Hong Kong Journal of Emergency Medicine Nurses treating patients in the emergency department? A patient survey YS Ong, YL Tsang, YH Ho, FKL Ho, WP Law, CA Graham, TH Rainer Background: Hong Kong residents are familiar with prolonged waiting times in emergency departments (ED), particularly with semi-urgent or non-urgent conditions. In the United Kingdom and Australasia, extended nurse practitioners are well established. The aim of this study was to identify whether Hong Kong patients would prefer treatment by ED nurses or traditional care by doctors under various waiting time conditions. Methods: This was a prospective questionnaire study of patients who had been triaged into category 4 (semi-urgent) or 5 (non-urgent) during office hours from 20 to 27 June 2005. Following verbal consent, three waiting time scenarios were considered by the patient using an interviewer-administered structured questionnaire. Statistical analysis used the chi square test. Results: Overall, 253 patients were approached and 249 patients [119 (47.8%) male; mean age 48 (SD 19.4) years] verbally agreed to participate (98.4%). Patients were classified into three age groups. When the waiting time for nurse treatment was four hours shorter than doctors, patients aged 15-30 and 31-64 years more often chose nurses (overall 59.3%) for treatment but those aged 65 years preferred doctors to nurses (58.1% in favour of doctors), despite the longer waiting time (p=0.013, chi square test). Men also preferred nursing treatment compared to women (p<0.001). When the waiting time for doctors was 4 hours shorter than nurses or the same, 99.2% and 95.5% chose doctors respectively. Conclusion: When the waiting times are long, Hong Kong patients <65 years would prefer to see suitably trained nurses in preference to doctors. Consideration should be given to providing training for senior nurses to have an extended role in Hong Kong EDs. (Hong Kong j.emerg.med. 2007;14:10-15) 27 2005 6 20 253 249 119 47.8% 48 19.4 98.4% Correspondence to: Colin A Graham, MPH, FRCS, FCEM Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Trauma and Emergency Centre, Shatin, N.T., Hong Kong Email: cagraham@cuhk.edu.hk Ong Yin Sheng, MBBS, MRCSEd, FHKAM(Emergency Medicine) Tsang Yuk Ling, BN, MSc, RN Ho Yim Ha, MBChB Ho Kwok Leung, Franklin, MBChB Law Wai Ping, MBChB Timothy H Rainer, MD, FCEM, FHKAM(Emergency Medicine)
Ong et al./nurses treating patients? 11 15-30 31-64 59.3% 65 p=0.013 58.1% p<0.001 99.2% 95.5% 65 Keywords: Nurse clinicians, nurse practitioners, nurse's role, patient satisfaction, time factors Introduction Residents in Hong Kong are no strangers to overcrowding and prolonged waiting times in emergency departments (ED) across the territory. 1 This is in line with the experience throughout the world, with similar problems being reported in the United States, 2 United Kingdom (UK), 3 and Australasia. 4 Patients with semi-urgent (triage category 4) or nonurgent (triage category 5) conditions often have to wait for several hours to see an ED doctor. 'Long waiting times in EDs' occasionally appears in the headlines of local newspapers when patients have to wait more than six hours before being seen by ED doctors. The long waiting time can be a great source of frustration not only to patients, but also to health care personnel. Disgruntled patients and their accompanying relatives have been witnessed "storming" the nursing counter, demanding to see doctors earlier: this is a common sight in local EDs. ED staff are under pressure from clinical and non-clinical sources and they work under constant threat of verbal abuse and sporadic physical violence by agitated patients and relatives. A proportion of patient complaints have been attributed to long waiting times. 5 Despite the implementation of the ED service charge since November 2002, there has only been a modest drop in ED attendances. 6 In the UK and Australasia, the concept of extended nurse practitioners (ENP) or advanced practice nurses is well established. 7-10 This came as a result of the urge for nurses to exercise greater professional knowledge and to assume a more autonomous role in practice. They provide a protocol-based extended scope of nursing, including assessment, treatment and discharge for patients presenting with minor injuries and illnesses. They have to undergo significant training periods to be capable of performing this role, and start by working under supervision; with increasing experience they become more autonomous. In some parts of the UK, ENPs work independently in rural and difficult to staff areas to provide a minor injury and illness service to the local communities. The aim of this study was to identify whether ED patients in Hong Kong would be willing to have their diagnostic and treatment process performed by nurses in the ED under different waiting time conditions as opposed to doctor-provided care. If patients were willing to have such care provided, this might offer at least a partial solution to the ED waiting time issue in Hong Kong. Methods Study design The questionnaire study was carried out between 09:00 hour and 18:00 hour daily between 20 June and 27 June 2005. Following verbal consent, patients who had been triaged as semi-urgent (triage category 4) or non-urgent (triage category 5) conditions were asked to consider three different scenarios to ascertain their opinion on being seen and treated by senior nurses in the ED, taking into consideration the prevailing waiting time. The survey was conducted using an intervieweradministered structured questionnaire (Figure 1).
