INTEGRATION OF PRIMARY HEALTH CARE NURSE PRACTITIONERS INTO EMERGENCY DEPARTMENTS

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1 INTEGRATION OF PRIMARY HEALTH CARE NURSE PRACTITIONERS INTO EMERGENCY DEPARTMENTS Section I Facilitators Reasons for integrating the Nurse Practitioner into the Emergency Department 1. Please consider some of the reasons why (you think) the hospital where you work integrated an NP into the emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. There was inadequate time to handle the amount of work There were inadequate resources (MDs, RNs) to handle the amount of work The emergency department staff was overworked The number of people coming to the emergency department for minor problems (e.g., earaches, sore throats) was high Patient volume in the emergency department was high Patients with minor problems (e.g., earache, sore throat) had to wait too long to be treated We weren t able to recruit physicians Many people in the community depend on the emergency department for their primary health care needs There is a shortage of family practitioners in our community Many emergency department patients will benefit from primary care teaching that the NP would provide Fewer patients will return to the ED if they are given appropriate primary care teaching Specific funding for an NP was available (e.g., funding from MOHLTC) Support for the Nurse Practitioner Role 2. To what extent do you think each of the following facilitated the integration of the NP into your emergency department. Please indicate the extent by checking ( ) one box only.

2 Extremely Somewhat Not very Not at all important important important important Initial support for the NP role among ED staff. The emergency department staff s belief that many patients could be treated effectively by an NP The emergency department staff s belief that EDs are appropriate settings for NPs A supportive hospital administration (e.g., medical director, ED Administrator) Nursing staff support for the role ED physician support for the NP Community support for the NP role in the ED Culture of the Emergency Department 3. Based on the experience of having an NP in your ED, please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. An NP that functions well in a team integrates into an ED more easily Integration of the NP is easier at a teaching hospital Integration of an NP is easier in a culture that is collegial

3 Experience working with Nurse Practitioners 4. Based on the experience of having an NP in your ED, please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only NPs are integrated more easily if RNs in general are valued Integration of a second NP into an emergency department is easier because the first NP breaks the ground NPs are integrated more easily if there are NPs working in other departments in the hospital NPs must demonstrate their expertise to gain credibility among ED staff The NP is integrated more easily if he/she has previously worked as an ED nurse Physicians supervise the NP more closely at the beginning Does not apply Credibility of the NP occurs slowly over time More recently trained physicians adjust more easily to NPs There is some reluctance among some consultants in the ED to accept the NP role Consultants in EDs accept referrals from the NP Solution to Variable Skills 5. Based on the experience of having an NP in your ED, please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only MDs were willing to mentor NPs in order to develop their skills. The NP was integrated easily because he/she was always willing to learn new skills.

4 Nurse Practitioner Skills and Competencies 6. Consider the skills that you feel were essential for a Nurse Practitioner and helped him/her to be integrated into the emergency department. Check all the skills that apply, and rank your top three choices starting with 1 as the most valuable skill. Skills Rank top three Critical-thinking skills (e.g., the NP can integrate patient information to make a diagnosis) Interpersonal skills (e.g., the NP gets along well with staff, patients) Willingness to learn (e.g., the NP is open to learning new skills and procedures) Time-management skills (e.g., the NP manages his/her workload in a timely manner) Initiative (e.g., the NP does things without having to be told) Ability to function well under pressure Flexibility/adaptability (e.g., the NP switches to a nursing role when necessary) Organizational skills (e.g., the NP is well prepared) Knowledge of emergency department medical procedures Conflict management (e.g., the NP deals with conflict well) Communication skills (e.g., the NP explains treatment to patients) Functions as part of a team (e.g., the NP is a team player) Decision-making skills (e.g., the NP recognizes when something is not within scope of practice)

5 Strategies to Help Integrate the Nurse Practitioner 7. Below are strategies used to help integrate a Nurse Practitioner in to the emergency department. Please indicate whether you agree or disagree with each of the following strategies by checking ( ) one box only. Networking with key political leaders (e.g., mayor, MPP) Educating patients about the role of an NP Involving the physicians in the decision to integrate a NP Conducting a needs assessment to determine how an NP might fit into an emergency department Considering the specific needs of the ED before the NP was integrated Communicating the role of the NP to the ED staff Communicating the role of the NP in the ED to hospital staff outside of the ED. Consulting the ED staff for their input before the NP was integrated Providing education and awareness programs about the NP role to ED staff Did the ED staff receive information about the NPs role before the role was introduced? No Yes If yes, please specify how you received this information (e.g., discussed in a meeting, pamphlet):

