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Knowledge and attitudes of ED staff before and after implementation of the emergency Nurse Practitioner role
Australasian Emergency Nursing Journal (2005) 8, 73—78
Knowledge and attitudes of ED staff before and after implementation of the emergency Nurse Practitioner role Roslyn Martin, RN, RM, EmergCert, GDipCritCare, GDipMid ∗, Julie Considine, RN, RM, BN, EmergCert, MN(Research), FRCNA The Northern Hospital, Emergency Department, 185 Cooper St, Epping, Vic. 3076, Australia KEYWORDS Nurse Practitioner; Emergency department; Staff attitudes; Australia; Victoria
Summary Introduction: The Emergency Nurse Practitioner (ENP) role was implemented in the Emergency Department (ED) at The Northern Hospital (TNH) in April 2004. Implementation of the ENP role occurred as part of a Department of Human Services funded project to establish the ENP model as an effective and sustainable model of care delivery in Victorian EDs. Aim: The aim of this study was to examine the attitudes and knowledge of ED medical and nursing staff prior to, and following, implementation of the ENP role. Methods: The design was a pre-test/post-test design and the Northern Emergency Nurse Practitioner Staff Survey was used for data collection. A total of 104 ED staff completed the pre-test survey and the post-test survey was completed by 79 ED staff. Results: The attitudes and knowledge of ED medical and nursing staff changed significantly during implementation of the ENP role. Pre-test data indicated that staff were generally supportive of the role but had a poor understanding of the requirements for endorsement and how the role would function in clinical practice. Post-test data showed significant increases in support for the ENP role, a greater understanding of the requirements to become an ENP and increased understanding of the logistics and functions of an ENP. Conclusion: The implementation of the Nurse Practitioner role within the emergency department of The Northern Hospital, Victoria Australia has been a positive experience for both medical and nursing staff. © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction In the Australian state of Victoria a Nurse Practitioner is defined as ‘‘. . . a registered nurse edu∗
Corresponding author.
cated for advanced practice who is an essential member of an interdependent health care team and whose role is determined by the context in which she/he practices (18)’’.1,2 Although emergency nurse practitioners (ENPs) have been practicing in the United Kingdom and the United States
1574-6267/$ — see front matter © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.10.002
74 for more than two decades, the role of the ENP is relatively new in Australia.1,2 In Victoria, the title, Nurse Practitioner, is protected by legislation preventing its use by persons who have not met the requirements of the Nurses Board of Victoria (NBV). Nurses who are working towards endorsement as a Nurse Practitioner are referred to as nurse practitioner candidates (NPC).The ENP role extends current advanced emergency nursing practice to include prescribing medications, initiating diagnostic imaging and pathology testing, approving absence from work certificates, referring to specialists, and admitting and discharging patients. It is a requirement in Victoria that these extensions to practice are supported by a framework of evidence-based, multidisciplinary clinical practice guidelines. Currently, organizational-specific interim measures enable NPCs to engage in these extensions to practice while legislative frameworks are being developed.The ENP model of care implemented at The Northern Hospital (TNH) was a collaborative model that focused on the management of minor illness and injury. TNH is the only acute care campus of Northern Health and is located approximately 30 km north of Victoria’s capital, Melbourne. Presentations to the Emergency Department (ED) at TNH have increased over the last five years; during 2004 in excess of 64,800 patients were treated. The ENP role was implemented at TNH in April 2004 as part of the Victorian Department of Human Services (DHS) funded Emergency Nurse Practitioner Project. The key aim of this initiative was to develop, implement and evaluate the ENP role in Victorian EDs. As the ENP role is new in Victoria, little is known about the attitudes and knowledge of ED staff toward it. Many researchers have investigated patient satisfaction with NP care,3—11 however only a few of these studies related to staff satisfaction with the NP role and these have been conducted in acute care contexts rather than EDs. Examination of medical and nursing staff satisfaction with the acute care NP role by McMullen et al.12 showed that all staff were highly satisfied with the acute care NP role. This study did not examine staff knowledge and, because the study was conducted at a single point in time, only descriptive statistics were reported. Knaus et al.13 also examined physician and staff satisfaction with the acute care NP role in a surgical inpatient unit. Medical staff reported that NPs provided assistance in areas such as discharge planning, teaching and administrative tasks allowing the medical staff to redirect their time to other activities. Nursing staff reported that NPs enhanced communication, and
R. Martin, J. Considine their roles as a liaison and resource person and as a teacher were highly valued. Studies of staff satisfaction make an important contribution to the body of knowledge related to the NP role and highlight areas of NP expertise. Although it may be proposed that staff satisfaction is related to staff knowledge and attitudes, staff attitudes and knowledge related to the ENP role over time remain largely unexplored. One of the strategies used to evaluate the implementation of the ENP role at TNH was investigation of the knowledge and attitudes of ED medical and nursing staff over time. The purpose of this paper is to present the results of a staff attitude and knowledge survey before and after implementation of the ENP role.
Aims The aims of this study were to examine the: • attitudes and knowledge of ED medical and nursing staff regarding the ENP role before and after implementation of an ENP model of care; • effect of implementation of the ENP role on the attitudes and knowledge of ED medical and nursing staff regarding this role.
