Evaluating an emergency nurse practitioner educational program for its relevance to the role

Nurse Educator Evaluating an emergency nurse practitioner educational program for its relevance to the role Author: Frank L. Cole, PhD, RN, CEN, CS, FNP, and Elda Ramirez, MSN, RN, CEN, FNP, Houston, Texas Section Editor: Anne Phelan Bowen, MS, RN

The educational program In 1994, the emergency care faculty at the University of Texas Health Science Center at Houston, School of Nursing, developed and implemented the Emergency Nurse Practitioner (ENP) program in response to a demand from prospective employers and potential students. A review of the literature revealed minimal information about the role of nurse practitioners in emergency departments. With little prior information available, we developed this innovative program based on beliefs that faculty held about the role of the ENP. These beliefs were that graduates of the program must be able to: (1) assess, diagnose, and treat patients of all ages with conditions ranging from nonurgent through emergent, (2) order and interpret diagnostic tests, as well as perform diagnostic and therapeutic noninvasive and invasive procedures for these patients, and (3) determine the disposition of ED patients.1 Predicated on these beliefs, the faculty taught students through a series of courses how to assess patients’ complaints by obtaining a health history, including chief complaint, history of present illness, medical history, family history, and review of systems. Students were also instructed in physical examination skills, the diagnostic reasoning process used in emergency care, and treatment options for all age ranges including criteria for admission or discharge. Students also received instruction in invasive and noninvasive Frank L. Cole, Houston Chapter, is Associate Professor of Nursing, Division Head of Emergency Care, and Director of Emergency Nurse Practitioner Education, The University of Texas Health Science Center at Houston. Elda Ramirez, Houston Chapter, is Assistant Professor of Clinical Nursing, The University of Texas Health Science Center at Houston. Supported by the Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, Advanced Nurse Education grant No. 1-D23-NU-01193-01. J Emerg Nurs 1999;25:547-50. Copyright © 1999 by the Emergency Nurses Association. 0099-1767/99 $8.00 + 0 18/9/102863

diagnostic procedures including diagnostic peritoneal lavage, chest tube insertion, needle decompression of the chest, cricothyrotomy, suturing of simple lacerations and complex lacerations requiring wound revision and multiple layer closure, nerve blocks, 12-lead EKG interpretation, radiographic interpretation, laboratory serum and other bodily fluid test interpretation, microscopy of bodily fluids, splinting of extremity injuries, lumbar punctures, and cutdowns. Although the faculty believed they had created a comprehensive program that matched their beliefs, we still wondered if the knowledge and skills taught were those best serving graduates as they implemented roles as ENPs.

Because ENPs most frequently ordered radiographs and were responsible for the initial interpretation, we increased the amount of time student ENPs spend in this area by adding radiology rounds with a radiologist. Evaluating the relevance of the program We designed a project to examine whether the knowledge and skills taught were consistent with implementation of the ENP role in actual clinical practice. Detailed information was obtained from all 3 ENPs who graduated from the ENP program at the University of Texas Health Science Center at Houston in 1995. These ENPs had worked as registered nurses for 8 to 17 years and as ED nurses for 6 to 16 years before becoming an ENP. One of the ENPs worked in

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Table 1

Table 2

Categories of discharge diagnoses made by ENPs

Diagnostic tests ordered

Discharge diagnosis Injury Eyes, ears, nose, throat Lower respiratory tract Gastrointestinal Genitourinary Sensory/ neurologic Integumentary Musculoskeletal Endocrine Cardiovascular Psychiatric Other

Examples

Frequency

Head trauma, burns, fractures, lacerations Conjunctivitis, otitis, tonsillitis, sinusitis Pneumonia, asthma

147

Small bowel obstruction, constipation Pyelonephritis, urinary tract infection Cephalgia, cerebrovascular accident, meningitis Tinea, cellulitis, urticaria Arthritis, Baker’s cyst, costochondritis New onset diabetes mellitus Hypertension, palpitations Anxiety, substance abuse Cardiopulmonary arrest, hyperventilation syndrome, drug reaction, dehydration

57 24 22 19 18

Frequency

Radiographs Laboratory studies (eg, serum studies, cultures) Pulse oximetry Arterial blood gasses Computerized axial tomography Electrocardiograms Peak flow Ultrasound Venogram Intravenous pyelogram Holter monitor Ventilation perfusion scan

118 52 27 13 11 6 2 2 1 1 1 1

15 10 4 3 3 14

a rural emergency department consisting of 4 beds, one worked in a fast track consisting of 6 beds located within a main emergency department in a suburban area, and one worked in a freestanding, suburban 9-bed urgent care clinic owned by a health maintenance organization. All of the ENPs were employed in Texas. One had been working for 12 months as an ENP and two had been working for 13 months as ENPs before participating in this project. The ENP working in the rural emergency department was a sole practitioner without a physician present; the remaining 2 ENPs have physicians physically present in the emergency department or clinic. All 3 ENPs work 12-hour shifts ranging form 36 to 48 hours per week and reported having prescriptive authority. This program evaluation was approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center at Houston. For the same 2-week period, each ENP documented on a recording form developed for this project the date of care, age, gender, discharge diagnosis, diagnostic tests ordered, procedures performed, referrals made, and disposition for each patient. At the end of the 2-week period, each ENP mailed the data collection forms to us.