6 Section II Barriers Attracting Nurse Practitioners to Emergency Departments 8. Please indicate what you think were the barriers to integrating NPs into your emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. NPs are difficult to recruit (e.g., few NPs respond to recruitment efforts) Few NPs are interested in positions available in emergency departments Emergency departments have only recently begun to recruit NPs There are not enough pay incentives for NPs to work in emergency departments (e.g., extra pay on weekends) Nurse Practitioner Job Description 9. Consider some of the factors that create barriers to the Nurse Practitioner in his/her ability to work in the emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. Lack of a clear job description for the NP Lack of written guidelines about what NPs can and cannot do Lack of clarity about the NP role Uncertainty about the NPs role Lack of MDs understanding of the NP s role Confusion about where the NP role fits in the many levels of nursing Lack of awareness by the NP of the role he/she was hired to perform Lack of ledge by RNs of the NPs scope of practice

7 Knowledge of the Nurse Practitioner s Role 10. Consider the role of the Nurse Practitioner within your emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. NPs can work independently in the emergency department The NP is able to practice under a wider-scope in the community than in emergency department NPs work independently because they follow medical directives Physicians should always supervise the NP I had a good understanding of a NP s role before he/she was integrated into the ED Having a good understanding of NPs educational training helps the NP to integrate into emergency departments NPs education prepares them for the complexity of patient s health problems seen in emergency departments Previous training and experience in an emergency department definitely helps integrate a NP An ideal NP already has emergency department background and training Skills used an emergency department are unique and cannot be easily learned in other departments The NP practices under his/her own authority. The MDs should sign all of the NPs charts. The process of having the NP check with the MD is a very smooth process. I m not sure what the guidelines are as to what a NP is allowed to see in the ED. It may be useful to have some written guidelines about what an NP can and cannot do. I am not aware of any written guidelines that indicate what an NP can and cannot do in the ED. The NPs should review each patient with the MD. The Public Hospitals Act (PHA) is one of the biggest barriers to integrating NPs into the ED.

8 10. Consider the role of the Nurse Practitioner within your emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. The PHA should be changed so that the NPs can function more independently in the ED. The NP role in the ED is not restricted in any way. The PHA is not a barrier for the NP because he/she works under medical directives. The NP should be able to take over the fast-track area of the ED. Payment Structure of Emergency Department 11. Consider the type of payment plan the physicians receive in the emergency department, and whether it affects integrating Nurse Practitioners. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. An emergency department where MDs are fee-forservice creates a barrier to integrating the NPs An emergency department where MDs are on an alternative payment plan (e.g., salaried) creates a barrier to integrating the NPs Section III Ranking Facilitators and Barriers to the Integration of the Nurse Practitioner role Facilitators

9 12. In your experience, what factors facilitate effective integration of NPs in EDs? Check all that apply and rank the top 3 facilitators How the working relationship between the MD and NP is structured Co-workers understanding of the role of the NP Co-workers acceptance of the role of the NP Acceptance of the role of the NP by health care providers outside of the ED (e.g. specialist MDs) Practice style of the NP Expertise of the NP Confidence of the NP Acceptance of NP role by patients Acceptance of NP role by the Community Other (please specify) _ Facilitators Rank Top Three Do you have any comments regarding this section in general or any of the specific statements above? If so, please note Barriers 13. In your experience, what factors create barriers to effective integration of NPs? (Check all that apply and rank the top 3 barriers) Barriers Rank Top Three

10 13. In your experience, what factors create barriers to effective integration of NPs? (Check all that apply and rank the top 3 barriers) How the working relationship between the MD and NP is structured Co-workers level of understanding of the role of the NP Co-workers level of acceptance of the role of the NP Level of acceptance of the role of the NP by health care providers outside of the ED (e.g. specialist MDs) Practice style of the NP Expertise of the NP Confidence of the NP Resistance of patients to the NP role Resistance of the community to the NP role Lack of space for NP Inadequate funding for NP salary Inadequate funding for NP-related expenses (i.e., continuing education) Legislative barriers to NPs practicing within their scope of training (e.g. Public Hospitals Act, Regulated Health Professions Act) Other (please specify) Do you have any comments regarding this section in general or any of the specific statements above? If so, please note 14.How has your workload been affected by working with the NP? Increased _ % increase or _ hours per week Decreased _% decrease or _ hours per week

11 No change Not Applicable (e.g. have always worked with an NP) Do you have any comments regarding this section in general or any of the specific statements above? If so, please note 15.Is (or was) your role in the ED clearly defined? Yes No 16. In an average week, please allocate what percentage of your time is spent on each of the following categories of duties: Percentage of Time Patient care Education Clerical Personal/ professional development Research Administrative (meetings, writing protocols) Total 100% 17. What percentage of time do you spend providing the following types of services to your clients? (check all that apply) Percentage of Time Wellness care/health promotion (including teaching) Care of minor acute illness