Method Design This study used a prospective pre-test/post-test design. Pre-test data was collected in early July 2004 (prior to implementation of the ENP role) and post-test data was collected during March 2005 (9 months after implementation of the ENP role).
Participants All medical (57) and nursing staff (91) working in the ED at TNH were invited to participate in the study. This approach was used in preference to random sampling because the number of potential participants was limited. Seventy-two ED nursing staff and 32 ED medical staff completed the pre-test survey and 52 ED nursing staff and 27 ED medical staff completed the post-test survey. The pre-test response rates were 79% for nursing staff and 56.1% for medical staff; the post-test response rates were 57% for nursing staff and 47.3% for medical staff. The reason for the decreased response rates during the post-test period was unclear however greater time constraints in the post-test data collection period are a possible explanation.
Knowledge and attitudes of ED staff Because convenience sampling was used, post hoc power calculations were performed. The Northern Emergency Nurse Practitioner Staff Survey14 had 21 items, with each item requiring participants to rate their responses using a five point Likert scale. When the scores attributed to each point on the Likert scale were totalled, the mean increase in knowledge and attitudes was 13.33% (S.D. = 15.76%); equating to an effect size of 0.84. Post hoc power calculations using sample size tables for one sample t-test — a significance level of 0.05 (2 sided) and power of 0.80 — showed that 14 participants would be required in each group.15 This study had 104 participants in the pre-test group and 79 participants in the post-test group which exceeded the minimum sample size numbers needed for statistical power of 0.80.
75
Procedure ED nursing staff were approached by the project officer during nursing staff education time and asked to complete a survey. A box was set up in the ED tutorial room to enable return of completed surveys. ED medical were approached by the project officer at quiet times during ED shifts and asked to complete a survey. A box was set up at the ED staff station to enable return of completed surveys. After the completion of the pre-testing, an education session was conducted during which ED staff were informed of the ENP project, the requirements for endorsement as an ENP, the scope of ENP practice, logistics of the ENP role at TNH and lines of reporting for the ENP.
Data analysis Ethical considerations In-principle agreement was given by the Human Research and Ethics Committee at The Northern Hospital. The surveys were not coded ensuring anonymity and confidentiality. Consent was implied by the return of the surveys so formal written consent was not obtained.
Instrument The Northern Emergency Nurse Practitioner Staff Survey (developed by the researchers) was used to collect data. Content and face validity were established by expert panel review. Reliability was established by exploratory factor analysis that resulted in five factors with eigenvalues greater than 1 and tests of internal consistency that resulted in a Cronbach’s coefficient ˛ of 0.926. The factors were titled and arranged in a logical sequence to form The Northern Emergency Nurse Practitioner Staff Survey. A detailed description of the development, reliability and validity of this instrument and the Northern Emergency Nurse Practitioner Staff Survey is presented elsewhere.14 The five factors examined were: (i) ED Nurse Practitioner role; (ii) requirements to become an ED Nurse Practitioner; (iii) advanced Emergency Nursing Practice; (iv) extensions to Emergency Nursing Practice; (v) collaborative practice; (vi) Staff were asked to rate their knowledge or attitude for each item using a five point Likert scale: 1 = strongly disagree; 2 = disagree; 3 = no opinion; 4 = agree; and 5 = strongly agree.
Data analyses were performed using the computer software SPSS for Windows 10.0® .16 Descriptive statistics were used to examine participants’ employment characteristics. Group equivalence was established using Chi-square. Pre- and post-test data were compared using Wilcoxon signed-ranks test.17—19
Results Staff attitudes and knowledge were measured using The Northern Emergency Nurse Practitioner Staff Survey.14 This instrument examined the following factors: (i) ED Nurse Practitioner role; (ii) requirements to become an ED Nurse Practitioner; (iii) advanced Emergency Nursing Practice; (iv) extensions to Emergency Nursing Practice; (v) collaborative practice. There were 72 ED nursing staff and 32 ED medical staff in the pre-test sample and 52 ED nursing staff and 27 ED medical staff in the post-test sample. There was no statistically significant difference in the composition of the pre-test and post-test groups (2 = 0.239, d.f. = 1, p = 0.625). Participants responses were collapsed into three categories: negative (strongly disagree or disagree); neutral (no opinion); and positive (agree and strongly agree). The attitudes and knowledge of ED medical and nursing staff changed significantly during implementation of the role (see Table 1). The frequency of positive responses increased for all 24 items examined and the
76 Table 1
R. Martin, J. Considine Pre- and post-test responses related to the ENP role Positive reponses (%)
ED Nurse Practitioner 1 I have a good understanding of the ED Nurse Practitioner role 2 I have a good understanding of how the ED Nurse Practitioner role will function in my ED 3 I have a good understanding of which patients are suitable for management by an ED Nurse Practitioner 4 I have a good understanding of the ED Nurse Practitioner’s scope of practice 5 I have a good understanding of how the ED Nurse Practitioner is different to other senior nurses working in the ED 6 I have a good understanding of how the Nurse Practitioner Clinical Practice Guidelines will form the basis for ED Nurse Practitioner’s practice Requirements to become an ED Nurse Practitioner 7 I have a good understanding of the educational preparation required to become an ED Nurse Practitioner 8 I have a good understanding of the Nurses Board of Victoria requirements for endorsement as an ED Nurse Practitioner Advanced emergency nursing practice 9 The ED Nurse Practitioner has the skills and knowledge to provide appropriate emergency care to specific patient groups 10 The ED Nurse Practitioner has the skills and knowledge to provide appropriate education to specific patient groups 11 The ED Nurse Practitioner has the skills and knowledge to appropriately refer specific patient groups 12 The ED Nurse Practitioner has the skills and knowledge to initiate diagnostic imaging Extensions to emergency nursing practice 13 The ED Nurse Practitioner has the skills and knowledge to prescribe medications from a limited formulary of drugs 14 The ED Nurse Practitioner has the skills and knowledge to refer patients directly to outpatients or specialist clinics 15 The ED Nurse Practitioner has the skills and knowledge to write absence from work certificates 16 The ED Nurse Practitioner has the skills and knowledge to discharge patients from the ED 17 The ED Nurse Practitioner has the skills and knowledge to refer patients to inpatient Registrars for assessment for admission 18 The ED Nurse Practitioner will make the ED team more effective 19 The ED Nurse Practitioner will improve access to emergency care Collaborative practice 21 I am comfortable with being approached by the ED Nurse Practitioner for advice regarding patient management 22 Emergency Physicians are the most appropriate personnel to supervise/advise the ED Nurse Practitioner regarding patient management issues
