THE NUMBER OF patients treated in emergency care settings in the United States between 1996 and 2006 increased by 32% whereas the number of facilities providing emergency care decreased (Pitts, Niska, Xu, & Burt, 2008). This increase in demand and decrease in resources resulted in emergency department (ED) overcrowding and increased waiting times for care. In response to this increase in demand for services, there is growing interest in the role of the emergency nurse practitioner (ENP). The use of nurse practitioners in this setting is still a relatively new healthcare delivery model. In 2006, only 4.2% of ED visits were managed by Advanced Practice Registered Nurses (APRN) in the United States (Pitts et al.).
Both the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) have issued policy papers recognizing the ENPs' role in emergency care (Emergency Nurses Association, ENA, 2007; American College of Emergency Physicians, 2003). Although an ENP certification test does not exist at this time, the ENA is investigating the development of a validation process for nurse practitioners in emergency care. As a part of that quest, the ENA approved a set of competencies for nurse practitioners working in this setting in 2008 (ENA, 2008).
There are very few advanced practice nursing programs in the United States with a specialization in emergency care. The ENA supports development of programs with this specialization and provides a framework for this curriculum through publications such as Competencies for Nurse Practitioners in Emergency Care, Scope of Practice for the Nurse Practitioner in the Emergency Care Setting, Standards of Practice for the Nurse Practitioner in the Emergency Care Setting, and Advanced Practice in Emergency Nursing (ENA, 2009). An important aspect of creating more educational programs with the specialization and expanding the role of the nurse practitioner in this setting is determining patients' willingness to be treated by an ENP.
There is very little in the literature regarding patients' perception of care by nurse practitioners in the ED. The majority of studies that do exist are from healthcare systems outside of the United States (Corbett & McGuigan, 2008; Moser, Abu-Laban, & van Beek, 2004; Thrasher, & Purc-Stephenson, 2008). Because of the unique structure of the U.S. healthcare system, these studies are not readily applicable to the healthcare settings in the United States.
REVIEW OF THE LITERATURE
The number of APRNs in the United States grew from approximately 102,649 in 2000 to more than 141,209 in 2004 (U.S. Department of Health & Human Services, 2004). In 2007, The American Academy of Nurse Practitioners (AANP) reported that 325 universities and colleges prepared close to 6,000 new nurse practitioner graduates (American Academy of Nurse Practitioners, 2009). As the supply of nurse practitioners increases, there is increased interest in the contributions these providers make to healthcare in the United States. The American College of Physicians recently released a monograph recognizing the contributions of nurse practitioners in primary care. Although this article acknowledges concerns over the variation in education and certification of APRNs, it does recognize the importance of the APRN role in primary care and supports the inclusion of this healthcare provider in pilot programs related to a medical home (American College of Physicians, 2009).
APRNs have traditionally worked in adult and pediatric primary care settings. Recent data suggest that more APRNs are choosing to enter specialty practice settings (Rollet & Lebo, 2008). This increase in specialization and variation in educational preparation and licensure led to a consensus statement and the development of a regulatory model for APRN practice. This model promotes uniformity for licensure, accreditation, certification, and education (LACE) of advanced practice nurses. According to this consensus statement, advanced practice nurses must be prepared in one of four roles and one of six population foci. If an APRN chooses a specialty practice, such as emergency care, this education must be additional education beyond the preparation for the population foci (APRN Consensus Work Group & National Council of State Boards of Nursing ARPN Advisory Committee, July 2008). The majority of existing ENP programs prepare students for certification in family or acute care programs with a family/individual life span population foci. There is very little literature concerning patient perceptions of nurse practitioners in specialty areas.
Recent studies that focus on patient satisfaction with care provided by ENPs were conducted in Australia, Canada, and the United Kingdom (Corbett & McGuigan, 2008; Thrasher & Purc-Stephenson, 2008; Wilson & Shifaza, 2008). Thrasher and Purc-Stephenson (2008) conducted a survey in Canada and found that patients were satisfied with the attentiveness of the care, treatment, and information they received from the ENP. This study reported that 71% of the patients surveyed (n = 113) preferred to see the APRN, whereas 29% preferred to see the physician (Thrasher, & Purc-Stephenson, 2008). Corbett and McGuigan (2008) surveyed patients (n = 930) in a U.K. minor injury and illness clinic, and they also found that patients were satisfied with the care they received from nurse practitioners. Wilson and Shifaza (2008) audited 100 charts and surveyed 57 patients in an Australian minor injury and illness facility, and they also found that the majority of patients were satisfied with their care. The lack of recent U.S. studies evaluating patient satisfaction with nurse practitioner care in the ED may be related to the very low percentage of care currently provided by ENPs in the United States.
