- Email: [email protected]
Highlighting the Invisible Work of Emergency Nurse Practitioners
ORIGINAL RESEARCH
Highlighting the Invisible Work of Emergency Nurse Practitioners Matthew Lutze, MN, NP, Margaret Fry, PhD, NP, Glenda Mullen, Grad Cert Paed Crit Care, NP, Jane O’Connell, PhD, NP, and Danielle Coates, MN, NP ABSTRACT
This study sought to quantify and qualify the hidden work practices of emergency nurse practitioners (ENPs). A prospective multicenter study design was employed using 12 ENPs across 4 hospital emergency departments (ED) in Sydney, Australia. Using a Delphi technique, an electronic medical record template was developed to capture the hidden activities of ENPs defined as secondary consultations. Approximately one-quarter of ENP consultations are spent providing expertise to other ED clinicians. ED re-presentation rates are lower when an ENP provides a secondary consultation. This study highlights the invisible and valuable work of ENP contribution to emergency care. Keywords: Delphi studies, emergency nursing, medical audits, medical informatics, nurse practitioners, referral and consultation Ó 2017 Elsevier Inc. All rights reserved.
INTRODUCTION
I
nternationally, emergency nurse practitioner (ENP) models of care have demonstrated safety, effectiveness, and quality-of-care outcomes.1-5 However, the Australian ENP contribution to the delivery and value of health services has yet to be determined.6 Previous Australian ENP studies have focused on defining clinical practice activities7,8 with some drawing direct comparisons with medical practitioners to determine efficiency and safety.8 Other studies have focussed on patient satisfaction.8 Many studies7,9 and systematic reviews5,10 have evaluated the role of the ENP as the responsible treating clinician (primary consultations) with respect to accuracy, timeliness of care, and patient outcomes. However, these studies have not captured the invisible clinical, procedural, or service support activities (secondary consultations) in addition to the ENPs primary consulting role. The value of facilitating care through ENP secondary consultations and clinical support is currently invisible and largely unknown.
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Recent research describing ENP practice was published detailing the role, function, and practice standards for Australian ENPs.7,11,12 Three clinical modes of practice were identified that reflected the nature of ENP functionality. An overarching dimension spaning these modes was the collaborative practice and consulting role of the ENP. Traditional tracking and reporting of ENP practice has focused on ENP primary patient consultation activities. Reporting has predominantly been driven by quality metrics such as key performance indicators specific to the emergency department (ED; Emergency Treatment Performance) and National Emergency Access Target.13 However, these quality metrics do not capture all elements of ENP practice, particularly the secondary consultations. Although secondary consulting and collaborative practices are not captured, there is an expectation that nurse practitioners (NPs) will practice in this manner as evidenced by the Nurse Practitioner Standards for Practice.14 Further, according to the Clinical Practice Standards, ENPs are also required to demonstrate collaborative and consultation
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practices.11 O’Connell11 describes ENPs as working within a collaborative environment, yet the manner in which ENPs act as an expert resource within the clinical setting remains unclear. Across Australia, secondary ENP consultations have never been captured or quantified, and therefore this domain of practice continues to remain invisible. Highlighting the invisible work of ENPs is important to fully demonstrate the value and contribution of the ENP role.6 Therefore, the primary aim of the study was to develop an electronic tool that could quantify and qualify the collaborative and secondary clinical consultation practice patterns of the ENP. In this way, the hidden work of ENPs could be made visible and measured. METHODS
This was a prospective multicenter study design. The study was conducted between July 1, 2016 and September 30, 2016. Site
The setting was 4 hospitals across metropolitan Sydney, New South Wales, Australia. The study sites comprised 3 tertiary referral EDs and 1 metropolitan district hospital. Of the 3 tertiary sites, 1 was a mixed adult and pediatric, 1 was adults only, and 1 was a pediatric centre. The metropolitan district ED was a mixed unit with both adult and pediatric patients. All sites shared a common electronic medical record (EMR) platform. Sample
The sample consisted of endorsed ENPs and transitional emergency NPs (TENPs; master’s students progressing toward NP endorsement), working in EDs in 2 local health districts. All sites employed at least 2 ENPs/TENPs. The sample group will be collectively referred to as ENPs. The ENPs are primarily based within a fast-track model of care, and their scope of practice typically focuses on managing patients with nonelife-threatening conditions or illnesses. Across Australia, emergency medical practitioners include interns, residents, registrars, and physicians. During the
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study, ENPs represented 2%e3% of the ED autonomous practitioner workforce. ENP Data Consultation Tool
An electronic ENP data consultation form was used as a tool to capture secondary consultations (direct and indirect patient contact). For this study, primary consultations were defined as a consultation conducted by the ENP whereby he or she was the treating practitioner for that patient. Secondary consultations were defined as work, support, or expertise given by the ENP where he or she was not the responsible treating practitioner. The electronic ENP consultation template was developed using a Delphi technique. The methods and results have been published elsewhere.15 The consultation categories and subelements were developed into a single screen, multifunction EMR template. The consultation template captured both direct (patient contact) and indirect (staff advice) ENP activity. The template was then developed to interface with the ED EMR platform (Cerner-FirstNet). Before commencement of the study, a 1-hour training session was provided to the 12 participants by the lead researcher. The session included definitions of consultation type (primary/secondary), definitions of the categories, elements, documentation requirements, coding for diagnostic groups, and timing of episodes. A 1-month lead-in period was implemented to enable induction of the template into daily practice. A survey of the participating ENPs was conducted to capture the utility and functionality of the electronic consultation medical record template. The survey comprised 8 questions, and the response rate was 100% (n ¼ 12). All ENPs reported ease of use in accessing (agreed n ¼ 2; 17%; strongly agreed n ¼ 10; 83%) and navigating (agreed n ¼ 3; 25%; strongly agreed n ¼ 9; 75%) the EMR consultation template. Half the ENPs (n ¼ 6; 50%) perceived that they spent less than 30 seconds on reporting their secondary consultations. The majority (n ¼ 11, 92%) of ENPs reported that the template captured their secondary consultation practices. The average time for an ENP to complete the EMR template was 38 seconds (SD 48.0 seconds).