increases were statistically significant for all but four items. Pre-test data indicated that staff were generally supportive of the ENP role but had poor understanding of how the role would function in clinical practice and the requirements for endorse-
Pre-test
Post-test
p-value
49 38.7
87.3 89.9
<0.001 <0.001
33.0
89.9
<0.001
32.1
84.8
<0.001
53.3
92.3
<0.001
38.7
82.2
<0.001
41.0
74.6
<0.001
24.5
58.2
<0.001
90.5
98.7
0.010
94.3
98.8
0.005
91.5
96.2
0.013
83.0
98.8
1.000
85.8
93.6
0.003
76.4
87.3
0.117
70.7
92.4
0.004
68.9
89.9
0.006
71.7
93.7
<0.001
83.9 83.1
93.6 88.6
0.142 0.455
89.6
96.2
0.039
79.2
91.2
0.007
ment as an ENP. Post-test data showed statistically significant increases in the understanding of the ENP role and how an ENP would function in the ED at TNH and also a greater knowledge of the requirements for endorsement as an ENP. Although pre-test
Knowledge and attitudes of ED staff Table 2
77
Cronbach’s coefficient ˛ for each factor
Factor
Number of items
˛
1 2 3 4 5
6 2 4 7 2
0.950 0.861 0.915 0.883 0.492
data indicated that the majority of staff agreed that the ENP had the skills and knowledge to engage in advanced and extended emergency nursing practice, there were statistically significant increases in the frequency of positive responses related to provision of emergency care (p = 0.010), patient education (p = 0.005) and referral (p = 0.013), prescribing (p = 0.003), approval of certificates (p = 0.004) and discharge of patients from the ED (p = 0.006) following implementation of the ENP role. Calculation of Cronbach’s coefficient ˛ was used for post hoc measures of internal consistency. The Cronbach’s coefficient ˛ for the scale in total was 0.934 indicating a high degree of internal consistency. Coefficient ˛ was also calculated for each of the factors to establish the internal consistency of each factor (see Table 2). For factors 1—4, these coefficients were greater than 0.7 indicating a high degree of internal consistency. The coefficient ˛ for factor 5 was 0.492, so the results from these two items should be interpreted with caution.
Limitations The requirement of participants to agree to participate may be a source of sampling bias because participants were, to some degree, self selecting.20 This limitation did not affect the statistical power of this study. The advantage of the sampling method employed in this study was that all ED medical and nursing staff were given the same opportunity to participate acknowledging that it was not possible to control the individual choices to participate. The Northern Hospital also employed a single NPC during the studied period, which may have resulted in some participants evaluating the individual rather than the role itself.
Discussion Staff attitudes to and knowledge of the ENP role clearly changed following implementation of the ENP role. Pre-test data indicated that staff were
generally supportive of the ENP role but had poor understanding of the requirements for endorsement and how an ENP function in clinical practice. Post-test data showed statistically significant increases in support for the ENP role, a greater understanding of the requirements to become an ENP and increased understanding of the logistics and functions of the NPC. The four items that did not elicit statistically significant increases in the frequency of positive responses were related to initiation of diagnostic imaging, referral to outpatient clinics, effectiveness of the ED team and access to emergency care. For each of these items, greater than 75% of respondents agreed or strongly agreed during the pretest period and the frequency of positive responses increased in the post-test period. There are a number of reasons for failure to reach statistical significance for these items. Firstly, there were a high numbers of positive responses in the pre-test data. Secondly, triage nurses in the ED at TNH initiate diagnostic imaging and referral outpatient clinics as part of their usual practice and finally, the ED at TNH has implemented a number of strategies aimed at managing the increasing numbers of presentations and reducing waiting times so ED performance and access to emergency care are issues that are commonly discussed. The statistically significant improvements in staff attitudes and knowledge raise questions about the role of education when implementing a new role or major change in work practices. Tailored education sessions were provided to ED medical and nursing staff following the pre-test data collection and immediately prior to the formal implementation of the ENP role. The findings of this study suggest that staff education about the ENP role was effective and may have been a key influence on the positive findings of this study. The education sessions in conjunction with the clinical presence of the NPC were a valuable method of increasing awareness of ENP scope of practice, role of clinical practice guidelines in underpinning the ENP model of care and use of extensions to current emergency nursing practice. One of the key findings of this study is that ED attitudes and knowledge related to the ENP role improved even though implementation of the ENP role was a major change in ED work practices and the ENP role may be considered by many to encroach on conventional professional boundaries and potentially threaten the traditional domains of other members in the health care team.21 The results of this study highlight the importance of an inclusive and collaborative approach to implementation of the ENP role. Ensuring that staff at all
78 levels have an understanding of the ENP role, how an ENP will interact with other members of the ED team, the requirements for endorsement as an ENP, ENP scope of practice and organisational processes for to support use of extensions to practice by the NPC are pivotal to successful implementation of the ENP role.