One step in facilitating the expansion of the ENP role is to evaluate patients' willingness to be treated by this provider. Moser et al. (2004) surveyed ED patients in British Columbia, concerning their perception of treatment by an APRN. The results indicated that most patients, 72.5%, were willing to be treated by an APRN for their current condition, 15% were uncertain, and 12.2% said they were not willing to be treated by a nurse practitioner. The healthcare system of Canada is vastly different from that of the United States and the limited number of presenting complaints included in this population limit the applicability of these findings for a U.S. facility.
Many hospital EDs contract independent physician groups to provide emergency care in their agencies. The hospital and the involved physician group determine whether they will use APRNs in their model of care. McGee and Kaplan (2007) state that physician education regarding the value of APRNs in emergency care is vital to increase their utilization. A better understanding of patients' perceptions of treatment by an APRN in the ED is an essential component of that education. This study was a modified replication of that by Moser et al. (2004) and used US facilities, a modified survey, and an expanded fast track population.
The research design for this study was a descriptive survey conducted in three Southeastern U.S. EDs, which varied in location and patient volume. The 2008 annual volumes for those EDs varied from 37,000 to 65,000 patient visits.
PROCEDURE AND DATA COLLECTION
After an ED was selected as a study site, the researchers met with the nurse manager and the leader of the emergency physician group to review the study design and procedure and to ask for their participation in the study. All three agencies approached agreed to participate. Registered nurses assigned to the fast track area of the participating EDs distributed surveys to patients as they waited for care in the fast track unit. Each survey contained a cover letter that explained the purpose of the survey, defined a nurse practitioner, and explained that participation was voluntary. The cover letter detached from the survey so that the patient had a copy. In addition to the written informed consent, study participants were informed verbally by the fast track nurse that the survey was voluntary and that their participation in the survey would not affect their ED care. Patients were given a ballpoint pen for completion of the survey. A box labeled “Nurse Practitioner Survey” was placed by the triage desk for survey return. The researchers collected surveys from the box twice a week. The researchers were available by telephone for any questions the triage nurse might have.
The survey is a 1-page questionnaire designed by the researchers on the basis of the survey used by Moser et al. (2004). Although the survey is significantly different from the original study, the authors of the first study were contacted and permission to use their survey as a template for this study was obtained. The survey was distributed to four APRNs with ED experience, for feedback and content validity. Minor changes to spacing and wording were integrated into the survey on the basis of feedback from these content experts. Consistent with the study by Moser et al. (2004), the survey was designed to take approximately 5 minutes to complete and the cover letter explained the purpose of the study and provided a definition of a nurse practitioner. The cover letter and survey are displayed in Tables 1 and 2.
SUBJECTS AND SETTINGS
Adult patients triaged to ED fast track units in the Southeastern United States comprise the population for this study. The study sample was a convenience sample from three EDs. Study participants were ED patients triaged to a fast track area, older than 18 years, English speaking, and legally able to sign for their own treatment. To avoid patient confusion regarding their care, surveys were not distributed on days when an APRN was working in the fast track area.
The EDs for this study were chosen because of their variation in location and patient volume. The first facility is the only ED in the municipal area. The annual ED volume is approximately 50,000 patients, with 17,633 fast track visits. The second facility is a suburban branch of a very large hospital system. The annual volume is 37,000 with 9,300 annual fast track visits. The third facility is an inner city ED located within close proximity to several other EDs, including a level 1 trauma center. The third facility has on average 60,000–65,000 annual ED visits and a fast track volume of approximately 21,900 annual visits. A minimum goal of 30 surveys from each facility was established prior to data collection.
Approval for the study was obtained by the institutional review committee for each healthcare agency and from a local university. Two hundred surveys were delivered to each facility to be consecutively distributed by the registered nurse assigned to the fast track area to all fast track patients who met the study criteria. Of the 600 surveys, 300 (50%) were distributed during the study time frame. Of the 300 surveys distributed, 190 were returned, for a response rate of 64%. The researchers and the fast track nurses identified several reasons for the low survey-distribution rate. Survey distribution was interrupted when an APRN was on duty. Other limitations to distribution included extremely high patient volume in the EDs during the study period and a large number of patients being held in the ED waiting on inpatient beds. During the study period, one facility had to relocate the fast track section of the ED to accommodate the main ED patient volume. Table 3 summarizes the facility fast track volume, the number of surveys distributed, and the survey response rate from each facility.
Table 4 illustrates the demographic characteristics of the survey sample. A majority of the respondents (54%) were between the ages of 25 and 44 years and 64% were women. Fifty-nine respondents did not list the reason for their visit. Of the 131 reported chief complaints, the three most commonly reported involved the musculoskeletal system (n = 37; 28%); wounds and injuries (n = 37; 28%); and eye, ear, nose, and throat complaints (n = 18; 14%).