12 Hong Kong j. emerg. med. Vol. 14(1) Jan 2007 Figure 1. English and Chinese versions of the questionnaire. A brief introduction as outlined in the questionnaire form was given to the respondents. Interviewers were available to answer any queries from the patients. The questionnaire form and interview format were piloted prior to the start of the study and data collection. Inclusion and exclusion criteria Consecutive patients designated as semi-urgent (triage category 4) or non-urgent (triage category 5) at the triage station between the hours stated previously, whether ambulatory or non-ambulatory, were identified and approached. Patients aged below 15 years and patients with abnormal mentation were excluded. Data collection Three scenarios were posed and patients were asked questions by the interviewers about their preference for being assessed and treated by either a doctor or trained senior nurse, with the waiting time taken into account. The patient's age, sex and triage category were recorded on the questionnaire (Figure 1). Details of the three scenarios are given as in Figure 1. The patients were classified by sex and into three age groups (age 15 to 30 years; age 31 to 64 years; age 65 years or above) for analysis. Data was entered on to an Excel (Microsoft Corporation) worksheet and analysed using SPSS v13.0 (SPSS Inc; Chicago, Ill, USA). Categorical data were presented. Statistical analysis to compare the three age groups was performed by means of the chi square test. Results Overall, 253 patients were approached during the study period and invited to participate, and 249 verbally agreed to be interviewed (98.4%).
Ong et al./nurses treating patients? 13 There were 119 (47.8%) male and 130 (52.2%) female respondents. The respondents' age ranged from 15 years to 90 years, with a mean of 48 years (standard deviation 19.4 years). The patients were classified into three age groups: 55 (22.1%) patients were aged 15 to 30 years, 132 (53.0%) were between 31 and 64 years and 62 (24.9%) patients were aged 65 years. For Question 1, 249 valid responses were recorded as shown in Table 1. Patients aged 65 or above were more likely to prefer a doctor to a nurse, despite long waiting time. Younger patients (age 15-64) were more inclined to choose a senior nurse to manage their illness. Overall, there were significant differences between the age groups as to their choice of health care provider (p=0.013, chi square test). More men were willing to have treatment from a nurse (84/119, 70.6%) whereas most women preferred to wait for a doctor (77/130, 59.2%), p<0.001 by chi square test. For Question 2, 245 valid responses were recorded as shown in Table 2. Almost all respondents chose the doctor. There was no difference between the age groups (p=0.6, chi square test). There was also no difference between men and women (p=0.2, chi square test). For Question 3, 246 valid responses were recorded as shown in Table 3. Again most respondents chose the Table 1. Question 1 by age group: "If your illness/injury is semi-urgent or non-urgent, would you prefer to wait up to 6 hours to see a doctor for assessment and treatment or to wait 1-2 hours to see a nurse for assessment and treatment?" Count (% within age group) Total Doctor Nurse Age group (years) 15-30 17 (30.9%) 38 (69.1%) 55 (100%) 31-64 59 (44.7%) 73 (55.3%) 132 (100%) 65 36 (58.1%) 26 (41.9%) 62 (100%) Total 112 (45.0%) 137 (55.0%) 249 (100%) Table 2. Question 2 by age group: "If your illness/injury is semi-urgent or non-urgent, would you prefer to wait up to 6 hours to see a nurse for assessment and treatment or to wait 1-2 hours to see a doctor for assessment and treatment?" Count (% within age group) Total Doctor Nurse Age group (years) 15-30 55 (100%) 0 (0%) 55 (100%) 31-64 128 (99.2%) 1 (0.8%) 129 (100%) 65 60 (98.4%) 1 (1.6%) 61 (100%) Total 243 (99.2%) 2 (0.8%) 245 (100%) Table 3. Question 3 by age group: "If the waiting time to see a doctor or a nurse is the same, whom would you prefer?" Count (% within age group) Total Doctor Nurse Age group (years) 15-30 52 (94.5%) 3 (5.5%) 55 (100%) 31-64 124 (95.4%) 6 (4.6%) 130 (100%) 65 59 (96.7%) 2 (3.3%) 61 (100%) Total 235 (95.5%) 11 (4.5%) 246 (100%)