Conclusion The implementation of the ENP role in Victorian EDs provided an excellent opportunity to explore the attitudes and knowledge of staff in this specialty area. The results of this study showed that although attitudes and knowledge of ED medical and nursing staff towards the ENP role were generally positive, attitudes and knowledge could be improved by education sessions regarding specific aspects of the ENP role and a collaborative approach to the formal implementation of the ENP role in a clinical setting.
Acknowledgements The authors acknowledge the support of the executive of Northern Health/The Northern Hospital and the Victorian Department of Human Services (Nurse Policy Branch). The authors also thank the following people for their assistance in conducting this study and preparing this paper for publication: Doreen Power, Operations Director (Emergency/Obstetrics/Paediatrics) TNH; Jane Jenkins, ED Nurse Unit Manager TNH; Petrina Halloran, Nurse Practitioner Project Officer, Nurse Policy Branch, Victorian Department of Human Services.
References 1. Victorian Department of Human Services. The Victorian Nurse Practitioner Project: Final Report of the Taskforce. Melbourne: Policy Development and Planning Division, Victorian Government Department of Human Services; 1999. 2. Nurses Board of Victoria. Process for Nurse Practitioner Endorsement. http://www.nbv.org.au/nbv/nbvonlinev1. nsf/attachment/NPProcessforendorsement/$File/ NPProcessforendorsement.pdf; 2003. Accessed.
R. Martin, J. Considine 3. Byrne G, Richardson D, Brunsdon J, Patel A. Patient satisfaction with emergency Nurse Practitioner in A & E. J Clin Nurs 2000;9:83—93. 4. Chang E, Daly J, Hawkins A, McGirr J, Fielding K, Hemmings L, et al. An evaluation of the nurse practitioner role in a major rural emergency department. J Adv Nurs 1999;30:260—8. 5. Cole FL, Mackey TA, Lindenberg J. Wait time and satisfaction with care and service at a nurse practitioner managed clinic. J Am Acad Nurse Pract 2001;13:467—72. 6. Byrne G, Richardson M, Brunsdon J, Patel A. An evaluation of the care of patients with minor injuries in emergency settings. Accid Emerg Nurs 2000;8:101—9. 7. Rhee KJ, Dermyer AL. Patient satisfaction with a nurse practitioner in a university emergency service. Ann Emerg Med 1995;26:130—2. 8. Horrocks S, Anderson E, Salisbury C. Review: nurse practitioner primary care improves patient satisfaction and quality of care with no difference in health outcomes. Evid Based Nurs 2002;5:121. 9. Barr M, Johnston D, McConnell D. Patient satisfaction with a new nurse practitioner service. Accid Emerg Nurs 2000;8:144—7. 10. Powers MJ, Jalowiec A, Reichelt PA. Nurse practitioner and physician care compared for nonurgent emergency room patients. Nurse Pract 1984;9:39, 42, 44—5. 11. Cooper MA, Lindsay GM, Kinn S, Swann I. Evaluating Emergency Nurse Practitioner services: a randomised controlled trial. J Adv Nurs 2002;40:721—30. 12. McMullen M, Alexander MK, Bourgeois A, Goodman L. Evaluating a nurse practitioner service 2001;20:30—4. 13. Knaus VL, Felten S, Burton S, Fobes P, Davis K. The use of nurse practitioners in the acute care setting. J Nurs Admin 1997;27:20—7. 14. Considine J, Martin R. Development, reliability and validity of an instrument measuring the attitudes and knowledge of emergency department staff regarding the Emergency Nurse Practitioner Role. 2005;13:36—43. 15. Machin D, Campbell M. Statistical tables for the design of clinical trials. Oxford: Blackwell Scientific Publications; 1987. 16. SPSS for Windows. In: 10.0.7 ed.; June 2000. 17. Brace N, Kemp R, Sneglar R. SPSS for psychologists: A guide to data analysis using SPSS for windows. 2nd ed. Hampshire: Palgrave MacMillan; 2003. 18. Gravetter F, Wallnau L. Statistics for the behavioral sciences. 5th ed. Stamford: Wadsworth/Thomson Learning; 2000. 19. Polit DF, Hungler BP. Nursing research: principles and methods. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. 20. Suen HK, Ary D. Analyzing quantitative behavioral observation data. Hillsdale: L. Erlbaum Associates; 1989. 21. Tye CC, Ross FM. Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department. J Adv Nurs 2000;31:089—96.