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EMR Audit
A 3-month EMR audit was undertaken to capture ENP primary and secondary clinical activities. Across the study sites, ENPs independently manage patient presentations appropriate to their scope of practice. ED patient audit data was extracted from Cerner-FirstNet (an ED computer software program). Data retrieved included patient demographics, such as age and sex. Clinical information was also retrieved including time of arrival to the ED, triage code (Australasian Triage Scale), diagnostic code, length of stay, and disposition. “Left at Own Risk” and patient re-presentations within 48 hours of ED visit were also examined. Data Analysis
Statistical analyses of data were conducted using IBM SPSS v. 21. Descriptive statistics were calculated (frequencies, mean, and SD) to summarize data. Comparisons of groups by age, sex, triage category, referral, and length of stay were undertaken using Pearson c2 and Mann-Whitney U tests for categorical variables. Statistical significance was considered met at P ¼ 0.05 and 95% confidence intervals where appropriate. Ethics
Ethical approval for all sites were granted by the Local Health District (HREC ref no. 15/231 LNR/ POWH/610). Consent was obtained from all participants, and privacy and confidentially was maintained. RESULTS
For the 3-month study period, there were 54,970 ED presentations across 4 sites, of which 17,553 (32%) were admitted (Table 1). ENPs (n ¼ 12) were rostered for a total of 2,640 hours (1.6%) during the study period between the hours of 07:00 and 23:00. Each ENP worked an average of 220 hours over the 3-month period. The ENPs were involved in 2,628 (5%) episodes of patient care of which 2017 (77%) involved primary patient consultations. ENPs spent 96% (2,526.4 hours) of their time providing primary consultations. ENP primary consultations totalled 2,017 patients (July 711 [35%], August 736 [36%], September 570 28
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[28%]). Of the primary consultations, the main diagnostic groups were musculoskeletal (n ¼ 891; 44%) followed by wounds and burns (n ¼ 441; 22%). A slightly greater number were male (n ¼ 1138; 56%) with an average age of 35 years (SD 22.7) (Table 1). The majority of patients were allocated a triage category 4 (65%). The average length of stay for primary consultations was 2:40 (SD 0.1) with 85% of patients staying less than 4 hours. For those patients staying longer than 4 hours, 45% (n ¼ 133) were admitted and 53% (n ¼ 156) were discharged. Most primary consultation patients were discharged home (n ¼ 1758; 87%). Of those admitted (n ¼ 233; 12%), the majority were admitted to a nonecritical care ward (n ¼ 185; 9%). Of the 2,628 episodes of care, secondary consultations by the ENPs involved 611 (23%) cases of which the majority were male (n ¼ 316, 52%) with an average patient age of 40 years (SD 26) (Table 1). The majority of patients (n ¼ 350; 57%) were allocated triage category 4, and most secondary consultations were discharged from the ED (n ¼ 470, 77%). For the 611 cases, ENPs spent 114.0 hours (3.8%) on secondary consultations. The average secondary consultation time for ENPs was 11.1 minutes (SD 11.4 minutes). Most secondary consultations were initiated by a registered nurse (n ¼ 191; 31%) followed by emergency registrars (n ¼ 136; 22%), junior medical officers (interns and residents) (n ¼ 105; 17%), self-initiated (n ¼ 87; 14%), staff specialist (consultants) (n ¼ 44, 7%), allied health (n ¼ 19, 3%), other NPs (n ¼ 14; 2%), other (n ¼ 15; 2%). For the secondary consultation episodes, the majority (n ¼ 367; 60%) required direct clinical care by the ENP. Of the secondary consultation episodes, the majority (n¼424; 69%) involved patients with musculoskeletal (n¼238; 39%) and wounds and burn care (n¼186; 30%). On 172 (28%) occasions the ENP provided secondary consultations for a condition or issue that was not related to the principle diagnosis of the patient. During secondary consultations, ENPs requested 155 (21%) investigations, the majority of which (n ¼ 141; 91%) were radiology (n ¼ 83; 54%) Volume 14, Issue 1, January 2018
Table 1. Demographics and characteristics of ED presentations and ENP cases
Sex (male, female) Age (mean, SD)
ENP Secondary Consultation (n ¼ 611)
ENP Primary Consultation (n ¼ 2,017)
ED Presentations (n ¼ 54,970)
316 (52%, 48%)
1,138 (56%, 44%)
27,940 (51%, 49%)
40 (26)
35 (22)
38 (28)
Pediatrics (0e15 years)
150 (25%)
444 (22%)
15,958 (29%)
Geriatrics (> 65 years)
133 (22%)
249 (12%)
12,952 (24%)
Triage code 1
5 (1%)
1 (<1%)
512 (1%)
2
26 (4%)
16 (1%)
5,856 (11%)
3
151 (25%)
286 (14%)
22,514 (41%)
4
350 (57%)
1,301 (65%)
23,160 (42%)
5
79 (13%)
413 (20%)
2,854 (5%)
Fractures/sprains/strains
238 (39%)
891 (44%)
9,578 (17%)
Wounds/burns
186 (30%)
441 (22%)
3,202 (6%)
Medicala
58 (9%)
169 (8%)
22,650 (41%)
Surgicalb
29 (5%)
129 (6%)
5,614 (10%)
Infections and lesions
23 (4%)
99 (5%)
1,525 (3%)
Ear, nose, and throatc
20 (3%)
99 (5%)
2,317 (4%)
Obstetrics and gynecology
19 (3%)
57 (3%)
1,131 (2%)
Neurological
13 (2%)
50 (2%)
4,329 (6%)
Ophthalmology
12 (2%)
47 (2%)
802 (1%)
Toxicology
9 (1%)
14 (1%)
687 (1%)
Mental health
4 (1%)
14 (1%)
1,893 (3%)
Diagnoses
Missing data
0
0
1,099 (2%)
Disposition Admitted
141 (23%)
233 (12%)
17,553 (32%)
Discharged
470 (77%)
1,758 (88%)
37,417 (68%)
36 (1.0%)
86 (2.4%)
3,564 (6.5%)
Re-presentations a b c
Medical ¼ general medicine, cardiology, rheumatology, respiratory, dermatology, renal, endocrinology, immunology, oncology, hematology. Surgical ¼ general surgery, vascular, urology, trauma, cardiothoracics. Ear, nose, and throat includes dental and maxillofacial.