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Test

Results During the 2-week evaluation period, the ENP in the rural emergency department reported examining, diagnosing, and treating 63 patients. The ENP in the freestanding urgent care clinic provided care to 44 patients, and the ENP in the fast track setting provided care to 172 patients. A total of 279 patients were cared for by the ENPs. The discharge and diagnoses of these patients and the diagnostic tests ordered for them are shown in Tables 1 and 2, respectively. The procedures performed by the ENPs are listed in Table 3. Table 4 shows the referral status of the ENPs’ patients.

Because graduates are also involved in ordering and interpreting other radiologic studies, such as computerized axial tomography and ultrasounds, we added a lecture and practice session on this content. Implications for the program The results of this project were useful to us for validating the beliefs upon which the program was founded and for making decisions about changes. The first belief concerned the ability of graduates to assess, diagnose, and treat patients of all ages with conditions ranging from nonurgent through emergent. Although we did not ask the triage designation

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Table 3

Table 4

Procedures performed by ENPs

Referrals for follow-up care of patients seen by ENPs

Procedure

Frequency

Suture of simple and complex lacerations Application of splint Digital nerve block Venipuncture Reduce dislocation Wound debridement Removal of foreign body Lumbar puncture Slit lamp examination Occipital nerve block Application of sterile adhesive strips Anascope Advanced cardiac life support

31 14 5 4 3 3 2 2 2 2 2 1 1

of the patients that ENPs treated, we examined the discharge diagnoses as an approximation of the level of triage category. The results confirmed that graduates were providing care to persons from 1 month to 95 years of age with nonurgent to emergent conditions. Treatment of all of the conditions reported as discharge diagnoses were part of the educational program. Therefore, we are teaching management of patient conditions treated by the ENPs. Moreover, none of the ENPs reported referring a patient either to their supervising physician or to another physician because the patient’s condition was outside their scope of practice or because they were uncomfortable treating the patient’s condition. This information indicated to us that the education provided to ENPs prepared them to manage the conditions of patients for whom they provided care.

Because central line insertion and intraosseous infusion are more commonly practiced than a cutdown, these 2 skills were also added to the program. The second belief was related to graduates’ ability to interpret diagnostic tests, as well as to perform diagnostic and therapeutic noninvasive and invasive skills for these patients. To assess this belief, we compared the procedures and skills taught to ENPs with the procedures and diagnostic tests they actually performed.

To whom referral made Primary care provider Specialist Clinic No referral*

Frequency 131 75 71 2

*One patient discharged to morgue and one patient left against medical advice.

The vast majority of procedures and diagnostic tests reported by the ENPs were part of their instructional program. Because ENPs most frequently ordered radiographs and were responsible for the initial interpretation, we increased the amount of time student ENPs spend in this area by adding radiology rounds with a radiologist. For 3 semesters, students attend radiology rounds for 2 hours once a month with a radiologist who gives a brief patient history and physical examination findings and then displays the obtained radiographs. Student’s classroom knowledge is enhanced by practice with actual cases as they learn the subtleties of interpretation from an expert. Because graduates are also involved in ordering and interpreting other radiologic studies, such as computerized axial tomography and ultrasounds, we added a lecture and practice session on this content that is provided by the radiologist. Because the most frequently performed procedure was suture of simple and complex lacerations, we added a second practice session in this area. No ENP reported performing diagnostic peritoneal lavage. This procedure was originally taught with the belief that graduates who were employed in rural hospitals may be called upon to perform it. Recognizing that no ENPs performed the procedure and that if a positive tap was obtained by an ENP a surgeon would need to be available, which is less likely in a rural facility, faculty eliminated this procedure from the instructional program. Even though no ENPs reported performing chest tube insertion, needle decompression of the chest, cricothyrotomy, or venisection for the 2-week period of data collection, we continue to believe that instruction in these areas is important for emergency management and have chosen to continue to teach these skills. Moreover, because central line insertion and intraosseous infusion are more commonly practiced than a cutdown, these 2 skills were also added to the program. The third belief was that ENPs need to be able to determine the disposition of ED patients. As part of the educational program, we address the criteria for admission versus discharge of a patient with a particular condition along with the need for referral to the primary

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care physician or other health care provider for followup. All of the patients released from the emergency department were provided with a referral either to a primary care physician or other health care provider. While the intricacies of each case are unknown to us, the discharge diagnoses and referrals made correspond to the reported disposition of each patient. This finding allows us to infer that ENPs made correct decisions related to the disposition of patients.

Summary As nurse educators, we designed an educational program to teach nurses the knowledge and skills needed to function as ENPs. Because the role of the ENP was not well delineated in the published literature, little information was available to assist in the

O

development of this program. Once the program was developed, we chose to assess the actual practice of all 3 ENPs from our first graduating class to examine the congruency between what the program taught and what graduates were doing in practice. This assessment was valuable for highlighting the areas in which we were excelling and the areas in need of refinement.

Acknowledgment We thank Robert Leach, MSN, RN, ENP, Rita Dello-Stritto, MSN, RN, ENP, and Harriatt Downey-Pitts, MSN, RN, ENP, for their assistance with data collection.

Reference 1. Cole FL, Ramirez, E. The emergency nurse practitioner: an educational model. J Emerg Nurs 1997:23:112-5.

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