Knowledge and attitudes of ED staff before and after implementation of the emergency Nurse Practitioner role Roslyn Martin, RN, RM, EmergCert, GDipCritCare, GDipMid ∗, Julie Considine, RN, RM, BN, EmergCert, MN(Research), FRCNA The Northern Hospital, Emergency Department, 185 Cooper St, Epping, Vic. 3076, Australia KEYWORDS Nurse Practitioner; Emergency department; Staff attitudes; Australia; Victoria
Summary Introduction: The Emergency Nurse Practitioner (ENP) role was implemented in the Emergency Department (ED) at The Northern Hospital (TNH) in April 2004. Implementation of the ENP role occurred as part of a Department of Human Services funded project to establish the ENP model as an effective and sustainable model of care delivery in Victorian EDs. Aim: The aim of this study was to examine the attitudes and knowledge of ED medical and nursing staff prior to, and following, implementation of the ENP role. Methods: The design was a pre-test/post-test design and the Northern Emergency Nurse Practitioner Staff Survey was used for data collection. A total of 104 ED staff completed the pre-test survey and the post-test survey was completed by 79 ED staff. Results: The attitudes and knowledge of ED medical and nursing staff changed significantly during implementation of the ENP role. Pre-test data indicated that staff were generally supportive of the role but had a poor understanding of the requirements for endorsement and how the role would function in clinical practice. Post-test data showed significant increases in support for the ENP role, a greater understanding of the requirements to become an ENP and increased understanding of the logistics and functions of an ENP. Conclusion: The implementation of the Nurse Practitioner role within the emergency department of The Northern Hospital, Victoria Australia has been a positive experience for both medical and nursing staff. © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction In the Australian state of Victoria a Nurse Practitioner is defined as ‘‘. . . a registered nurse edu∗
Corresponding author.
cated for advanced practice who is an essential member of an interdependent health care team and whose role is determined by the context in which she/he practices (18)’’.1,2 Although emergency nurse practitioners (ENPs) have been practicing in the United Kingdom and the United States
1574-6267/$ — see front matter © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.10.002
74 for more than two decades, the role of the ENP is relatively new in Australia.1,2 In Victoria, the title, Nurse Practitioner, is protected by legislation preventing its use by persons who have not met the requirements of the Nurses Board of Victoria (NBV). Nurses who are working towards endorsement as a Nurse Practitioner are referred to as nurse practitioner candidates (NPC).The ENP role extends current advanced emergency nursing practice to include prescribing medications, initiating diagnostic imaging and pathology testing, approving absence from work certificates, referring to specialists, and admitting and discharging patients. It is a requirement in Victoria that these extensions to practice are supported by a framework of evidence-based, multidisciplinary clinical practice guidelines. Currently, organizational-specific interim measures enable NPCs to engage in these extensions to practice while legislative frameworks are being developed.The ENP model of care implemented at The Northern Hospital (TNH) was a collaborative model that focused on the management of minor illness and injury. TNH is the only acute care campus of Northern Health and is located approximately 30 km north of Victoria’s capital, Melbourne. Presentations to the Emergency Department (ED) at TNH have increased over the last five years; during 2004 in excess of 64,800 patients were treated. The ENP role was implemented at TNH in April 2004 as part of the Victorian Department of Human Services (DHS) funded Emergency Nurse Practitioner Project. The key aim of this initiative was to develop, implement and evaluate the ENP role in Victorian EDs. As the ENP role is new in Victoria, little is known about the attitudes and knowledge of ED staff toward it. Many researchers have investigated patient satisfaction with NP care,3—11 however only a few of these studies related to staff satisfaction with the NP role and these have been conducted in acute care contexts rather than EDs. Examination of medical and nursing staff satisfaction with the acute care NP role by McMullen et al.12 showed that all staff were highly satisfied with the acute care NP role. This study did not examine staff knowledge and, because the study was conducted at a single point in time, only descriptive statistics were reported. Knaus et al.13 also examined physician and staff satisfaction with the acute care NP role in a surgical inpatient unit. Medical staff reported that NPs provided assistance in areas such as discharge planning, teaching and administrative tasks allowing the medical staff to redirect their time to other activities. Nursing staff reported that NPs enhanced communication, and
R. Martin, J. Considine their roles as a liaison and resource person and as a teacher were highly valued. Studies of staff satisfaction make an important contribution to the body of knowledge related to the NP role and highlight areas of NP expertise. Although it may be proposed that staff satisfaction is related to staff knowledge and attitudes, staff attitudes and knowledge related to the ENP role over time remain largely unexplored. One of the strategies used to evaluate the implementation of the ENP role at TNH was investigation of the knowledge and attitudes of ED medical and nursing staff over time. The purpose of this paper is to present the results of a staff attitude and knowledge survey before and after implementation of the ENP role.
Aims The aims of this study were to examine the: • attitudes and knowledge of ED medical and nursing staff regarding the ENP role before and after implementation of an ENP model of care; • effect of implementation of the ENP role on the attitudes and knowledge of ED medical and nursing staff regarding this role.
Method Design This study used a prospective pre-test/post-test design. Pre-test data was collected in early July 2004 (prior to implementation of the ENP role) and post-test data was collected during March 2005 (9 months after implementation of the ENP role).