and pathology (n ¼ 58; 37%) investigations (see Supplementary Table, available online at http:// www.npjournal.org/). Medicines were prescribed by ENPs during secondary consultations (n ¼ 144, 24%). The ENPs primarily prescribed analgesia (n ¼ 55; 38%), local/regional anesthesia (n ¼ 21; 15%), or intravenous rehydration (n ¼ 17; 12%). When the ENP was consulted for procedural support www.npjournal.org
(n ¼ 303, 50%) the predominant activities were for wound care (n ¼ 141; 47%) or for plaster/splints/ crutches-related activity (n ¼ 113; 37%). ENPs were also recruited to assist with deteriorating patients by the ED team (n ¼ 27; 4%). The majority of these cases were for complex care (n ¼ 11; 41%). There were 6 (22%) occasions when the ENP was required to assist with patient resuscitation. The Journal for Nurse Practitioners - JNP
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Of the secondary consultations, the ENP collaborated on 106 (17%) occasions with medical practitioners to guide patient follow-up. Most of these consultations were supporting referrals to inpatient teams or a medical specialist (n ¼ 39; 37%). The ED re-presentation rate (within 48 hours) was 6.5% (n ¼ 3564). ENP primary and secondary consultation re-presentation rates were 2.4% (n ¼ 86), and 1.0% (n ¼ 36), respectively. When comparing the primary and secondary consultation groups there were statistical differences in baseline characteristics. The statistical differences were for gender (c2 29.8, P ¼ .001), age (U 584,625, P < .001), age > 65 years (c2 1,322.2 P ¼ .001) triage category (U 501,151, P < .001), diagnosis (U 559,760, P < .001), and length of stay (U 406,239 P ¼ .001). DISCUSSION
This is the first time a study has attempted to identify the invisible workload of ENPs. Previous literature has detailed the primary consultation dimension of ENP practice but not their secondary practices used to support, mentor, and collaborate within their service. This study has demonstrated that approximately one-quarter of ENP patient encounters are secondary consultations. Secondary consultations involved highly complex and urgent patient conditions, which were managed throughout all areas of the ED. The majority of ENP re-presentation rates were lower compared with the total ED patient group. Internationally, secondary consultations have been invisible in the ENP literature. This study demonstrates that ENPs support emergency services and the clinical team in the provision of care beyond individual patient primary consultations. Specifically, ENPs provide expertise and clinical support to a range of clinicians based within the ED. Future ENP scopes of practice and performance metrics need to reflect the invisible workload of secondary consultations. International literature5,16,17 details that NPs are most often used in emergency fast-track models of care. However, this study reflects ENPs are practicing more broadly across a range of diagnostic groups not limited to fast track. Indeed, many ENPs on occasion 30
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were providing management and support for complex, high-acuity patients including those requiring resuscitation. This is not unexpected as most ENPs are often the most senior or experienced clinical nurses in the ED. Recent evidence suggests ENPs are managing patients beyond minor injury and illness models of care.18 ENPs need to ensure individual competence, capability, scope of practice, and skill set meet the demands of emergency services in both acute and nonacute patient groups. Secondary consultations have not been well defined in the emergency literature. Traditionally, expertise on clinical management of conditions falling outside the scope of emergency medicine are directed toward specialty teams.19 Reliance on specialist team input has been associated with increased ED length of stay.19 Awaiting speciality team input typically contributes to 50% of the patients’ ED length of stay.19 This study reflects that the ENP is most commonly consulted for expertise in the management of orthopedic and plastic surgery conditions. ENP secondary consultations were brief and typically involved interpretation of radiographs, management of wounds, and advice on orthopedic and plastic surgical conditions. A recent study noted that the majority of ED wounds are expertly managed by ENPs.20 However, the reasons other health professionals sought ENP expertise were not explored in this study and warrant further investigation. This study highlighted that health professionals approached ENPs for advice on a range of patient conditions and injuries. This suggests that across a range of health professionals, the expertise of the ENP is acknowledged. The study also highlights that clinicians seek support, mentoring and guidance from ENPs similar to the traditional role of the emergency physician. International literature21-24 reveals that where NP models of care have been successfully integrated, NPs have been shown to act as clinical leaders and team members who inspire, support, and coordinate evidence-based practice. Further, NP roles clearly need to be designed to support both nurses and junior physicians.21 However, there is inherent risk for ENPs in managing task switching and balancing interruptions to workflow. A recent study by Benda et al25 explored task switching by emergency physicians and Volume 14, Issue 1, January 2018
identified an increase in patient harm. The authors recommended that EMR templates need to be designed to better capture all elements of clinical work. The electronic template designed for this study goes some way to addressing this issue and balanced information acquisition with flexibility for local adaptation.26 Introducing new electronic templates needs to be well considered against the impact on clinicians’ workload. For this study, the template was developed with workload in mind. Consequently, the new template needed to have a low workload burden. ENPs designed and then reported that the template was quick to complete, reliable, readily accessible, and easy to use. The study demonstrated ENPs could capture task switching and invisible clinical work information while minimizing impact on workflow. Further, testing of the template is needed to explore adaptability to other health practitioners and specialties. This study highlights that there may be an opportunity to examine the activities of NPs against activity-based funding (ABF) models. In ABF models, NPs are classed in the same series (20 series group) as medical practitioners when providing medical consultations.27 This may help address some of the cost-effectiveness issues limiting implementation of Australian NP models of care and calls for greater demonstration of ENP value.6 ENP secondary consultations could play a key role in meeting emergency performance indicators. In this study, the ENPs supported key performance indicators whereby re-presentation rates were lower. Further, ENP re-presentation rates were lower compared with the total ED patient group, particularly when ENPs provided secondary consultations. These findings potentially have both financial and patient benefits that warrant further investigation. This study has highlighted the invisible but valuable work of ENPs in providing secondary consultations within the ED. Secondary consultations support emergency services by providing other health care professionals with expert advice and care. The hidden work can contribute to the safe and efficient management of emergency patients. Nursing theorists and workforce experts have described the challenges in capturing and describing the hidden www.npjournal.org
work of nurses.28 Nurses regularly undertake hidden work to facilitate safe and effective patient management.28 However, it is often electronic platforms and programs that limit the nursing profession’s ability to articulate, capture, and value the hidden work of nurses. Our study has attempted to capture and provide evidence of the nature and character of the hidden work of ENPs. Limitations
The study has a number of limitations that need to be considered. Sample bias may be present because participants self-reported secondary consultation episodes. The ENP workload may have been underreported during the month of September because the national NP conference was held and no ENPs were replaced. The estimation of time for each consultation was dependent on the ENP accurately monitoring time, and ED workload may have influenced the accuracy of data entry. To obtain the ED data, 8 different reports were required to be generated despite all sites sharing the same EMR platform. This meant that primary and secondary group comparisons were limited, with no comparisons being conducted for disposition and re-presentation rates. Further analysis of the re-presentation rates may be warranted because we were unable to differentiate unplanned from planned representations. These rates may be lower than our findings suggest, and further study should be considered. CONCLUSIONS
This study has identified some of the expert invisible workload delivered by ENPs. A significant proportion of ENP workload involved secondary consultations that provided episodic clinical care to a range of ED patients. These secondary consultations involved the ENP providing expertise to support the management of highly complex and urgent patient conditions throughout ED. The EMR consultation template developed for this study has the potential to be adapted for other nurse practitioner specialties. This study provides evidence of the additional workload and valuable contribution that ENPs bring to the clinical setting, which until now has been largely hidden. Future research is needed to further The Journal for Nurse Practitioners - JNP
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explore the invisible workload of NPs. Only in this way can we detail the hidden contribution and valuable difference that these roles can make to service provision, quality care, collaborative practice, and clinician mentorship.
19.
20.
21.
SUPPLEMENTARY DATA
The supplementary table associated with this article can be found in the online version at http://www. npjournal.org/.
22.
23.