The majority of patients (n = 123; 65%) responded that they were willing to be treated by a nurse practitioner for their current condition. Thirty-two (17%) responded that they were not sure whether they wanted to be treated by a nurse practitioner for the current complaint, 33 (17%) indicated they were not willing to be treated by a nurse practitioner for their current condition, and 5 did not respond. If respondents indicated that they were not willing to be treated by a nurse practitioner, they were asked what conditions would influence their decision to be treated by a nurse practitioner. Participants included multiple answers to this question. The majority of participants (n = 23; 70%) indicated that if they had a different problem from the one they presented with on this day, they would be willing to be treated by a nurse practitioner. Two (6%) wrote in that they wanted to see only a physician, and four (12%) participants did not answer this question. Table 5 illustrates the responses to this question.
When asked whether they had been treated by a nurse practitioner before this visit, 108 (56%) responded “Yes,” 42 (22%) responded “No,” and 40 (21%) responded that they were not sure. Of the patients who had been treated by a nurse practitioner in the past, 100 (93%) indicated that they were satisfied with the care they received from a nurse practitioner.
Chi-square analysis indicated that willingness to be treated by an APRN for this ED visit was dependent on whether or not the patient had been treated by a nurse practitioner in the past X2 (4, N = 187) = 12.657, p = 0.013. Chi-square analysis, at the significance level of less than 0.05, indicated that one's willingness to be treated by a nurse practitioner was independent of race: X2 (4, N = 188) = 2.707, p = 0.608; gender: X2 (2, N = 183) = 1.665, p = 0.433; age: X2 (6, N = 188) = 11.026, p = 0.088; or ED facility: X2 (4, N = 190) = 9.199, p = 0.056.
Participants provided very few comments in the space provided. The few comments made by participants willing to be seen by a nurse practitioner included, “I feel that if you are here to help patients it doesn't matter if you are a nurse practitioner or a doctor, the patient is the important factor,” “I think it would be great,” and “I came here for help and if they can help, so be it.” Comments by patients who indicated that they were not willing to be seen by a nurse practitioner included, “I was sent here by my doctor for treatment” and “If I wanted to be seen by a nurse practitioner I would have gone to a clinic.”
Studies in Australia, Canada, and the United Kingdom demonstrate that patients are willing to be treated by a nurse practitioner in an emergency care setting and that they are satisfied with the care they receive (Corbett & McGuigan, 2008; Moser et al. 2004; Thrasher, & Purc-Stephenson, 2008; Wilson & Shifaza, 2008). This survey of ED fast track patients in the Southeastern United States indicated that a majority of patients are willing to be treated by a nurse practitioner. Patients treated by a nurse practitioner in the past indicated that they were satisfied with the care they received. Results of this survey also indicated that patients treated by a nurse practitioner in the past were more willing to be treated at present by a nurse practitioner for ED fast track visit.
Participants who were not willing to be treated by a nurse practitioner for this visit were asked whether they would be willing to see a nurse practitioner under different conditions. The majority indicated that if they had a problem different from the current complaint, they would be willing to see a nurse practitioner. Surprisingly, only a small percentage of patients not willing to be seen by a nurse practitioner for this visit would change their mind if it reduced their wait time, saved them money, or included more physician involvement.
Presently, nurse practitioners provide a very limited amount of care in EDs. If the number of nurse practitioners providing care in EDs increases and more patients are treated by a nurse practitioner, the number of ED patients willing to see a nurse practitioner may also increase. The noteworthy number of patients who indicated that they were not sure whether they were willing to be treated by a nurse practitioner signals the need for further public education concerning the nurse practitioner role.
Limitations in this study include the convenience sampling technique. Additional limitations included the low number of surveys distributed because of high patient volumes, the relocation of the fast track at one facility, and the interruption of survey distribution when a nurse practitioner was working in fast track. The high-stress, unpredictable nature of the study environment may also have influenced participant response. A lack of survey distribution during busy periods may have influenced the survey results.
IMPLICATIONS FOR ADVANCED PRACTICE EMERGENCY NURSING
Nurse practitioners are meeting the needs of patients, as indicated by reports of patient satisfaction with the care they receive from APRNs. The results of this study support adding nurse practitioners to patient care teams in EDs in the Southeastern United States. Efforts to increase public awareness of the nurse practitioner role are warranted.
RECOMMENDATIONS FOR FUTURE RESEARCH
Both qualitative and quantitative studies are needed on the willingness of emergency physician groups to incorporate nurse practitioners into their practices. This study should be replicated using a larger national sample. Additional studies that focus on the cost-effectiveness of using nurse practitioners in this setting will be useful to evaluate this practice model. As the number of nurse practitioners practicing in the emergency setting grows, outcome studies focusing on the quality of care APRNs provided in this setting are warranted.
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