Participants All medical (57) and nursing staff (91) working in the ED at TNH were invited to participate in the study. This approach was used in preference to random sampling because the number of potential participants was limited. Seventy-two ED nursing staff and 32 ED medical staff completed the pre-test survey and 52 ED nursing staff and 27 ED medical staff completed the post-test survey. The pre-test response rates were 79% for nursing staff and 56.1% for medical staff; the post-test response rates were 57% for nursing staff and 47.3% for medical staff. The reason for the decreased response rates during the post-test period was unclear however greater time constraints in the post-test data collection period are a possible explanation.
Knowledge and attitudes of ED staff Because convenience sampling was used, post hoc power calculations were performed. The Northern Emergency Nurse Practitioner Staff Survey14 had 21 items, with each item requiring participants to rate their responses using a five point Likert scale. When the scores attributed to each point on the Likert scale were totalled, the mean increase in knowledge and attitudes was 13.33% (S.D. = 15.76%); equating to an effect size of 0.84. Post hoc power calculations using sample size tables for one sample t-test — a significance level of 0.05 (2 sided) and power of 0.80 — showed that 14 participants would be required in each group.15 This study had 104 participants in the pre-test group and 79 participants in the post-test group which exceeded the minimum sample size numbers needed for statistical power of 0.80.
75
Procedure ED nursing staff were approached by the project officer during nursing staff education time and asked to complete a survey. A box was set up in the ED tutorial room to enable return of completed surveys. ED medical were approached by the project officer at quiet times during ED shifts and asked to complete a survey. A box was set up at the ED staff station to enable return of completed surveys. After the completion of the pre-testing, an education session was conducted during which ED staff were informed of the ENP project, the requirements for endorsement as an ENP, the scope of ENP practice, logistics of the ENP role at TNH and lines of reporting for the ENP.
Data analysis Ethical considerations In-principle agreement was given by the Human Research and Ethics Committee at The Northern Hospital. The surveys were not coded ensuring anonymity and confidentiality. Consent was implied by the return of the surveys so formal written consent was not obtained.
Instrument The Northern Emergency Nurse Practitioner Staff Survey (developed by the researchers) was used to collect data. Content and face validity were established by expert panel review. Reliability was established by exploratory factor analysis that resulted in five factors with eigenvalues greater than 1 and tests of internal consistency that resulted in a Cronbach’s coefficient ˛ of 0.926. The factors were titled and arranged in a logical sequence to form The Northern Emergency Nurse Practitioner Staff Survey. A detailed description of the development, reliability and validity of this instrument and the Northern Emergency Nurse Practitioner Staff Survey is presented elsewhere.14 The five factors examined were: (i) ED Nurse Practitioner role; (ii) requirements to become an ED Nurse Practitioner; (iii) advanced Emergency Nursing Practice; (iv) extensions to Emergency Nursing Practice; (v) collaborative practice; (vi) Staff were asked to rate their knowledge or attitude for each item using a five point Likert scale: 1 = strongly disagree; 2 = disagree; 3 = no opinion; 4 = agree; and 5 = strongly agree.
Data analyses were performed using the computer software SPSS for Windows 10.0® .16 Descriptive statistics were used to examine participants’ employment characteristics. Group equivalence was established using Chi-square. Pre- and post-test data were compared using Wilcoxon signed-ranks test.17—19
Results Staff attitudes and knowledge were measured using The Northern Emergency Nurse Practitioner Staff Survey.14 This instrument examined the following factors: (i) ED Nurse Practitioner role; (ii) requirements to become an ED Nurse Practitioner; (iii) advanced Emergency Nursing Practice; (iv) extensions to Emergency Nursing Practice; (v) collaborative practice. There were 72 ED nursing staff and 32 ED medical staff in the pre-test sample and 52 ED nursing staff and 27 ED medical staff in the post-test sample. There was no statistically significant difference in the composition of the pre-test and post-test groups (2 = 0.239, d.f. = 1, p = 0.625). Participants responses were collapsed into three categories: negative (strongly disagree or disagree); neutral (no opinion); and positive (agree and strongly agree). The attitudes and knowledge of ED medical and nursing staff changed significantly during implementation of the role (see Table 1). The frequency of positive responses increased for all 24 items examined and the
76 Table 1
R. Martin, J. Considine Pre- and post-test responses related to the ENP role Positive reponses (%)
ED Nurse Practitioner 1 I have a good understanding of the ED Nurse Practitioner role 2 I have a good understanding of how the ED Nurse Practitioner role will function in my ED 3 I have a good understanding of which patients are suitable for management by an ED Nurse Practitioner 4 I have a good understanding of the ED Nurse Practitioner’s scope of practice 5 I have a good understanding of how the ED Nurse Practitioner is different to other senior nurses working in the ED 6 I have a good understanding of how the Nurse Practitioner Clinical Practice Guidelines will form the basis for ED Nurse Practitioner’s practice Requirements to become an ED Nurse Practitioner 7 I have a good understanding of the educational preparation required to become an ED Nurse Practitioner 8 I have a good understanding of the Nurses Board of Victoria requirements for endorsement as an ED Nurse Practitioner Advanced emergency nursing practice 9 The ED Nurse Practitioner has the skills and knowledge to provide appropriate emergency care to specific patient groups 10 The ED Nurse Practitioner has the skills and knowledge to provide appropriate education to specific patient groups 11 The ED Nurse Practitioner has the skills and knowledge to appropriately refer specific patient groups 12 The ED Nurse Practitioner has the skills and knowledge to initiate diagnostic imaging Extensions to emergency nursing practice 13 The ED Nurse Practitioner has the skills and knowledge to prescribe medications from a limited formulary of drugs 14 The ED Nurse Practitioner has the skills and knowledge to refer patients directly to outpatients or specialist clinics 15 The ED Nurse Practitioner has the skills and knowledge to write absence from work certificates 16 The ED Nurse Practitioner has the skills and knowledge to discharge patients from the ED 17 The ED Nurse Practitioner has the skills and knowledge to refer patients to inpatient Registrars for assessment for admission 18 The ED Nurse Practitioner will make the ED team more effective 19 The ED Nurse Practitioner will improve access to emergency care Collaborative practice 21 I am comfortable with being approached by the ED Nurse Practitioner for advice regarding patient management 22 Emergency Physicians are the most appropriate personnel to supervise/advise the ED Nurse Practitioner regarding patient management issues