24. References 1. Evans DD, Ashooh MP, Kimble LP, Heilpern KL. An exemplar interprofessional academic emergency nurse practitioner program: a blueprint for success. Adv Emerg Nurs J. 2017;39(1):59-67. 2. Aplin N. Advanced nurse practitionereled abdominal therapeutic paracentesis. Emerg Nurse. 2017;24(10):34-37. 3. Van Der Biezen M, Adang E, Van Der Burgt R, Wensing M, Laurant M. The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasiexperimental study. BMC Fam Pract. 2016;17(1):132. 4. Lacny S, Zarrabi M, Martin-Misener R, Donald F, Sketris I, Murphy AL, et al. Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study. J Adv Nurs. 2016;72(9):2138-2152. 5. Jennings N, Clifford S, Fox AR, O’Connell J, Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. Int J Nurs Stud. 2015;52(1):421-435. 6. Jennings N, Lutze M, Clifford S, Maw M. How do we capture the emergency nurse practitioners’ contribution to value in health service delivery? Aust Health Rev. 2016;41(1):89-90. 7. O’Connell J, Gardner G, Coyer F. Profiling emergency nurse practitioner service: an interpretive study. Adv Emerg Nurs J. 2014;36(3):279-290. 8. Victoria State Government, Department of Health and Human Services. Best care for older people everywhere: the toolkit 2012. Melbourne, Australia: Finsbury Green; 2012. 9. Masso M, Thompson C. Rapid Review of the Nurse Practitioner Literature: Nurse Practitioners in NSW “Gaining Momentum”. North Sydney, Australia: NSW Government; 2014. 10. Kilpatrick K, Reid K, Carter N, Donald F, Bryant-Lukosius D, Marti-Misener R, et al. A systematic review of the cost-effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Nurs Leadersh (Tor Ont). 2015;28(3):56-76. 11. O’Connell J. The Emergency Nurse Practitioner Clinical Practice Standards. Brisbane, Australia: Queensland University of Technology. http://www.azille .com.au/standards.pdf, 2015. Accessed February 1, 2017. 12. O’Connell J, Gardner G. Development of clinical competencies for emergency nurse practitioners: a pilot study. Australas Emerg Nurs J. 2012;15(4):195-201. 13. Sullivan C, Staib A, Khanna S, Good NM, Boyle J, Cattell R, et al. The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target. Med J Aust. 2016;204:354. 14. Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice. Melbourne, Australia: Australian Health Practitioner Regulation Agency; 2014. http://www.nursingmidwiferyboard.gov.au. Accessed February 1, 2017. 15. Lutze M, Mullen G, Coates D, O’Connell J, Fry M. Using a Delphi technique to develop a data collection tool to capture nurse practitioner workload. 2016. www.dcconferences.com.au/acnp2016/pdf/ACNP_Abstracts/Lutze_M3.pdf. Accessed February 1, 2017. 16. Fry M, Fong J, Asha S, Arendts G. A 12-month evaluation of the impact of transitional emergency nurse practitioners in one metropolitan emergency department. Australas Emerg Nurs J. 2011;14(1):4-8. 17. Lutze M, Ross M, Chu M, Green T, Dinh M. Patient perceptions of emergency department fast track: a prospective pilot study comparing two models of care. Australas Emerg Nurs J. 2014;17(3):112-118. 18. Roche TE, Gardner G, Lewis PA. Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain: protocol for a multicentre, longitudinal nested cohort study. BMJ Open.
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2015;5. http://bmjopen.bmj.com/content/5/2/e006997. Accessed February 1, 2017. Brick C, Lowes J, Lovstrom L, Kokotilo A, Villa-Roel C, Lee P, et al. The impact of consultation on length of stay in tertiary care emergency departments. Emerg Med J. 2014;31(2):134-138. Cross R, Jennings N, McGuiness W, Miller C. Profiling wound management in the emergency department: a descriptive analysis. Australas Emerg Nurs J. 2016;19(3):166-171. Andregård AC, Jangland E. The tortuous journey of introducing the nurse practitioner as a new member of the healthcare team: a meta-synthesis. Scand J Caring Sci. 2015;29(1):3-14. Hurlock-Chorostecki C, Forchuk C, Orchard C, Reeves S, van Soeren M. The value of the hospital-based nurse practitioner role: development of a team perspective framework. J Interprof Care. 2013;27(6):501-508. Hurlock-Chorostecki C, Forchuk C, Orchard C, Soeren M, Reeves S. Hospitalbased nurse practitioner roles and interprofessional practice: a scoping review. Nurs Health Sci. 2014;16:403-410. Williamson S, Twelvetree T, Thompson J, Beaver K. An ethnographic study exploring the role of ward-based advanced nurse practitioners in an acute medical setting. J Adv Nurs. 2012;68(3):1579-1588. Benda NC, Meadors ML, Hettinger AZ, Ratwani RM. Emergency physician task switching increases with the introduction of a commercial electronic health record. Ann Emerg Med. 2016;67(6):741-746. Bjørn P, Burgoyne S, Crompton V, MacDonald T, Pickering B, Munro S. Boundary factors and contextual contingencies: configuring electronic templates for healthcare professionals. European Journal of Information Systems. 2009;18:428-441. Collins N, Miller R, Kapu A, Martin R, Morton M, Forrester M, et al. Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. J Trauma Acute Care Surg. 2014;76(2):353-357. McWilliam CL, Wong CA. Keeping it secret: the costs and benefits of nursing’s hidden work in discharging patients. J Adv Nurs. 1994;19(1): 152-163.
Matthew Lutze, MN, NP, Nurse Practitioner at St George Hospital, Emergency Department, Kogarah, New South Wales, Australia. He may be reached at [email protected]. gov.au. Margaret Fry, PhD, NP, Professor of Nursing at University of Technology Sydney & Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia. Glenda Mullen, Grad Cert Paed Crit Care, NP, Nurse Practitioner at Sydney Children’s Hospital, Emergency Department, Randwick, Australia. Jane O’Connell, PhD, NP, Senior Lecturer at University of Technology Sydney, New South Wales, Australia. Danielle Coates, MN, NP, Nurse Practitioner at Sydney Children’s Hospital Emergency Department, Randwick, New South Wales, Australia. Funding: Matthew Lutze was the recipient of a Research Scholarship awarded by the Australian College of Nurse Practitioners in 2015. The Australian College of Nurse Practitioners had no role in the conduct of the research or the preparation of the manuscript. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.09.023
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Supplementary Table. Characteristics of Secondary ENP Consultations (n [ 611) Consultation Element
Supplementary Table. (continued ) Consultation Element
N (%)
Investigations (n ¼ 155) Radiology
83 (54)
Pathology
58 (37)
N (%)
Adjust management/plan
24 (23)
Phone follow-up
10 (9)
Escalate/outside scope
4 (4)
a
POCUS Point of Care Ultrasound Antiemetic (4), Potassium (1), Insulin (1), Isoprenaline (1), antifungal (1), antihistamine (2), aspirin (1), glyceryl trinitrate (1), antiviral (1) c For example, indwelling catheter, nasogastric tube, pigtail drain insertion. b
ECG
6 (4)
POCUSa
4 (3)
Other
4 (3)
Prescribing (n ¼ 144) Opioid analgesia
30 (21)
Simple analgesia
25 (17)
Local/regional anesthesia
21 (15)
IV therapy
17 (12)
b
Other
16 (11)
Antibiotics
15 (10)
Topical prescription
9 (6)
Sedation (NO2)
6 (4)
Immunisations
4 (3)
Oral rehydration
1 (1)
Procedural support (n ¼ 303) Wound care
141 (47)
Plaster/splint/crutches
113 (37)
Fracture/joint reduction
17 (6)
Vascular access
10 (3)
Foreign body removal
6 (2)
Topical prescription
5 (2) c
Device management
5 (2)
Arthrocentesis
3 (1)
Sedation/blocks
3 (1)
Team care (n ¼ 27) Complex care
11 (41)
Deteriorating patient
6 (22)
Resuscitation
6 (22)
Triage
4 (15)
Follow-up (n ¼ 106) Refer to specialty team
39 (37)
Review results
29 (27) continued
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Highlighting the Invisible Work of Emergency Nurse Practitioners Matthew Lutze, MN, NP, Margaret Fry, PhD, NP, Glenda Mullen, Grad Cert Paed Crit Care, NP, Jane O’Connell, PhD, NP, and Danielle Coates, MN, NP ABSTRACT
This study sought to quantify and qualify the hidden work practices of emergency nurse practitioners (ENPs). A prospective multicenter study design was employed using 12 ENPs across 4 hospital emergency departments (ED) in Sydney, Australia. Using a Delphi technique, an electronic medical record template was developed to capture the hidden activities of ENPs defined as secondary consultations. Approximately one-quarter of ENP consultations are spent providing expertise to other ED clinicians. ED re-presentation rates are lower when an ENP provides a secondary consultation. This study highlights the invisible and valuable work of ENP contribution to emergency care. Keywords: Delphi studies, emergency nursing, medical audits, medical informatics, nurse practitioners, referral and consultation Ó 2017 Elsevier Inc. All rights reserved.
