Mapping workforce configuration and operational models in Australian emergency departments: a national survey.

Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population sample (n=135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P=0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development.

Review article: Diagnostic accuracy of risk stratification tools for patients with chest pain in the rural emergency department: A systematic review.

Risk stratification tools for patients presenting to rural EDs with undifferentiated chest pain enable early definitive treatment in high-risk patients. This systematic review compares the most commonly used risk stratification tools used to predict the risk of major adverse cardiac event (MACE) for patients presenting to rural EDs with chest pain. A comprehensive search of MEDLINE and Embase for studies published between January 2011 and January 2015 was undertaken. Study quality was assessed using QUADAS-2 criteria and the PRISMA guidelines.Eleven studies using eight risk stratification tools met the inclusion criteria. The percentage of MACE in the patients stratified as suitable for discharge, and the percentage of patients whose scores would have recommended admission that did not experience a MACE event were used as comparisons. Using the findings of a survey of emergency physicians that found a 1% MACE rate acceptable in discharged patients, the EDACS-ADP was considered the best performer. EDACS-ADP had one of the lowest rates of MACE in those discharged (3/1148, 0.3%) and discharged one of the highest percentage of patients (44.5%). Only the GRACE tool discharged more patients (69% - all patients with scores <100) but had a MACE rate of 0.3% in discharged patients. The HFA/CSANZ guidelines achieved zero cases of MACE but discharged only 1.3% of patients.EDACS-ADP can potentially increase diagnostic efficiency of patients presenting at ED with chest pain. Further assessment of tool in a rural context is recommended.

The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: a systematic review.

AIMS: To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients. BACKGROUND: The delivery of quality care in the emergency department is emerging as one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services. DATA SOURCES: A comprehensive search of four electronic databases from 2006 to 2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago. REVIEW METHODS: A three step approach was used. Following a comprehensive search, two reviewers assessed all identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data were extracted using standardised tools. RESULTS: Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding outcomes of a cost benefit analysis. CONCLUSION: Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reform of emergency service provision. The findings suggest that further high quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in evidence based health service planning.

Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing.

AIM: This paper presents a discussion on the application of a capability framework for advanced practice nursing standards/competencies. BACKGROUND: There is acceptance that competencies are useful and necessary for definition and education of practice-based professions. Competencies have been described as appropriate for practice in stable environments with familiar problems. Increasingly competencies are being designed for use in the health sector for advanced practice such as the nurse practitioner role. Nurse practitioners work in environments and roles that are dynamic and unpredictable necessitating attributes and skills to practice at advanced and extended levels in both familiar and unfamiliar clinical situations. Capability has been described as the combination of skills, knowledge, values and self-esteem which enables individuals to manage change, be flexible and move beyond competency. DESIGN: A discussion paper exploring 'capability' as a framework for advanced nursing practice standards. DATA SOURCES: Data were sourced from electronic databases as described in the background section. IMPLICATIONS FOR NURSING: As advanced practice nursing becomes more established and formalized, novel ways of teaching and assessing the practice of experienced clinicians beyond competency are imperative for the changing context of health services. CONCLUSION: Leading researchers into capability in health care state that traditional education and training in health disciplines concentrates mainly on developing competence. To ensure that healthcare delivery keeps pace with increasing demand and a continuously changing context there is a need to embrace capability as a framework for advanced practice and education.

Using the Donabedian framework to examine the quality and safety of nursing service innovation.

AIMS AND OBJECTIVES: To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure, Process and Outcome. BACKGROUND: Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation. DESIGN: A mixed-methods design within the Donabedian evaluation framework was used. METHODS: The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n = 36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes. RESULTS: The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients. CONCLUSIONS: This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components. RELEVANCE TO CLINICAL PRACTICE: Understanding the Structure and Process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care.

Development of clinical competencies for emergency nurse practitioners: a pilot study.

BACKGROUND: Nurse practitioner education and practice has been guided by generic competency standards in Australia since 2006. Development of specialist competencies has been less structured and there are no formal standards to guide education and continuing professional development for specialty fields. There is limited international research and no Australian research into development of specialist nurse practitioner competencies. This pilot study aimed to test data collection methods, tools and processes in preparation for a larger national study to investigate specialist competency standards for emergency nurse practitioners. Research into specialist emergency nurse practitioner competencies has not been conducted in Australia. METHODS: Mixed methods research was conducted with a sample of experienced emergency nurse practitioners. Deductive analysis of data from a focus group workshop informed development of a draft specialty competency framework. The framework was subsequently subjected to systematic scrutiny for consensus validation through a two round Delphi Study. RESULTS: The Delphi study first round had a 100% response rate; the second round 75% response rate. The scoring for all items in both rounds was above the 80% cut off mark with the lowest mean score being 4.1 (82%) from the first round. CONCLUSION: The authors collaborated with emergency nurse practitioners to produce preliminary data on the formation of specialty competencies as a first step in developing an Australian framework.

Clients' understanding of the role of nurse practitioners.

Nurse practitioners (NPs) have an emerging role in the Australian health care system. However, there remains a dearth of data about public understanding of the NP role. The aim of this study was to evaluate clients' understanding of the role of the NP and their satisfaction with education received, quality of care and NP knowledge and skill. All authorised NPs working in a designated NP position in Western Australia and those working in three area health services in New South Wales were invited to recruit five consecutive clients to complete the self-administered survey. Thirty-two NPs (NP response rate 93%) recruited 129 clients (client response rate 90%). Two-thirds of clients (63%) were aware they were consulting an NP. The majority rated the following NP-related outcomes as 'excellent' or 'very good': education provided (89%); quality of care (95%); and knowledge and skill (93%). Less than half reported an understanding that NPs could prescribe medications (40.5%) or interpret X-rays (33.6%). Clients of NPs practising in a rural or remote setting were more likely than those in an urban setting to have previously consulted an NP (P = 0.005), and where applicable would to prefer to see an NP rather than a doctor (P = 0.022). Successful implementation and expansion of the NP role requires NP visibility in the community. Despite high levels of satisfaction, more awareness of the scope of the NP role is required.

Identifying measures for evaluating new models of nursing care: a survey of NSW nurse practitioners.

Health-care reforms in Australia and worldwide have seen the creation of the position of nurse practitioner (NP). To date, no protocol has been developed in Australia to guide the evaluation of this new role. All NSW authorized NPs were invited to participate in a self-administered questionnaire. Generic process and outcome measures of NP services were taken from a review of the literature. NPs were asked to determine how 'essential' each of these measures would be to describe their clinical practice. Of the 36 eligible authorized NPs in NSW, 30 returned completed questionnaires (83% response rate). The following measures were rated 'essential' by all (100%) NPs: presenting issue as stated by patient; current medications; patient satisfaction with education, quality of care received, and provider knowledge and skill. Our results provide a unique set of indicators with which to evaluate process and outcome measures of NP services. Standard outcome measures will enable NPs to evaluate their service efficiently and to benchmark against other NPs.