increases were statistically significant for all but four items. Pre-test data indicated that staff were generally supportive of the ENP role but had poor understanding of how the role would function in clinical practice and the requirements for endorse-
Pre-test
Post-test
p-value
49 38.7
87.3 89.9
<0.001 <0.001
33.0
89.9
<0.001
32.1
84.8
<0.001
53.3
92.3
<0.001
38.7
82.2
<0.001
41.0
74.6
<0.001
24.5
58.2
<0.001
90.5
98.7
0.010
94.3
98.8
0.005
91.5
96.2
0.013
83.0
98.8
1.000
85.8
93.6
0.003
76.4
87.3
0.117
70.7
92.4
0.004
68.9
89.9
0.006
71.7
93.7
<0.001
83.9 83.1
93.6 88.6
0.142 0.455
89.6
96.2
0.039
79.2
91.2
0.007
ment as an ENP. Post-test data showed statistically significant increases in the understanding of the ENP role and how an ENP would function in the ED at TNH and also a greater knowledge of the requirements for endorsement as an ENP. Although pre-test
Knowledge and attitudes of ED staff Table 2
77
Cronbach’s coefficient ˛ for each factor
Factor
Number of items
˛
1 2 3 4 5
6 2 4 7 2
0.950 0.861 0.915 0.883 0.492
data indicated that the majority of staff agreed that the ENP had the skills and knowledge to engage in advanced and extended emergency nursing practice, there were statistically significant increases in the frequency of positive responses related to provision of emergency care (p = 0.010), patient education (p = 0.005) and referral (p = 0.013), prescribing (p = 0.003), approval of certificates (p = 0.004) and discharge of patients from the ED (p = 0.006) following implementation of the ENP role. Calculation of Cronbach’s coefficient ˛ was used for post hoc measures of internal consistency. The Cronbach’s coefficient ˛ for the scale in total was 0.934 indicating a high degree of internal consistency. Coefficient ˛ was also calculated for each of the factors to establish the internal consistency of each factor (see Table 2). For factors 1—4, these coefficients were greater than 0.7 indicating a high degree of internal consistency. The coefficient ˛ for factor 5 was 0.492, so the results from these two items should be interpreted with caution.
Limitations The requirement of participants to agree to participate may be a source of sampling bias because participants were, to some degree, self selecting.20 This limitation did not affect the statistical power of this study. The advantage of the sampling method employed in this study was that all ED medical and nursing staff were given the same opportunity to participate acknowledging that it was not possible to control the individual choices to participate. The Northern Hospital also employed a single NPC during the studied period, which may have resulted in some participants evaluating the individual rather than the role itself.
Discussion Staff attitudes to and knowledge of the ENP role clearly changed following implementation of the ENP role. Pre-test data indicated that staff were
generally supportive of the ENP role but had poor understanding of the requirements for endorsement and how an ENP function in clinical practice. Post-test data showed statistically significant increases in support for the ENP role, a greater understanding of the requirements to become an ENP and increased understanding of the logistics and functions of the NPC. The four items that did not elicit statistically significant increases in the frequency of positive responses were related to initiation of diagnostic imaging, referral to outpatient clinics, effectiveness of the ED team and access to emergency care. For each of these items, greater than 75% of respondents agreed or strongly agreed during the pretest period and the frequency of positive responses increased in the post-test period. There are a number of reasons for failure to reach statistical significance for these items. Firstly, there were a high numbers of positive responses in the pre-test data. Secondly, triage nurses in the ED at TNH initiate diagnostic imaging and referral outpatient clinics as part of their usual practice and finally, the ED at TNH has implemented a number of strategies aimed at managing the increasing numbers of presentations and reducing waiting times so ED performance and access to emergency care are issues that are commonly discussed. The statistically significant improvements in staff attitudes and knowledge raise questions about the role of education when implementing a new role or major change in work practices. Tailored education sessions were provided to ED medical and nursing staff following the pre-test data collection and immediately prior to the formal implementation of the ENP role. The findings of this study suggest that staff education about the ENP role was effective and may have been a key influence on the positive findings of this study. The education sessions in conjunction with the clinical presence of the NPC were a valuable method of increasing awareness of ENP scope of practice, role of clinical practice guidelines in underpinning the ENP model of care and use of extensions to current emergency nursing practice. One of the key findings of this study is that ED attitudes and knowledge related to the ENP role improved even though implementation of the ENP role was a major change in ED work practices and the ENP role may be considered by many to encroach on conventional professional boundaries and potentially threaten the traditional domains of other members in the health care team.21 The results of this study highlight the importance of an inclusive and collaborative approach to implementation of the ENP role. Ensuring that staff at all
78 levels have an understanding of the ENP role, how an ENP will interact with other members of the ED team, the requirements for endorsement as an ENP, ENP scope of practice and organisational processes for to support use of extensions to practice by the NPC are pivotal to successful implementation of the ENP role.