14 Hong Kong j. emerg. med. Vol. 14(1) Jan 2007 doctor. There was no difference between the age groups (p=0.8, chi square test). Again, there was no difference between men and women (p=0.3, chi square test). Discussion In this questionnaire survey, 55% of the respondents preferred to be assessed and treated by a senior nurse rather than a doctor in face of a long waiting time. Men were more willing to have the opinion of a nurse compared to women. This might reflect the perceptions of the respondents who were triaged semi-urgent or non-urgent that their illness was not as serious as to warrant a doctor's attention and therefore they were happy to accept health care treatment from a senior ED nurse. This did not apply to the patients aged 65 years or above, as 58% within this age group chose the doctor despite up to a 6-hour waiting time. This may be explained by the fact that many of them are already retired and they do not mind spending many hours waiting to see a doctor in the ED. However, it may also reflect deeply held cultural beliefs that a doctor provides a higher standard of care compared to a nurse. Older people may also feel more 'entitled' to see a doctor by account of their seniority in society, and are unwilling to compromise on that. It remains unclear as to why men are more willing to have nursing assessment and treatment compared to women. On the other hand, if the time factor is taken out, almost all patients prefer a doctor to a senior nurse. This suggests that patients still have more faith and confidence in doctors' assessments and treatments, which is not surprising. However, reality is such that a long waiting time is a fact of life in many of Hong Kong's EDs, and the current system of offering every patient the chance to see a doctor may not be sustainable in the future. The high response rate may be attributable to the simplicity of the questionnaire. Minor injuries make up a sizeable proportion of the ED patient population. Aside from those who present to the ED independently, patients who have sustained minor cuts or small wounds are often referred to local EDs by general practitioners or government-run general outpatient clinics. They will have their wounds briefly assessed by a triage nurse, and usually be assigned to triage category 4, with a bandage applied if the wound is bleeding. They will then spend possibly some hours waiting before seeing a doctor. After the doctor's assessment, it would again be some time before their wounds get sutured (usually by a nurse in Hong Kong) or other definitive treatments completed. The management of patients with minor injuries (especially wounds and minor musculoskeletal injuries) is a promising area for extended nursing care. If patients with minor injuries were managed by trained, senior nurses working independently, it would serve to cut down the waiting time of this large group of patients and this could be achieved without compromise on the quality of care. Indeed, the reduction in waiting time could lead to an improvement in perceived quality of care. In conclusion, the response rate in this small study was very high, and hence the results would appear reliable. Since the study was carried out during the daytime and in Prince of Wales Hospital exclusively, applying these results to the whole ED patient population in Hong Kong may not be appropriate. Nevertheless, this study provides initial insights into the attitudes of ED patients with minor illnesses and injuries with respect to possibly being treated by senior ED nurses. Acknowledgement We would like to express our thanks to the nursing staff of the Emergency Department, Prince of Wales Hospital, for their efforts in supporting this study. References 1. Choi YF, Wong TW, Lau CC. Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department. Emerg Med J 2006;23(4):262-5.
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