INTRODUCTION
I
nternationally, emergency nurse practitioner (ENP) models of care have demonstrated safety, effectiveness, and quality-of-care outcomes.1-5 However, the Australian ENP contribution to the delivery and value of health services has yet to be determined.6 Previous Australian ENP studies have focused on defining clinical practice activities7,8 with some drawing direct comparisons with medical practitioners to determine efficiency and safety.8 Other studies have focussed on patient satisfaction.8 Many studies7,9 and systematic reviews5,10 have evaluated the role of the ENP as the responsible treating clinician (primary consultations) with respect to accuracy, timeliness of care, and patient outcomes. However, these studies have not captured the invisible clinical, procedural, or service support activities (secondary consultations) in addition to the ENPs primary consulting role. The value of facilitating care through ENP secondary consultations and clinical support is currently invisible and largely unknown.
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Recent research describing ENP practice was published detailing the role, function, and practice standards for Australian ENPs.7,11,12 Three clinical modes of practice were identified that reflected the nature of ENP functionality. An overarching dimension spaning these modes was the collaborative practice and consulting role of the ENP. Traditional tracking and reporting of ENP practice has focused on ENP primary patient consultation activities. Reporting has predominantly been driven by quality metrics such as key performance indicators specific to the emergency department (ED; Emergency Treatment Performance) and National Emergency Access Target.13 However, these quality metrics do not capture all elements of ENP practice, particularly the secondary consultations. Although secondary consulting and collaborative practices are not captured, there is an expectation that nurse practitioners (NPs) will practice in this manner as evidenced by the Nurse Practitioner Standards for Practice.14 Further, according to the Clinical Practice Standards, ENPs are also required to demonstrate collaborative and consultation
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practices.11 O’Connell11 describes ENPs as working within a collaborative environment, yet the manner in which ENPs act as an expert resource within the clinical setting remains unclear. Across Australia, secondary ENP consultations have never been captured or quantified, and therefore this domain of practice continues to remain invisible. Highlighting the invisible work of ENPs is important to fully demonstrate the value and contribution of the ENP role.6 Therefore, the primary aim of the study was to develop an electronic tool that could quantify and qualify the collaborative and secondary clinical consultation practice patterns of the ENP. In this way, the hidden work of ENPs could be made visible and measured. METHODS
This was a prospective multicenter study design. The study was conducted between July 1, 2016 and September 30, 2016. Site
The setting was 4 hospitals across metropolitan Sydney, New South Wales, Australia. The study sites comprised 3 tertiary referral EDs and 1 metropolitan district hospital. Of the 3 tertiary sites, 1 was a mixed adult and pediatric, 1 was adults only, and 1 was a pediatric centre. The metropolitan district ED was a mixed unit with both adult and pediatric patients. All sites shared a common electronic medical record (EMR) platform. Sample
The sample consisted of endorsed ENPs and transitional emergency NPs (TENPs; master’s students progressing toward NP endorsement), working in EDs in 2 local health districts. All sites employed at least 2 ENPs/TENPs. The sample group will be collectively referred to as ENPs. The ENPs are primarily based within a fast-track model of care, and their scope of practice typically focuses on managing patients with nonelife-threatening conditions or illnesses. Across Australia, emergency medical practitioners include interns, residents, registrars, and physicians. During the
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study, ENPs represented 2%e3% of the ED autonomous practitioner workforce. ENP Data Consultation Tool
An electronic ENP data consultation form was used as a tool to capture secondary consultations (direct and indirect patient contact). For this study, primary consultations were defined as a consultation conducted by the ENP whereby he or she was the treating practitioner for that patient. Secondary consultations were defined as work, support, or expertise given by the ENP where he or she was not the responsible treating practitioner. The electronic ENP consultation template was developed using a Delphi technique. The methods and results have been published elsewhere.15 The consultation categories and subelements were developed into a single screen, multifunction EMR template. The consultation template captured both direct (patient contact) and indirect (staff advice) ENP activity. The template was then developed to interface with the ED EMR platform (Cerner-FirstNet). Before commencement of the study, a 1-hour training session was provided to the 12 participants by the lead researcher. The session included definitions of consultation type (primary/secondary), definitions of the categories, elements, documentation requirements, coding for diagnostic groups, and timing of episodes. A 1-month lead-in period was implemented to enable induction of the template into daily practice. A survey of the participating ENPs was conducted to capture the utility and functionality of the electronic consultation medical record template. The survey comprised 8 questions, and the response rate was 100% (n ¼ 12). All ENPs reported ease of use in accessing (agreed n ¼ 2; 17%; strongly agreed n ¼ 10; 83%) and navigating (agreed n ¼ 3; 25%; strongly agreed n ¼ 9; 75%) the EMR consultation template. Half the ENPs (n ¼ 6; 50%) perceived that they spent less than 30 seconds on reporting their secondary consultations. The majority (n ¼ 11, 92%) of ENPs reported that the template captured their secondary consultation practices. The average time for an ENP to complete the EMR template was 38 seconds (SD 48.0 seconds).