Conclusion The implementation of the ENP role in Victorian EDs provided an excellent opportunity to explore the attitudes and knowledge of staff in this specialty area. The results of this study showed that although attitudes and knowledge of ED medical and nursing staff towards the ENP role were generally positive, attitudes and knowledge could be improved by education sessions regarding specific aspects of the ENP role and a collaborative approach to the formal implementation of the ENP role in a clinical setting.
Acknowledgements The authors acknowledge the support of the executive of Northern Health/The Northern Hospital and the Victorian Department of Human Services (Nurse Policy Branch). The authors also thank the following people for their assistance in conducting this study and preparing this paper for publication: Doreen Power, Operations Director (Emergency/Obstetrics/Paediatrics) TNH; Jane Jenkins, ED Nurse Unit Manager TNH; Petrina Halloran, Nurse Practitioner Project Officer, Nurse Policy Branch, Victorian Department of Human Services.
References 1. Victorian Department of Human Services. The Victorian Nurse Practitioner Project: Final Report of the Taskforce. Melbourne: Policy Development and Planning Division, Victorian Government Department of Human Services; 1999. 2. Nurses Board of Victoria. Process for Nurse Practitioner Endorsement. http://www.nbv.org.au/nbv/nbvonlinev1. nsf/attachment/NPProcessforendorsement/$File/ NPProcessforendorsement.pdf; 2003. Accessed.
R. Martin, J. Considine 3. Byrne G, Richardson D, Brunsdon J, Patel A. Patient satisfaction with emergency Nurse Practitioner in A & E. J Clin Nurs 2000;9:83—93. 4. Chang E, Daly J, Hawkins A, McGirr J, Fielding K, Hemmings L, et al. An evaluation of the nurse practitioner role in a major rural emergency department. J Adv Nurs 1999;30:260—8. 5. Cole FL, Mackey TA, Lindenberg J. Wait time and satisfaction with care and service at a nurse practitioner managed clinic. J Am Acad Nurse Pract 2001;13:467—72. 6. Byrne G, Richardson M, Brunsdon J, Patel A. An evaluation of the care of patients with minor injuries in emergency settings. Accid Emerg Nurs 2000;8:101—9. 7. Rhee KJ, Dermyer AL. Patient satisfaction with a nurse practitioner in a university emergency service. Ann Emerg Med 1995;26:130—2. 8. Horrocks S, Anderson E, Salisbury C. Review: nurse practitioner primary care improves patient satisfaction and quality of care with no difference in health outcomes. Evid Based Nurs 2002;5:121. 9. Barr M, Johnston D, McConnell D. Patient satisfaction with a new nurse practitioner service. Accid Emerg Nurs 2000;8:144—7. 10. Powers MJ, Jalowiec A, Reichelt PA. Nurse practitioner and physician care compared for nonurgent emergency room patients. Nurse Pract 1984;9:39, 42, 44—5. 11. Cooper MA, Lindsay GM, Kinn S, Swann I. Evaluating Emergency Nurse Practitioner services: a randomised controlled trial. J Adv Nurs 2002;40:721—30. 12. McMullen M, Alexander MK, Bourgeois A, Goodman L. Evaluating a nurse practitioner service 2001;20:30—4. 13. Knaus VL, Felten S, Burton S, Fobes P, Davis K. The use of nurse practitioners in the acute care setting. J Nurs Admin 1997;27:20—7. 14. Considine J, Martin R. Development, reliability and validity of an instrument measuring the attitudes and knowledge of emergency department staff regarding the Emergency Nurse Practitioner Role. 2005;13:36—43. 15. Machin D, Campbell M. Statistical tables for the design of clinical trials. Oxford: Blackwell Scientific Publications; 1987. 16. SPSS for Windows. In: 10.0.7 ed.; June 2000. 17. Brace N, Kemp R, Sneglar R. SPSS for psychologists: A guide to data analysis using SPSS for windows. 2nd ed. Hampshire: Palgrave MacMillan; 2003. 18. Gravetter F, Wallnau L. Statistics for the behavioral sciences. 5th ed. Stamford: Wadsworth/Thomson Learning; 2000. 19. Polit DF, Hungler BP. Nursing research: principles and methods. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. 20. Suen HK, Ary D. Analyzing quantitative behavioral observation data. Hillsdale: L. Erlbaum Associates; 1989. 21. Tye CC, Ross FM. Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department. J Adv Nurs 2000;31:089—96.