Evaluating Emergency Nurse Practitioner services: a randomized controlled trial

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Evaluating Emergency Nurse Practitioner services: a randomized

controlled trial

Mark A. Cooper BN RGN

ENP Course Co-ordinator, Accident and Emergency Departments, North Glasgow University Hospitals NHS Trust, Glasgow,

UK

Grace M. Lindsay BSc MN PhD RGN SCM

Senior Lecturer, Nursing and Midwifery School, University of Glasgow, Glasgow, UK

Sue Kinn BSc MSc PhD

Programme Leader, Nursing Research Initiative for Scotland, Glasgow Caledonian University, Glasgow, UK

and Ian J. Swann MBBS FRCS FFAEM DFM

Consultant in Accident and Emergency Medicine, Glasgow Royal Infirmary, Glasgow, UK

Submitted for publication 17 April 2002

Accepted for publication 25 September 2002

Correspondence:

Mark A. Cooper,

Accident and Emergency Departments,

Glasgow Royal Infirmary,

84 Castle Street,

Glasgow G4 0SF,

UK.

E-mail: [email protected]

COOPER MCOOPER M.AA., LINDSAY GLINDSAY G.MM., KINN SKINN S. && SWANN ISWANN I.JJ . (2002)(2002) Journal of

Advanced Nursing 40(6), 721–730

Evaluating Emergency Nurse Practitioner services: a randomized controlled trial

Background. Emergency Nurse Practitioners (ENP) are increasingly managing

minor injuries in Accident and Emergency departments across the United Kingdom.

This study aimed to develop methods and tools that could be used to measure the

quality of ENP-led care. These tools were then tested in a randomized controlled trial.

Methods. A convenience sample of 199 eligible patients, over 16 years old, and

with specific minor injuries was randomized either to ENP-led care (n ¼ 99) or

Senior House Officer (SHO)-led care (n ¼ 100) and were diagnosed, treated, re-

ferred or discharged by this lead clinician. Following treatment, patients were asked

to complete a patient satisfaction questionnaire related to the consultation. Clinical

documentation was assessed using a ‘Documentation Audit Tool’. A follow-up

questionnaire was sent to all patients at 1 month. Return visits to the department

and missed injuries were monitored.

Results. Patients were satisfied with the level of care from both ENPs and SHOs.

However, they reported that ENPs were easier to talk to (P ¼ 0Æ009); gave them

information on accident and illness prevention (P ¼ 0Æ001); and gave them enough

information on their injury (P ¼ 0Æ007). Overall they were more satisfied with the

treatment provided by ENPs than with that from SHOs (P < 0Æ001). ENPs’ clinical

documentation was of higher quality than SHOs (P < 0Æ001). No differences were

found in recovery times, level of symptoms, time off work or unplanned follow-up

between groups. Missed injuries were the same for both groups (n ¼ 1 in each group).

Conclusion. The study was sufficiently large to demonstrate higher levels of patient

satisfaction and clinical documentation quality with ENP-led than SHO-led care. A

larger study involving 769 patients in each arm would be required to detect a 2%

difference in missed injury rates. The methods and tools used in this trial could be

used in Accident and Emergency departments to measure the quality of ENP-led care.

� 2002 Blackwell Science Ltd 721

Keywords: Emergency Nurse Practitioners, Accident and Emergency, minor

injuries, randomized controlled trial, patient satisfaction, clinical documentation,

junior medical staff

Introduction

The number of patients attending Accident and Emergency

(A & E) departments in the United Kingdom (UK) each year

is rising (Audit Commission 2001) and this, combined with

changes in health service policy to reduce junior doctors’

hours (National Health Service [NHS] Management Execu-

tive 1992), has seen waiting times in A & E becoming

longer despite increases in overall numbers of A & E

doctors (Audit Commission 2001). One potential solution,

or at least a partial solution, has been the introduction of

Emergency Nurse Practitioners (ENPs) to many depart-

ments. Redesigning how A & E services are currently

delivered is expected to be one of the key features of a

modern health care system and is likely to provide many

opportunities for ENPs (Scottish Executive Health Depart-

ment 2001).

Just introducing a new service or redesigning an existing

one is, however, not enough. No longer is it acceptable just to

provide a service; it must now be demonstrated to be of

sufficient quality to justify its continued existence (Dickens

1994). A government publication has reported that:

A series of well publicised lapses in quality have prompted doubts in

the minds of patients about the overall standard of care they may

receive (Department of Health 1997).

The introduction or expansion of any ENP services must

therefore be shown to be both acceptable to patients and

provide a quality of service at least as good, if not better,

than existing services. The majority of patients who attend

A & E are managed by Senior House Officers (SHOs) who

are often in their first postregistration post (Wallis & Guly

2001). If ENPs are introduced to provide a service that

SHOs have been providing, it seems reasonable that they

should be expected to provide a service of at least equal

quality.

Emergency Nurse Practitioners

The ENPs are nurses who are ‘authorized to assess and

treat patients attending an A & E department’ (Read et al.