12 Monitoring of chronic illness Care of major acute illness Care of palliative patients Other (specify) _ Total 100% Do you have any comments regarding this section in general or any of the specific statements above? If so, please note 18.Please provide an estimate of the breakdown of the patient population that you (not the practiced) serve. Percentage of Time Wellness care/health promotion Patients with minor acute illness Patients with chronic illness Patients with major acute illness Patients with mental health problems Palliative patients Other (specify) _ Total 100% Do you have any comments regarding this section in general or any of the specific statements above? If so, please note below 19.Please estimate the average numbers of patients you provide care for in a shift (direct care, telephone follow-up) Average number of hours worked per shift Average number of patients seen per shift

13 20. What factors in your practice setting create barriers to your ability to fulfill your NP role? (Check all that apply and rank top 3 barriers) The personality and philosophy of physicians with whom I practice Orientation of the health care team to my role The nature of my employment relationship (i.e. collaborative practice, consultative practice, etc) The way my role has been defined too narrow The way my role has been defined too broad My educational preparation through the NP program My work experience prior to entering the NP program Barriers imposed by legislation such as the Public Hospitals Act Barriers imposed by health care financing (i.e. NP can t refer directly to specialist and specialists can t bill for referral from NP) Lack of my own confidence to take on the responsibilities of this new role Resistance from other health care providers in the ED Resistance from other health care providers outside the ED Resistance from patients Resistance from community Isolation in practice (i.e. hard to be the only NP in this setting) Too few patients to practice in this role satisfactorily Too many patients to practice in this role satisfactorily Limitations of space (e.g. not enough room in the office) Limitations of funding (i.e. lack of money for health promotion, travel, etc) Other (please specify) Barriers Rank Top Three

14 22. Have the physicians in the ED expressed any concerns regarding your scope of practice and their liability? Yes go to 23a & b No go to 24 23a. If yes, how have these concerns been addressed? We have discussed then and resolved the concerns We are still discussing these concerns These concerns have not been discussed 23b. Do you view this issue as a barrier to your practice? Yes No 24. Do you have any concerns regarding your own liability as a Nurse Practitioner? Yes go to 25a & b No go to 26 How Often Sometimes Often 25a. If yes, what are some of the reasons for these concerns? (Check all that apply) I feel that I am asked to practice outside of my scope I feel that I am not given enough information to treat patients properly I feel that I am not competent to perform some of the tasks I am asked to perform I feel that my liability insurance is inadequate Other (specify) 25b. Do you view this issue as a barrier to your practice? Yes No 26. If you could give advice to another ED about introducing or supporting an NP what would you say? What works? What doesn t work?

15 Comments: Strategies used by the Nurse Practitioner 27. Consider possible strategies you used to help integrate yourself into the emergency department. Please indicate whether you agree or disagree with each of the following statements by checking ( ) one box only. Does not apply Being very low key in the beginning really helped me to be integrated into the ED Educating the emergency department staff about my role as an NP was necessary to integrate into the department Inquiring about which duties the emergency department did not like to do, and then doing those duties myself Explaining the role of an NP to each patient I see Networking with other NPs who are already integrated into emergency departments Do you have any comments regarding this section in general or any of the specific statements above? If so, please note 28. Do you use Information Technology for any of the following? (check all that apply) Yes Number of months you have used it Electronic patient records Patient management features (e.g., preventative alerts) Generating statistical reports Communicating with labs Referral letters Clinical practice guidelines Tracking patient encounters Other (specify)

16 29. What are the 3 most positive aspects of your NP role? a. b. c. 30. What are the 3 most negative aspects of your NP role? a. b. c. 31. Any other comments you would like to make about your experience with the Nurse Practitioner in the Emergency Department or as an NP: Section VI - Personal Profile 1. Gender: Male Female 2. Your age: _ Years 3. What is the highest level of education that you have completed? Year of Graduation Undergraduate degree (BScN, MD) Post degree Program (COUPN, residency) Graduate Degree (MSc., PhD) 4. How long have you worked as an NP or MD in an ED? Less than one year 25 months to 36 months 12 months to 24 months More than three years

17 5. In the ED, I see patients in the following CTAS levels: (check all that apply): (CTAS) Level 1 Level 2 Level 3 Level 4 Level 5 6. In your opinion, in the ED, I should see patients in the following CTAS levels (check all that apply): Level 1 Level 2 Level 3 Level 4 Level 5 Please provide your name and address in order to be entered in the draw for $ This page will be removed from the questionnaire and dropped into a draw box. In this way, your name will not be linked at any time to the answers you have given on this survey. Name (Please print): Address (Please print): Street & Apt #: City: Postal Code: Phone Number (optional): THANK YOU FOR COMPLETING THIS SURVEY. PLEASE RETURN IT WITHIN ONE WEEK IN THE STAMPED ADDRESSED ENVELOPE THAT IS ENCLOSED.

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