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EMR Audit
A 3-month EMR audit was undertaken to capture ENP primary and secondary clinical activities. Across the study sites, ENPs independently manage patient presentations appropriate to their scope of practice. ED patient audit data was extracted from Cerner-FirstNet (an ED computer software program). Data retrieved included patient demographics, such as age and sex. Clinical information was also retrieved including time of arrival to the ED, triage code (Australasian Triage Scale), diagnostic code, length of stay, and disposition. “Left at Own Risk” and patient re-presentations within 48 hours of ED visit were also examined. Data Analysis
Statistical analyses of data were conducted using IBM SPSS v. 21. Descriptive statistics were calculated (frequencies, mean, and SD) to summarize data. Comparisons of groups by age, sex, triage category, referral, and length of stay were undertaken using Pearson c2 and Mann-Whitney U tests for categorical variables. Statistical significance was considered met at P ¼ 0.05 and 95% confidence intervals where appropriate. Ethics
Ethical approval for all sites were granted by the Local Health District (HREC ref no. 15/231 LNR/ POWH/610). Consent was obtained from all participants, and privacy and confidentially was maintained. RESULTS
For the 3-month study period, there were 54,970 ED presentations across 4 sites, of which 17,553 (32%) were admitted (Table 1). ENPs (n ¼ 12) were rostered for a total of 2,640 hours (1.6%) during the study period between the hours of 07:00 and 23:00. Each ENP worked an average of 220 hours over the 3-month period. The ENPs were involved in 2,628 (5%) episodes of patient care of which 2017 (77%) involved primary patient consultations. ENPs spent 96% (2,526.4 hours) of their time providing primary consultations. ENP primary consultations totalled 2,017 patients (July 711 [35%], August 736 [36%], September 570 28
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[28%]). Of the primary consultations, the main diagnostic groups were musculoskeletal (n ¼ 891; 44%) followed by wounds and burns (n ¼ 441; 22%). A slightly greater number were male (n ¼ 1138; 56%) with an average age of 35 years (SD 22.7) (Table 1). The majority of patients were allocated a triage category 4 (65%). The average length of stay for primary consultations was 2:40 (SD 0.1) with 85% of patients staying less than 4 hours. For those patients staying longer than 4 hours, 45% (n ¼ 133) were admitted and 53% (n ¼ 156) were discharged. Most primary consultation patients were discharged home (n ¼ 1758; 87%). Of those admitted (n ¼ 233; 12%), the majority were admitted to a nonecritical care ward (n ¼ 185; 9%). Of the 2,628 episodes of care, secondary consultations by the ENPs involved 611 (23%) cases of which the majority were male (n ¼ 316, 52%) with an average patient age of 40 years (SD 26) (Table 1). The majority of patients (n ¼ 350; 57%) were allocated triage category 4, and most secondary consultations were discharged from the ED (n ¼ 470, 77%). For the 611 cases, ENPs spent 114.0 hours (3.8%) on secondary consultations. The average secondary consultation time for ENPs was 11.1 minutes (SD 11.4 minutes). Most secondary consultations were initiated by a registered nurse (n ¼ 191; 31%) followed by emergency registrars (n ¼ 136; 22%), junior medical officers (interns and residents) (n ¼ 105; 17%), self-initiated (n ¼ 87; 14%), staff specialist (consultants) (n ¼ 44, 7%), allied health (n ¼ 19, 3%), other NPs (n ¼ 14; 2%), other (n ¼ 15; 2%). For the secondary consultation episodes, the majority (n ¼ 367; 60%) required direct clinical care by the ENP. Of the secondary consultation episodes, the majority (n¼424; 69%) involved patients with musculoskeletal (n¼238; 39%) and wounds and burn care (n¼186; 30%). On 172 (28%) occasions the ENP provided secondary consultations for a condition or issue that was not related to the principle diagnosis of the patient. During secondary consultations, ENPs requested 155 (21%) investigations, the majority of which (n ¼ 141; 91%) were radiology (n ¼ 83; 54%) Volume 14, Issue 1, January 2018
Table 1. Demographics and characteristics of ED presentations and ENP cases
Sex (male, female) Age (mean, SD)
ENP Secondary Consultation (n ¼ 611)
ENP Primary Consultation (n ¼ 2,017)
ED Presentations (n ¼ 54,970)
316 (52%, 48%)
1,138 (56%, 44%)
27,940 (51%, 49%)
40 (26)
35 (22)
38 (28)
Pediatrics (0e15 years)
150 (25%)
444 (22%)
15,958 (29%)
Geriatrics (> 65 years)
133 (22%)
249 (12%)
12,952 (24%)
Triage code 1
5 (1%)
1 (<1%)
512 (1%)
2
26 (4%)
16 (1%)
5,856 (11%)
3
151 (25%)
286 (14%)
22,514 (41%)
4
350 (57%)
1,301 (65%)
23,160 (42%)
5
79 (13%)
413 (20%)
2,854 (5%)
Fractures/sprains/strains
238 (39%)
891 (44%)
9,578 (17%)
Wounds/burns
186 (30%)
441 (22%)
3,202 (6%)
Medicala
58 (9%)
169 (8%)
22,650 (41%)
Surgicalb
29 (5%)
129 (6%)
5,614 (10%)
Infections and lesions
23 (4%)
99 (5%)
1,525 (3%)
Ear, nose, and throatc
20 (3%)
99 (5%)
2,317 (4%)
Obstetrics and gynecology
19 (3%)
57 (3%)
1,131 (2%)
Neurological
13 (2%)
50 (2%)
4,329 (6%)
Ophthalmology
12 (2%)
47 (2%)
802 (1%)
Toxicology
9 (1%)
14 (1%)
687 (1%)
Mental health
4 (1%)
14 (1%)
1,893 (3%)
Diagnoses
Missing data
0
0
1,099 (2%)
Disposition Admitted
141 (23%)
233 (12%)
17,553 (32%)
Discharged
470 (77%)
1,758 (88%)
37,417 (68%)
36 (1.0%)
86 (2.4%)
3,564 (6.5%)
Re-presentations a b c
Medical ¼ general medicine, cardiology, rheumatology, respiratory, dermatology, renal, endocrinology, immunology, oncology, hematology. Surgical ¼ general surgery, vascular, urology, trauma, cardiothoracics. Ear, nose, and throat includes dental and maxillofacial.