1992). The first department in the UK to introduce a

formal ENP service is generally acknowledged to be to

Oldchurch Hospital in Essex (Head 1988). They introduced

this following a Community Health Council Survey and

patient complaints about lengthening waiting times. How-

ever, nurses in many small community hospital casualty

units (Read & George 1994) and specialist ophthalmic A

& E units assessed and treated particular patients

independently and often unofficially (Jones et al. 1986,

Shaw et al. 1988), and hence worked as de facto ENPs

prior to this.

Since 1986, when ENPs started at Oldchurch, the

number of A & E departments using them has risen

dramatically. In a survey of all major A & E departments

in the UK in 1996, Tye et al. (1998) found that 36% of

major departments provided some kind of formal ENP

service. In 1998, in a survey of all A & E departments in

Scotland (including very small community hospitals) 47%

of departments reported having nurses who functioned as

ENPs (Cooper et al. 2001).

A growing body of research evidence appears to show that

ENPs are able to provide a safe and effective service to minor

injury patients. Most previous studies of the effectiveness of

ENPs have concentrated on particular skills, for example

ability to request and interpret X-rays (Macleod & Freeland

1992, Freij et al. 1996, Meek et al. 1998, Overton-Brown &

Anthony 1998) or administer medication under protocols

(Marshall et al. 1997). Two randomized controlled trials

have examined the package of care provide by ENPs: an

Australian study (Chang et al. 1999) which involved 169

patients and an English study (Sakr et al. 1999) with 1453

patients. Sakr et al. (1999) concluded that:

properly trained accident and emergency nurse practitioners, who

work within agreed guidelines can provide care for patients with

minor injuries that is equal or in some ways better than that provided

by junior doctors.

The ENPs in that trial had undertaken, or were undergoing,

the English National Board Autonomous Practice course

(A33), had locally agreed guidelines for practice and worked

in an A & E department with medical staff immediately

available for advice. Unfortunately, not all nurses working as

ENPs have had additional training and not all departments

have agreed working guidelines for them (Cooper et al.

2001). The type of department they work in also varies, from

large hospitals with medical staff available for referral and

advice to small community hospitals, minor injury units

(Cooper et al. 2001) and NHS Walk-in Centres (Munro et al.

2000) where medical staff may not always be on-site. The

M.A. Cooper et al.

722 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(6), 721–730

types and severity of injuries managed by ENPs also vary

between departments (Dolan et al. 1997, Cooper et al.

2001). ENP services in different settings, with different local

arrangements for referral and advice, with nurses who have

undergone different types of educational preparation, and

treating different types of injuries, should be evaluated within

their specific context. However, there should be common

objectives in such evaluations. Four important areas that

should be core to any evaluation are (1) patient satisfaction,

(2) clinical documentation, (3) unplanned follow-up and (4)

missed injuries.

When any new service is introduced it is vital that it is

acceptable to patients. This is an important influence deter-

mining whether a patient seeks medical advice and complies

with treatment (Larson & Rootman 1976).

The ability to write comprehensive and accurate clinical

notes is another important aspect of practising independently

as an ENP. Written clinical documentation is often the only

way of communicating vital information about an indivi-

dual’s care to colleagues who are also involved with and

responsible for a patient. Accurate information is essential for

proper care and effective service management (Audit Com-

mission 1996). Good notes are often said to imply good

practice (Montague 1996); hence it is vital that ENPs (and

doctors) accurately record details on every patient they treat.

Clinical documentation can be called as evidence before a

court of law, health service commissioner or professional

conduct committee (United Kingdom Central Council for

Nursing [UKCC] 1998). Hospitals need good records to

defend themselves against claims of negligence (Audit Com-

mission 1995). Whilst accurate documentation can help

protect patients and staff (Read 1999), poor documentation

makes it difficult to defend a hospital in a clinical negligence

case (Tingle 1995).

Most minor injuries are managed using relatively simple

techniques and are expected to heal within a relatively short

time and without substantial input from the health services. A

small percentage of minor injuries, however, if mismanaged

may cause significant morbidity (Gwynne et al. 1997).

Identifying mismanaged cases and missed injuries can be

difficult. Formal review of X-rays following discharge (and

usually within 24 hours) is practised in many departments.

This provides a safety net and should pick up any fractures

missed at initial attendance. These patients can then be

recalled for further assessment or to alter the initial manage-

ment. Missed injuries or problems with initial management

may subsequently be picked up at follow-up clinics. Patients

may also choose to re-attend or seek advice elsewhere if

concerned and problems may be picked up at that time, i.e.

unplanned follow-up.

The study

Aim

To develop methods and tools that could be easily used, in

different A & E departments, to measure the quality of ENP-

led care (in terms of patient satisfaction, quality of clinical

documentation, unplanned follow-up and missed injuries).

Following the introduction of ENPs at the research site, these

tools were tested using a randomized controlled trial to

compare ENP-led care with the existing predominantly SHO-

provided service.

