Development of nurse practitioner role in emergency care - a framework based participatory action research project Presenter: Erika Boman, RNT, PhD, postdoc researcher Co-authors: Kim Garde, Rika Levy-Malmberg, Francis Wong & Lisbeth Fagerström
Emergency care - APN can positively impact ED throughput delivery of effective and high quality care patient satisfaction Carter, A.J. & Chochinov, A.H. (2007); Tucker, A. & Bernard, M. (2015); Jennings, N., Clifford, S., Fox, A.R., O'Connell, J. & Gardner, G. (2015); Wilson, K., Cameron, P. & Jennings N. (2008)
Norway First NP education in Norway started in 2011 in geriatric care (Henni et al., 2018) NP education with NPs prepared for emergency care was asked for Developed and started NP-education in August 2015 Masters level, 120 ECTS, part time 7 enrolled RNs from the ED to NP programme Providing person-centred healthcare - Development of new models of advanced nursing practice in cooperation with patients, clinical field and higher education
PEPPA framework Participatory Evidence-based Patient-centred Process APN role development, implementation and evaluation (Bryant-Lukosius, D., & DiCenso, A., 2004).
Aim To describe the development of a NP model in an emergency care department (ED) in Norway, being guided by the PEPPAframework
Data collection Work-shops (n=6) Interviews (n=16) 2015-2016 2017 Observations (40 hours) Written material: work descriptions, statistical reports, and Grey and scientific literature
Analysis Thematic analysis (Braun & Clarke, 2006; Clark & Braun, 2013). The material was analysed in two steps 1. Theoretical/concept-driven (deductive) coding; used the PEPPA-framework as a matrix to sort the material under the five first steps 2. Inductive analyse the material under each step/heading
Setting (in brief) ED offering 24-hour care for patients with medical, surgical and/or orthopaedic diseases or injuries Organized under the orthopaedic clinic 28 000 annual patient visits Registered nurses, n=55 some NSs Junior doctors, n=26 placement ranging over six-month period Senior doctor n=1 and consultants Traditional care model Registered nurse Junior doctor Senior doctor/consultants
Stakeholders and participants Pre-project work (eg. planning NP education and the project) Recruitment of steering group Recruitment of NP students (2015, n=5; 2016, n=2 affiliated to the ED) Reports on patient experience and satisfaction
Determine needs for new models for care (preliminary results) Long wait times, especially for non-urgent patients For patients with DVT (deep venous thrombosis) it can take years and days, become winter and spring before they are looked at. (Boman et al., 2018) the non-urgent patients occupy an incredible amount of resources and time and space without necessarily needing it also withholding doctors from doing work where they are most needed. (Boman et al., 2018) Room for improvement in patient satisfaction referring to continuity of care and discharge process, including self-care instructions and coordering continuation of care (Holmboe & Bjertnæs, 2016a; Holmboe & Bjertnæs, 2016b). Non-adherence to guidelines (eg. orthogeriatric hip fracture patients)
Priority problems and goals to improve model of care (preliminary results) Comprehensive care for orthogeriatric patients with hip fractures, including following evidence-based guidelines/standards of care New model of care for nonurgent patients stressing the ED, including reduced wait times
Define new model of care and NP role Structure Patient. Patients with hip fractures (preoperative care) and minor orthopaedic injuries/fractures. Predicted maximum length of stay: 72 hours. Organizational. Observation unit with 10 beds. NP led unit, supported by medical consultants. Nurse. 1 NP and 2 RN. Process NP independent role. Comprehensive assessment. Nurse and medical diagnostics including risks and initiate preventive actions. Observe, prepare for and discharge orthopedic patients including giving advice on self-care management. Order laboratory tests. NP dependent role. Prescribing. Surgical procedures in operation theatre. NP interdependent role. Case manager. Outcomes Adherence to guidelines/standards of care Patient satisfaction, person-centeredness and trust in receiving optimal treatment Wait times and LOS among patients with minor orthopaedic injuries/fractures
Conclusion There is a need for new models in emergency care NP role is understood to be a valuable contribution in the puzzle to offer patients high quality care at the right place, and at the right time Implementation of the NP role is a balancing act between using NP competence to the fullest, and starting in a small scale; to put everything in place before expanding the role It is prime time to execute next steps in PEPPA, i.e. implement and evaluate NP role in emergency care in Norway PEPPA is a comprehensive and eligible framework for NP role development, implementation and evaluation NP role
Thank you for listening...and also thanks to: - Norwegian Research Council (PRAKSISVEL) for founding - Staff in ED including NP students - Co-authors and research team
References Boman, E., Egilsdottir, H.Ö., Levy-Malmberg, R. & Fagerström, L. (2018). Nurses understanding of a becoming nurse practitioner role in the Norwegian emergency care context a qualitative study. Nordic Journal of Nursing research. Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. Carter AJ, Chochinov AH. (2007) A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM, 9(4), 286 295. Clarke, V. & Braun V. (2013). Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning. The Psycologist, 26, 120-123. Elder, E., Johnston, A.N. & Crilly, J. (2015). Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas; 27(5): 394 404. Henni, S.H., Kirkevold, M., Antypas, K. & Foss, C. (2018). The role of advanced geriatric nurses in Norway: A descriptive exploratory study. International Journal of Older People Nursing. doi: 10.1111/opn.12188. Jennings, N., Clifford, S., Fox, A.R., O'Connell, J. & Gardner, G. (2015). The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review. International Journal of Nursing Studies, 52(1), 421 435. Tucker A, Bernard M. Making the case for nurse practitioners in the emergency department: a clinical case study. Advanced Emergency Nursing Journal 2015; 37(4): 308 312. Wilson, K., Cameron, P., & Jennings, N. (2008). Emergency nurse practitioners: an underestimated addition to the emergency care team. Emergency Medicine Australasia, 20(6): 453 455.