and pathology (n ¼ 58; 37%) investigations (see Supplementary Table, available online at http:// www.npjournal.org/). Medicines were prescribed by ENPs during secondary consultations (n ¼ 144, 24%). The ENPs primarily prescribed analgesia (n ¼ 55; 38%), local/regional anesthesia (n ¼ 21; 15%), or intravenous rehydration (n ¼ 17; 12%). When the ENP was consulted for procedural support www.npjournal.org
(n ¼ 303, 50%) the predominant activities were for wound care (n ¼ 141; 47%) or for plaster/splints/ crutches-related activity (n ¼ 113; 37%). ENPs were also recruited to assist with deteriorating patients by the ED team (n ¼ 27; 4%). The majority of these cases were for complex care (n ¼ 11; 41%). There were 6 (22%) occasions when the ENP was required to assist with patient resuscitation. The Journal for Nurse Practitioners - JNP
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Of the secondary consultations, the ENP collaborated on 106 (17%) occasions with medical practitioners to guide patient follow-up. Most of these consultations were supporting referrals to inpatient teams or a medical specialist (n ¼ 39; 37%). The ED re-presentation rate (within 48 hours) was 6.5% (n ¼ 3564). ENP primary and secondary consultation re-presentation rates were 2.4% (n ¼ 86), and 1.0% (n ¼ 36), respectively. When comparing the primary and secondary consultation groups there were statistical differences in baseline characteristics. The statistical differences were for gender (c2 29.8, P ¼ .001), age (U 584,625, P < .001), age > 65 years (c2 1,322.2 P ¼ .001) triage category (U 501,151, P < .001), diagnosis (U 559,760, P < .001), and length of stay (U 406,239 P ¼ .001). DISCUSSION
This is the first time a study has attempted to identify the invisible workload of ENPs. Previous literature has detailed the primary consultation dimension of ENP practice but not their secondary practices used to support, mentor, and collaborate within their service. This study has demonstrated that approximately one-quarter of ENP patient encounters are secondary consultations. Secondary consultations involved highly complex and urgent patient conditions, which were managed throughout all areas of the ED. The majority of ENP re-presentation rates were lower compared with the total ED patient group. Internationally, secondary consultations have been invisible in the ENP literature. This study demonstrates that ENPs support emergency services and the clinical team in the provision of care beyond individual patient primary consultations. Specifically, ENPs provide expertise and clinical support to a range of clinicians based within the ED. Future ENP scopes of practice and performance metrics need to reflect the invisible workload of secondary consultations. International literature5,16,17 details that NPs are most often used in emergency fast-track models of care. However, this study reflects ENPs are practicing more broadly across a range of diagnostic groups not limited to fast track. Indeed, many ENPs on occasion 30
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were providing management and support for complex, high-acuity patients including those requiring resuscitation. This is not unexpected as most ENPs are often the most senior or experienced clinical nurses in the ED. Recent evidence suggests ENPs are managing patients beyond minor injury and illness models of care.18 ENPs need to ensure individual competence, capability, scope of practice, and skill set meet the demands of emergency services in both acute and nonacute patient groups. Secondary consultations have not been well defined in the emergency literature. Traditionally, expertise on clinical management of conditions falling outside the scope of emergency medicine are directed toward specialty teams.19 Reliance on specialist team input has been associated with increased ED length of stay.19 Awaiting speciality team input typically contributes to 50% of the patients’ ED length of stay.19 This study reflects that the ENP is most commonly consulted for expertise in the management of orthopedic and plastic surgery conditions. ENP secondary consultations were brief and typically involved interpretation of radiographs, management of wounds, and advice on orthopedic and plastic surgical conditions. A recent study noted that the majority of ED wounds are expertly managed by ENPs.20 However, the reasons other health professionals sought ENP expertise were not explored in this study and warrant further investigation. This study highlighted that health professionals approached ENPs for advice on a range of patient conditions and injuries. This suggests that across a range of health professionals, the expertise of the ENP is acknowledged. The study also highlights that clinicians seek support, mentoring and guidance from ENPs similar to the traditional role of the emergency physician. International literature21-24 reveals that where NP models of care have been successfully integrated, NPs have been shown to act as clinical leaders and team members who inspire, support, and coordinate evidence-based practice. Further, NP roles clearly need to be designed to support both nurses and junior physicians.21 However, there is inherent risk for ENPs in managing task switching and balancing interruptions to workflow. A recent study by Benda et al25 explored task switching by emergency physicians and Volume 14, Issue 1, January 2018
identified an increase in patient harm. The authors recommended that EMR templates need to be designed to better capture all elements of clinical work. The electronic template designed for this study goes some way to addressing this issue and balanced information acquisition with flexibility for local adaptation.26 Introducing new electronic templates needs to be well considered against the impact on clinicians’ workload. For this study, the template was developed with workload in mind. Consequently, the new template needed to have a low workload burden. ENPs designed and then reported that the template was quick to complete, reliable, readily accessible, and easy to use. The study demonstrated ENPs could capture task switching and invisible clinical work information while minimizing impact on workflow. Further, testing of the template is needed to explore adaptability to other health practitioners and specialties. This study highlights that there may be an opportunity to examine the activities of NPs against activity-based funding (ABF) models. In ABF models, NPs are classed in the same series (20 series group) as medical practitioners when providing medical consultations.27 This may help address some of the cost-effectiveness issues limiting implementation of Australian NP models of care and calls for greater demonstration of ENP value.6 ENP secondary consultations could play a key role in meeting emergency performance indicators. In this study, the ENPs supported key performance indicators whereby re-presentation rates were lower. Further, ENP re-presentation rates were lower compared with the total ED patient group, particularly when ENPs provided secondary consultations. These findings potentially have both financial and patient benefits that warrant further investigation. This study has highlighted the invisible but valuable work of ENPs in providing secondary consultations within the ED. Secondary consultations support emergency services by providing other health care professionals with expert advice and care. The hidden work can contribute to the safe and efficient management of emergency patients. Nursing theorists and workforce experts have described the challenges in capturing and describing the hidden www.npjournal.org
work of nurses.28 Nurses regularly undertake hidden work to facilitate safe and effective patient management.28 However, it is often electronic platforms and programs that limit the nursing profession’s ability to articulate, capture, and value the hidden work of nurses. Our study has attempted to capture and provide evidence of the nature and character of the hidden work of ENPs. Limitations
The study has a number of limitations that need to be considered. Sample bias may be present because participants self-reported secondary consultation episodes. The ENP workload may have been underreported during the month of September because the national NP conference was held and no ENPs were replaced. The estimation of time for each consultation was dependent on the ENP accurately monitoring time, and ED workload may have influenced the accuracy of data entry. To obtain the ED data, 8 different reports were required to be generated despite all sites sharing the same EMR platform. This meant that primary and secondary group comparisons were limited, with no comparisons being conducted for disposition and re-presentation rates. Further analysis of the re-presentation rates may be warranted because we were unable to differentiate unplanned from planned representations. These rates may be lower than our findings suggest, and further study should be considered. CONCLUSIONS
This study has identified some of the expert invisible workload delivered by ENPs. A significant proportion of ENP workload involved secondary consultations that provided episodic clinical care to a range of ED patients. These secondary consultations involved the ENP providing expertise to support the management of highly complex and urgent patient conditions throughout ED. The EMR consultation template developed for this study has the potential to be adapted for other nurse practitioner specialties. This study provides evidence of the additional workload and valuable contribution that ENPs bring to the clinical setting, which until now has been largely hidden. Future research is needed to further The Journal for Nurse Practitioners - JNP
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explore the invisible workload of NPs. Only in this way can we detail the hidden contribution and valuable difference that these roles can make to service provision, quality care, collaborative practice, and clinician mentorship.
19.
20.
21.
SUPPLEMENTARY DATA
The supplementary table associated with this article can be found in the online version at http://www. npjournal.org/.
22.
23.
