The role of the Acute Care Nurse Practitioner (ACNP) is a topical issue and with increasing acuity of patients, it is not surprising that there is a need for advanced practitioners in this area (McMullen et al. 2001). Research has focused on the emergency nurse practitioners (ENPs) and this research has demonstrated their ability to care for low acuity patients within the Emergency Department (ED) (Barr et al. 2000, Byrne et al. 2000, Touche Ross 1994, Sakr et al. 1999). Most of the literature reports that Nurse Practitioners (NPs) are highly skilled, cost-effective and are able to provide a high level of care with better documentation compared with doctors (Spisso et al. 1990, Hylka & Beschle 1995, Cooper et al. 2002). Other studies have highlighted the patient's satisfaction levels with NPs (Rhee & Dermyer 1995, Spaite et al. 2002, Moser et al. 2004, Roblin et al. 2004). There is no doubt that the role of the ENP has been validated and the research demonstrates the advantages of the role in acute care. However, the care of the higher acuity patients has led many to consider an ACNP (Hollinger-Smith & Murphy 1998, Shapiro & Rosenberg 2002, Kleinpell 2005), as did Norris and Melby (2006) in their article examining the ACNP in the UK setting.
Norris and Melby (2006) carried out an exploratory study interviewing nurses and doctors in ED on their views on an ACNP. Within the article, Norris and Melby define an ACNP as an individual who can ‘…manage the health care of acutely ill patients at an advanced level…using…diagnostic reasoning and advanced therapeutic interventions’. This definition is taken from the American Nurses Credentialing Centre (2005) but what is not clear is whether Norris and Melby are applying this definition to their study. One issue is that the context in which the ACNP practises, therefore, further detail is needed on the types of advanced therapeutic that could be included (i.e. specifically relating to the ACNP position).
In the literature, the ACNP has been identified to manage acutely ill patients at an advanced level including intensive care units (ICU), cardiothoracic ICU, medical ICU and neurological ICUs (Kleinpell 2005). The type of procedures identified in Kleinpell's study of ACNPs included 12 lead ECG interpretation, pathology ordering and interpretation, performing intubation, management of invasive haemodynamic monitoring such as arterial lines and pulmonary artery catheters and performing cardioversions. Many of these skills identified as part of the ACNP role could also be performed by ENPs. Given that Norris and Melby are investigating perceptions on the ACNP role, it would have been beneficial to first identify which procedures the ENP perform and then outline the procedures that the ACNP could carry out as there would most likely be duplication of procedures within the roles.
The paper sets clear objectives examining the perceived boundaries and obtaining the opinions on the introduction of the ACNP role within ED. The design is appropriate and semi-structured interviews are acceptable to explore perceptions. However, a questionnaire examining their knowledge of the NP role (both emergency and acute care) may have potentially elicited more information on their knowledge of NP role and revealed the deficits in knowledge on aspects of the role. Knowledge deficits have been reported by Martin and Considine (2005). Norris and Melby reported that 22% of respondents were unsure about the role. One suggestion is that knowledge deficits could be identified by a knowledge questionnaire and also allow examination of which aspects the respondents are uncertain about.
The questions covered in the interview process appear to be negatively phrased especially with wording such as ‘advantages of the role if any’ and ‘concerns about role implementation’. Change management and uncertainty among staff are expected as with any new role or change in existing role (MacGuire 2006). A rewording of the items to convey positivity may have produced different perceptions.
With the results, the response rate of 47% among the doctors and nurses is commendable. However, only 19 doctors responded out of a possible 44. It would be interesting to explore why the remaining physicians did not respond and whether the low response rate was related to the NP role or some other issues. The length of experience of responders is of significance as the majority of nurses (n = 53) had more than three years emergency care experience, but the majority of doctors had <18 months experience (n = 10, 53%). Within the nursing respondents, 33% had 11 years or more experience but in the corresponding doctors, there were no respondents with that length of experience. One could speculate that if doctors with a longer exposure to ED had responded, the results might have been quite different.
The identification of support from the emergency consultants to implementing the role is positive. The other important factor for the ACNP role is the importance of knowledge and scope required for the role. The recognition of these is pertinent to implementing the role. Although these factors are important, they are hard to consolidate with other findings in the study. The importance of laboratory testing, ECG interpretation and prescribing medication were not seen as part of the ACNP role by the medical respondents. It is hard to consolidate the ACNP role without these skills as acutely ill patients would most probably require advanced diagnostics and interventions (as described by Kleinpell 2005). This would suggest that the doctors do not fully understand the extended scope of practice of an NP, especially an ACNP. The scope of practice of an ACNP needs to be defined as previously outlined.
The researchers transcribed the interviews and one theme that emerged was that of inter-professional conflict. A key point of ACNP is that the role cannot be independent but should be inter-dependent with the medical team and the associated Allied Health professionals. The ACNP needs to work very closely with the doctor for the role to work and a clear definition of the role also has to be established. This would reduce the risk of inter-professional conflict.
The perceived need for the ACNP role was also a theme that emerged. Part of this problem could be the lack of a clear definition of an ACNP and, therefore, a lack of clarity around the role. One argument that could be put forward is whether there is a need for an ACNP in ED when there is already the ENPs. I would argue that existing ENPs could extend their practice from the lower acuity patients to care for the higher acuity patients within the ED. The clinical skills identified as the three highest rated skills were cannulation and ordering pathology, X-ray ordering and interpretation and finally, suturing. These are clearly ENP skills and thus the argument for extending the ENP role to care for acutely ill patients in ED is justified. It is clear from the lowest-rated skills such as thoracocentesis that role definition is critical to the ACNP role being implemented.
One solution to issues of ACNP role autonomy and inter-professional conflict is to introduce a clinical internship model for ACNP training. The clinical internship model has been reported to be a positive programme to implementing the ACNP role (Hollinger-Smith & Murphy 1998, Blanzola et al. 2004). Within the School of Nursing and Midwifery at La Trobe University, we have developed a clinical internship with a curriculum developed to provide a detailed understanding of related physiology, pharmacology, psychological impact and contemporary interventions for the patient/client cohort, which integrates theory and practice through the clinical internship, using the NP competencies (Australian Nursing and Midwifery Council 2006). A clinical internship model allows students with an opportunity to develop clinical, research and leadership skills and knowledge related to care of patients/clients under the mentorship of a nominated nurse or medical practitioner. Research and management skills were identified as important in the study and it could be argued that their importance is crucial to the NP role.
The mentor would assist the student to develop and apply advanced assessment, diagnostic and pharmacological skills to become an ACNP. Of paramount importance, the mentor should have a good understanding of the NP model and the extended scope of practice of the role as well as being able to observe the ACNP nurse working clinically and be willing to provide thorough critical feedback on their performance. The development of this clinical mentorship model would help reduce the issues identified by Norris and Melby of inter-professional conflict.
Defining the ACNP role is essential to avoid the issues identified by Norris and Melby. It is vital to use the existing personnel and resources within the healthcare system and the collaboration between physicians and ACNPs is the key to providing high quality care to acutely ill patients. It is commendable to examine advanced nursing practice in ED, but it is worthwhile to consider extending the role of the existing ENPs.