Monday, June 11, 2012

My Area of Practice Essay

Area of Practice Essay

My area of practice is accident and emergency care. Due to the acute nature of the cases dealt in this department and the need to make rapid, life-saving decisions, emergency unit staff must be not only highly skilled and professionally competent, but should also be mentally flexible, with extremely well capabilities of working under pressure. That is, specific professional skills (e.g., animation and diagnoses of complex injuries) are only half of the story; the challenges of practitioners in emergency and accidents departments include, among others, the need to consider the properties of a single patient in the context of a whole event (e.g., an accident with several casualties), current priorities in the department, and rapid, often unexpected changes in vital signs.


Proper triage is a prerequisite for optimizing care in busy emergency departments. The Australasian triage scale (ATS) is a standard means of categorizing new admissions by prescribing maximum waiting time. As defined by the Australian College for Emergency Medicine (2000), patients can be ranked using five ascending scales between ATS1 to ATS5, which imply waiting time of 1 to 10, 30, 60 and 120 minutes, respectively. The triage is based on a battery of clinical indications, which define the critical interventions needed for patients who might be presented simultaneously in an emergency department.

The patient population who I cared for are patients who have been assigned a triage category of ATS 3-5. The cases varied significantly and included medical, surgical, orthopaedics, gynaecology, plastics, trauma, preventative care and other disorders. Some patients were bright into the unit by ambulance, whereas others were able to walk in independently. Due to the limitations imposed on my practice (see below), I handed only patients aged 13 and above.

As a member of the nursing staff, I carried on a wide array of tasks, including comprehensive health history, physical examination, clinical assessment, differential diagnoses and planning of care. Such tasks require a multidisciplinary approach, since the interventions (in terms of both pharmacological and non-pharmacological measures) relate to different medical disciplines. Apart from being highly challenging, this aspect of my practice was also very rewarding, as I constantly interacted not only with generalists, but also with specialists from diverse professional backgrounds. In addition to following general and case-specific instructions, my responsibilities included deep acquaintance and constant vigilance in regard to life threatening clinical situations, including the initiation of essential care immediately after onset.

In order to reduce the risk from employing an inexperienced staff member, I was excluded from caring for patients with ATS1 and 2, as well as below 13 years of age. In addition to patients over 65 years, these two populations are relatively more prone to complications, and thus are usually handled more by physicians rather than nurses (Read, Jones, & Williams, 1992). This approach is yet another important aspect of triage in emergency care; not only priorities of care, but also human resource allocation within the department must relate to the specific properties of incoming cases.

Holistic and multidisciplinary thinking is one of the cornerstones of success in emergency care units (Corker & Kellepourey, 2008). And indeed, in my area of practice, where trauma may involve multiple injuries in different organ systems, the collaboration among various staff members is imperative. Experts are responsible for undertaking specific procedures, such as surgical interventions, establishment of airway and dealing with comatose patients. Nurses, on the other hand, do not only perform many other interventions, but also takes to duty of establishing communication and coordination between the various departments and sub-specialties according to the presented symptoms and patient history. Such coordination has to be achieved in specific and predefined time frames according to the triage category.

It should be noted, however, that the tasks and responsibilities allocated to nurses might vary among regions and departments, as well as according to the individual nurse’s level of qualification. Nursing practitioners (NPs), registered nurses with advanced and extended clinical roles, are extremely important where physicians are scarce, especially in remote areas (Gardner, Hase, Gardner, Dunn, & Carryer, 2008). Although the concept is novel in the Australasian region, the premise of NPs is so significant, that NPs grow rapidly in number and extent of responsibilities. Following the successful implementation of training and assessment schemes for NPs in more than a few developed countries, we cannot go too far by saying that this as an important link in the healthcare delivery system, NPs should and will be utilized in greater proportions in the future (ibid.).

Nurse Practitioner Practice in New Zealand
The notion of empowering NPs to carry on a wide array of diagnostic and patient management tasks is nothing less than a radical reform, which raises significant questions and debates, particularly regarding issues of patients safety (Lim, Honey, & Kilpatrick, 2009). In the New Zealandian health care system, which implemented the reform only in 2001, the concept of NPs has yet to be fully recognized and accepted. We can observe, however, a gradual process of implementation, in which nursing evolves from its traditional participatory role to extended prescription rights – from physician assistant prescribing to supplementary prescribing and finally independent prescribing (Lim et al., 2009).

Independent prescribing for NPs has now been recognized as the preferred model in New Zealand, and as such requires designated mechanisms of education and licensing. Most of the responsibility for ensuring a successful implementation of NPs in the country falls within the premise of the Nursing Council of New Zealand (NCNZ), the regulatory authority responsible for the registration of nurses. NCNZ’s principal purpose is to look after the health and wellbeing of members of the community by assuring that nurses are capable and fit to practice. The NCNZ has set several thresholds for the qualification of NPs, including a master’s degree (or equivalent) as well as 4 to 5 years of experience in a specific area of practice. Training programs must include comprehensive knowledge of pathophysiology, advanced methods of assessment, pharmacology, nursing research and practicum.