24. References 1. Evans DD, Ashooh MP, Kimble LP, Heilpern KL. An exemplar interprofessional academic emergency nurse practitioner program: a blueprint for success. Adv Emerg Nurs J. 2017;39(1):59-67. 2. Aplin N. Advanced nurse practitionereled abdominal therapeutic paracentesis. Emerg Nurse. 2017;24(10):34-37. 3. Van Der Biezen M, Adang E, Van Der Burgt R, Wensing M, Laurant M. The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasiexperimental study. BMC Fam Pract. 2016;17(1):132. 4. Lacny S, Zarrabi M, Martin-Misener R, Donald F, Sketris I, Murphy AL, et al. Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study. J Adv Nurs. 2016;72(9):2138-2152. 5. Jennings N, Clifford S, Fox AR, O’Connell J, Gardner G. The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. Int J Nurs Stud. 2015;52(1):421-435. 6. Jennings N, Lutze M, Clifford S, Maw M. How do we capture the emergency nurse practitioners’ contribution to value in health service delivery? Aust Health Rev. 2016;41(1):89-90. 7. O’Connell J, Gardner G, Coyer F. Profiling emergency nurse practitioner service: an interpretive study. Adv Emerg Nurs J. 2014;36(3):279-290. 8. Victoria State Government, Department of Health and Human Services. Best care for older people everywhere: the toolkit 2012. Melbourne, Australia: Finsbury Green; 2012. 9. Masso M, Thompson C. Rapid Review of the Nurse Practitioner Literature: Nurse Practitioners in NSW “Gaining Momentum”. North Sydney, Australia: NSW Government; 2014. 10. Kilpatrick K, Reid K, Carter N, Donald F, Bryant-Lukosius D, Marti-Misener R, et al. A systematic review of the cost-effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Nurs Leadersh (Tor Ont). 2015;28(3):56-76. 11. O’Connell J. The Emergency Nurse Practitioner Clinical Practice Standards. Brisbane, Australia: Queensland University of Technology. http://www.azille .com.au/standards.pdf, 2015. Accessed February 1, 2017. 12. O’Connell J, Gardner G. Development of clinical competencies for emergency nurse practitioners: a pilot study. Australas Emerg Nurs J. 2012;15(4):195-201. 13. Sullivan C, Staib A, Khanna S, Good NM, Boyle J, Cattell R, et al. The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target. Med J Aust. 2016;204:354. 14. Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice. Melbourne, Australia: Australian Health Practitioner Regulation Agency; 2014. http://www.nursingmidwiferyboard.gov.au. Accessed February 1, 2017. 15. Lutze M, Mullen G, Coates D, O’Connell J, Fry M. Using a Delphi technique to develop a data collection tool to capture nurse practitioner workload. 2016. www.dcconferences.com.au/acnp2016/pdf/ACNP_Abstracts/Lutze_M3.pdf. Accessed February 1, 2017. 16. Fry M, Fong J, Asha S, Arendts G. A 12-month evaluation of the impact of transitional emergency nurse practitioners in one metropolitan emergency department. Australas Emerg Nurs J. 2011;14(1):4-8. 17. Lutze M, Ross M, Chu M, Green T, Dinh M. Patient perceptions of emergency department fast track: a prospective pilot study comparing two models of care. Australas Emerg Nurs J. 2014;17(3):112-118. 18. Roche TE, Gardner G, Lewis PA. Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain: protocol for a multicentre, longitudinal nested cohort study. BMJ Open.
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2015;5. http://bmjopen.bmj.com/content/5/2/e006997. Accessed February 1, 2017. Brick C, Lowes J, Lovstrom L, Kokotilo A, Villa-Roel C, Lee P, et al. The impact of consultation on length of stay in tertiary care emergency departments. Emerg Med J. 2014;31(2):134-138. Cross R, Jennings N, McGuiness W, Miller C. Profiling wound management in the emergency department: a descriptive analysis. Australas Emerg Nurs J. 2016;19(3):166-171. Andregård AC, Jangland E. The tortuous journey of introducing the nurse practitioner as a new member of the healthcare team: a meta-synthesis. Scand J Caring Sci. 2015;29(1):3-14. Hurlock-Chorostecki C, Forchuk C, Orchard C, Reeves S, van Soeren M. The value of the hospital-based nurse practitioner role: development of a team perspective framework. J Interprof Care. 2013;27(6):501-508. Hurlock-Chorostecki C, Forchuk C, Orchard C, Soeren M, Reeves S. Hospitalbased nurse practitioner roles and interprofessional practice: a scoping review. Nurs Health Sci. 2014;16:403-410. Williamson S, Twelvetree T, Thompson J, Beaver K. An ethnographic study exploring the role of ward-based advanced nurse practitioners in an acute medical setting. J Adv Nurs. 2012;68(3):1579-1588. Benda NC, Meadors ML, Hettinger AZ, Ratwani RM. Emergency physician task switching increases with the introduction of a commercial electronic health record. Ann Emerg Med. 2016;67(6):741-746. Bjørn P, Burgoyne S, Crompton V, MacDonald T, Pickering B, Munro S. Boundary factors and contextual contingencies: configuring electronic templates for healthcare professionals. European Journal of Information Systems. 2009;18:428-441. Collins N, Miller R, Kapu A, Martin R, Morton M, Forrester M, et al. Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. J Trauma Acute Care Surg. 2014;76(2):353-357. McWilliam CL, Wong CA. Keeping it secret: the costs and benefits of nursing’s hidden work in discharging patients. J Adv Nurs. 1994;19(1): 152-163.
Matthew Lutze, MN, NP, Nurse Practitioner at St George Hospital, Emergency Department, Kogarah, New South Wales, Australia. He may be reached at [email protected]. gov.au. Margaret Fry, PhD, NP, Professor of Nursing at University of Technology Sydney & Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia. Glenda Mullen, Grad Cert Paed Crit Care, NP, Nurse Practitioner at Sydney Children’s Hospital, Emergency Department, Randwick, Australia. Jane O’Connell, PhD, NP, Senior Lecturer at University of Technology Sydney, New South Wales, Australia. Danielle Coates, MN, NP, Nurse Practitioner at Sydney Children’s Hospital Emergency Department, Randwick, New South Wales, Australia. Funding: Matthew Lutze was the recipient of a Research Scholarship awarded by the Australian College of Nurse Practitioners in 2015. The Australian College of Nurse Practitioners had no role in the conduct of the research or the preparation of the manuscript. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.09.023
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Supplementary Table. Characteristics of Secondary ENP Consultations (n [ 611) Consultation Element
Supplementary Table. (continued ) Consultation Element
N (%)
Investigations (n ¼ 155) Radiology
83 (54)
Pathology
58 (37)
N (%)
Adjust management/plan
24 (23)
Phone follow-up
10 (9)
Escalate/outside scope
4 (4)
a
POCUS Point of Care Ultrasound Antiemetic (4), Potassium (1), Insulin (1), Isoprenaline (1), antifungal (1), antihistamine (2), aspirin (1), glyceryl trinitrate (1), antiviral (1) c For example, indwelling catheter, nasogastric tube, pigtail drain insertion. b
ECG
6 (4)
POCUSa
4 (3)
Other
4 (3)
Prescribing (n ¼ 144) Opioid analgesia
30 (21)
Simple analgesia
25 (17)
Local/regional anesthesia
21 (15)
IV therapy
17 (12)
b
Other
16 (11)
Antibiotics
15 (10)
Topical prescription
9 (6)
Sedation (NO2)
6 (4)
Immunisations
4 (3)
Oral rehydration
1 (1)
Procedural support (n ¼ 303) Wound care
141 (47)
Plaster/splint/crutches
113 (37)
Fracture/joint reduction
17 (6)
Vascular access
10 (3)
Foreign body removal
6 (2)
Topical prescription
5 (2) c
Device management
5 (2)
Arthrocentesis
3 (1)
Sedation/blocks
3 (1)
Team care (n ¼ 27) Complex care
11 (41)
Deteriorating patient
6 (22)
Resuscitation
6 (22)
Triage
4 (15)
Follow-up (n ¼ 106) Refer to specialty team
39 (37)
Review results
29 (27) continued
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