provision. The evidence of this study shows that identification of scope is not dependant of Physician’s or Trainees perception towards the role and supports the notion that there is consensus on the ENP’s scope of practice amongst Physicians and Trainees. Williams25 believes that ENPs scope of practice has been propagated by a medical lead, perceived as having overall authority to determine what practices nurses can perform. Whilst there is some validity in Williams argument, also supported by consensus within the survey on what the ENP scope may include, Australia ENPs are autonomous in developing their scope of practice and forms part of their authorisation as a Nurse Practitioner. The development of Scope of Practice is multifactorial and takes into account ENP’s expertise, clinical experience and needs of the health care service.26 Lee et al.27 identified 75% of doctors and nurses working in an Australian ED employing ENPs, positively identifying that ENPs have the skills and knowledge to provide appropriate emergency care to specific patient groups. Whilst this suggests that Australian nurses and doctors believe ENPs have the skills to work in their role a third of these same respondents were also shown to have a poor understanding of the ENPs scope of practice and or clinical practice guidelines. Specific knowledge deficits identified of those surveyed were specifically related to educational preparation required for endorsement as an ENP. There is therefore possible benefit to be gained in promoting interprofessional experiences between Nurse Practitioners and Medical Students, enhancing the future development of positive relationships. Lee’s findings support that the ENP role is not clearly understood even to those working with ENPs. This lack of clarity is thought to be partly due to the absence of a core scope of practice. Whilst autonomy of the development of a scope of practice is an essential factor in allowing an individual ENP or ENP service to fulfil its full potential the creation of a core ENP scope of practice may facilitate

M. Jones et al. better understanding and greater acceptance of the ENP role.

Limitations Although this research reached its aim of demonstrating perceptions of Emergency Physicians and Trainees, there were a number of unavoidable limitations. First the response rate could not be calculated. Unfortunately despite the survey being sent to 2868 ACEM members we could not determine how many actually received the survey. It was thought even taking this into account a response of 703 Emergency Physicians and Trainees was considerable and represented a valuable incite into the perception of the role. A major limitation of the study was the number of double barrelled questions, which as described before were omitted from analysis. Another limitation was that the survey allowed respondents to skip questions, therefore creating a variable response rate for each question. This was attributed by taking into account the variable response rate for each question independently. Lastly another major limitation identified was that there was no distinction between an ENP and an ENP candidate or trainee role. The findings of Lee et al. previously showing that the understanding of the role is poor in those working with ENPs suggests that the respondents of the survey may be unable to distinguish the difference between an ENP and an ENP candidate. Therefore the responses could be in reference to an ENP and or ENP candidate.

Recommendations With over half the respondents identifying scope of practice, accountability of practice and clinical responsibility as difficulties of the ENP role it is thought that further study is required to identify the specific nature of these issues. The authors also thought it concerning that 42.8% respondents saw becoming deskilled as an issue. As a result they would like to explore this aspect further in the near future. Lastly although the ACNP is currently exploring the concept of the development of a core scope of practice for ENPs, this could also be facilitated by its introduction at a Master of Nurse Practitioner level. It is believed the development of a core scope of practice would enhance the ENP role.

Conclusion Emergency service delivery is changing in Australia; NPs remain on the fringe of this development with roles emerging in all domains of health. We are experiencing ultra specialisation, increased patients expectations, and evolution in nursing, medicine and allied health to combat increasing demands. The role of the ENP to date has been one of the most widely implemented and researched new roles throughout Australia and arguably the world. Despite this evidence there still remains some reservation about the impact on service delivery and training. Whilst numerous international studies examined patient

An exploration of the perceptions of Emergency Physicians and Trainee perceptions there were few which examined Emergency Physician’s and Trainees perceptions of the role locally. This evidence is considered by the authors to be invaluable in the understanding, future planning and implementation of ENP’s in Australian ED’s. Whilst this study has limitations, it clearly demonstrates positive perceptions and recognition of benefits when Emergency Physicians and Trainees have had experience working with ENP’s. Regardless of experience or understanding of the role, consistency was observed in Physician’s and Trainees statements defining the benefits, challenges, difficulties, scope of practice, educational preparation, and clinical responsibilities of the ENP role. This paper provides understanding about the impact and implications of the ENP role and we hope that this helps support inclusion of the NPs in the ED, as opposed to being aimed at medical replacement. ENPs aim to provide a complementary service, value adding to that currently provided within the ED.

Contributors Mark Jones: Survey design and implementation, Data Analysis, Manuscript preparation and review and Final approval and editing of the version to be published. Luke Christoffis: Survey design and implementation, Literature review, Manuscript preparation and review and Final approval and editing of the version to be published. Stuart Smith: Survey design and implementation, Ethics application and follow-through, Literature review, Manuscript preparation and review, Final approval and editing of the version to be published. Nicolette Hodyl: Substantial contributions to analysis and interpretation of data, Critically revising paper for important intellectual content and Final approval and editing of the version to be published.

Provenance and conflict of interest None declared. This paper was not commissioned.

Acknowledgment We acknowledge our Emergency Department Medical Director Dr Hendrika Meyer for her time, input and support towards this study. We would also like to acknowledge Dr David Caldicott who was a key motivator in the commencement of this study, its survey design and initial review.

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