Health Practitioners Competence Assurance Act – 2003
Notwithstanding fundamental differences in the academic and regulatory treatment of NPs, the main characteristics of this profession in New Zealand are rather similar to those of the British and Australian systems (Currie, Edwards, Colligan, & Crouch, 2007). The Health Practitioners Competence Assurance Act 2003 (HPCAA) provided the legislative framework for standardizing the level of competence of practitioners and their fitness to maintain those standards throughout their professionally active life. The Act was passed by the New Zealand Parliament on September 11, 2003, received the Royal assent a week later and was operationalized during the following year.

The primary purpose of the Act is defending the wellness and safety of the populace by setting uniform guidelines for practitioners, as well as mechanisms to guarantee that registered practitioners are fully competent and capable of putting into practice their respective professions throughout their careers. At the same time it prevents the registered practitioners from practicing outside their settings of practice. The (Nursing council) registration agencies will be responsible for licensing the practitioners on a yearly basis (Ministry of Health, 2002), based on four domains of competencies: (Nursing Council of New Zealand, 2008)

  1. Professional responsibility and leadership: knowledgeable and skilled professional performance, including the ability to enhance patients’ and colleagues’ cooperation to optimize the outcomes of care. Typical indicators here are communication and follow-up activities, participation in joint efforts to promote health in the community and beyond (e.g., on the national level) and implementing novel methods of measurement and treatment.
  2. Management of nursing care: professionalism in proving direct patient care. As the very essence of NP is the ability to work independently (i.e. without direct supervision of a physician), NPs should posses extremely high decision-making and diagnostic abilities, as well as competencies such as learning from experience and create a sense of collaboration from patients and other caregivers (such as families and non-medical stakeholders).
  3. Interpersonal and inter-professional practice and quality improvement: The competencies within this domain ensures nurses’ engage in professional, respectful relationship with the client, can work with other health professionals to ensure best health outcomes for the client and participate in monitoring and improving own practice. A network of NPs acts as a central agent to nurture co-actions between members of all fields in the healthcare team to work toward faultless patient care.
  4. Prescribing practice: thoughtful and professional execution of the prescribing rights given to NPs, including understanding the nature, the use and the risks embedded in the clinical situation and pharmacological intervention in question.

Nurse Practitioner in Emergency department in New Zealand
By virtue of its role in the contemporary healthcare system, the Emergency department has the most heterogeneous array of tasks, in terms of both the patient population and the variety of clinical situations presented for care. Patients who will proceed from this point to most other departments will find a different reality, facing physicians and nurses practicing in highly specialized units. Similarly, the healthcare system as a whole adhere specialization and professional focus as a means to solve the scarcity of resources (first and foremost human capital), whereas the demand for healthcare services is soaring.

The role of emergency NPs in New Zealand underwent major changes throughout the recent decade, corresponding with trends in other countries and the growing importance of NPs in New Zealand (Currie et al., 2007). From rather minor duties of triage and assistance (Read et al., 1992), the responsibilities allocated to today’s emergency NPs are diverse, showing higher complexity and independent work. The contemporary position of emergency NPs is thus based on two grounds: the recognition of NP as a dominant and significant link in the chain of healthcare, and the variety and intensity of the departments in which emergency NPs practice (Fry & Rogers, 2009).

Comprehensive utilisation of NPs allows hospitals to ensure adequate care despite clear human resource shortages and overcrowding in their Emergency departments. Corker and Kellepourey (2008) report that as many as 30% of the patients present in the Emergency department can be handled by NPs instead of physicians, while retaining patients satisfaction and compliance. Reports from an Auckland Emergency department suggest that skilled and experienced NPs can solve 80% of the cases without consulting with a physician (Auckland District Health Board, 2008). These data relate not only to triage and initial diagnostic procedures, but also to the complete provision of care, ending with either further procedures in the clinical facility or by releasing the patient. Moreover, collaboration among NPs in the Emergency department and the ambulatory NPs was found to reduce appearances in the department and/or turn physical appearances into mere telephone consultations (Geraci & Geraci, 1994).

The influence of emergency NPs on patient outcomes grows both quantitatively and qualitatively, with considerable contribution to the clinical and nonclinical (e.g., efficiency) operations of Emergency departments. Although tasks and responsibilities may vary according to the nurse’s specific qualifications and environment, and despite what seems as rather incomprehensible definitions as of roles and responsibilities (Hooker, Potts, & Ray, 1997), recent research findings suggest that NPs’ performance is much more resilient than the bodies that regulates their activities. Emergency NPs tend to provide more holistic care, which goes beyond accurate clinical performance. Their ability to ensure patients’ understanding of the situation and to follow up on referrals and compliance increases satisfaction, treatment effectiveness and organizational efficiency (Corker & Kellepourey (2008).

These roles and indications from recent decades imply growing expectations from the emergency NP. If concentrating on core tasks (such as initial anamneses and triage) was sufficient to meet those expectations, contemporary emergency NPs must expand their line of activities and their involvement in the needs of the target populations, as well as the declining capacities of the system. Key implications are nurturing the communication between the department and the ambulatory system, methods of presenting cases to physicians, and decreasing repeated visits to the Emergency department of patients, who present because of misunderstandings and/or lack of alternatives for receiving the care they need.
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