Design

The trial was conducted over a 2-month period during

December 1998 and January 1999. All patients who attended

the Glasgow Royal Infirmary A & E department were

assessed by a triage nurse (routine practice). Patients with

minor injuries were then reviewed by the researcher (MC) for

suitability for inclusion. Consecutive patients who were over

16 and had sustained an injury, which fell within the ENP

protocols at the research site, were invited to participate in

the trial. Patients were only recruited when both the

researcher and an ENP were on duty.

Following informed written consent patients were ran-

domized to either the experimental group (ENP-led care) or

the control group (SHO-led care). Opaque, sequentially

numbered sealed envelopes containing randomized assign-

ments to the two groups were provided by one of the authors

(SK), not directly involved in the clinical part of the trial.

Methods

Demographic information and types of injury

Demographic information on patients in each arm of the trial

was collected by the A & E reception staff. This was done as

part of the normal process of patient registration prior to

recruitment. Following the patient’s departure from the

department the researcher reviewed the clinical documenta-

tion and collected data on the type of injury the patient had

sustained.

Deprivation was measured using the Carstair’s Score

(McLoone 1997). This score is derived from variables from

small area Census data and uses postcode sectors. Scores

range from DEPCAT 1 (the most affluent postcode sectors) to

DEPCAT 7 (the most deprived). The scores are based on four

different variables in the Census data: number of people per

room, male unemployment, social class and car ownership.

The score is a relative measure of the deprivation or affluence

Issues and innovations in nursing practice Evaluating Emergency Nurse Practitioner services

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(6), 721–730 723

which refers to the population of the postcode sector where

the patient lives and not to the patient individually.

Consultation and referral

Each ENP and SHO was asked to record on a trial ‘Treat-

ment Record’ form whether any advice on diagnosis, X-ray

interpretation or treatment was sought from any other cli-

nician. A more senior A & E doctor (usually a more experi-

enced SHO or a specialist registrar) was available for

consultation to both ENPs and SHOs, who could also

directly refer patients to specialities within the hospital for an

opinion on emergency treatment or possible admission.

Both SHOs and ENPs were able to refer patients to a

number of hospital follow-up clinics or to their general

practitioner (GP). Follow-up clinics available included an A

& E Soft Tissue Clinic, orthopaedic Fracture Clinic, Burns

Clinic run by the regional burns unit and Hand Clinic.

Information on numbers of patients referred to the various

clinics was collected from the A & E notes, as were details of

any investigations requested.

A ‘Clinic Referral Form’ was developed after discussions

with three A & E consultants and the nurse-in-charge of the

clinics. This was used to collect information on the appro-

priateness of referrals to follow-up clinics and on the clinical

management of the patient. The form was completed by the

doctor reviewing the patient at the clinic.

Patient satisfaction

A self-completion patient satisfaction questionnaire modified

from a previously validated questionnaire developed by

Jenkins and Thomas (1996) was used to measure satisfaction

with the consultation. The questionnaires were distributed to

patients at the time of recruitment. Each patient was asked to

complete the questionnaire immediately after their treatment

and prior to leaving the department. Patients were given the

opportunity to remain in the room where they had been

treated to provide privacy when completing the question-

naire. Completed questionnaires were collected via a sealed

post box in the waiting room. Although the questionnaires

were not anonymous, patients were assured that only the

researcher would see the data and no member of staff in-

volved with directly treating patients would have access to

individual questionnaires.

Quality of clinical documentation

The researcher measured the quality of each set of clinical

notes written by the ENPs and SHOs using a ‘Documentation

Audit Tool’ developed to evaluate the clinical documentation

of patients with minor injuries. Development of the tool using

an expert panel and a consensus methodology is described

elsewhere (Cooper et al. 2000). Each set of clinical notes was

given a score out of 30.

One-month follow-up

A postal questionnaire, developed from a patient diary ori-

ginally designed by Read and George (1994) for a proposed

RCT of ENPs, was posted to patients 1 month after their

attendance. Reminders were posted to nonrespondents. This

questionnaire collected information on (1) time to recovery,

(2) level and frequency of pain still being experienced,

(3) level of symptoms and activity, (4) time off work and (5)

whether any unplanned follow-up was sought.

Returns and missed injuries

Any study patients who returned to the department were

identified through its computer system and their clinical notes

were examined and the reasons for return noted. Missed in-

juries were identified by (1) monitoring return patients, (2) a

systematic search of patients through the department’s recall

register, (3) the ‘Clinic Referral Forms’ which allowed missed

injuries discovered at follow-up clinics to be reported to the

researchers, and (4) formal complaints.

Ethical approval

Ethical approval was obtained prior to the start of the trial from

the Glasgow Royal Infirmary Research Ethics Committee.

Data analysis

Data from the questionnaires were coded and entered into a

Microsoft Access 97 database created for the study. The SPSS

(Statistical Package for the Social Sciences v8Æ0) software was

used to analyse the data. Descriptive statistics were calculated

for all of the variables and histograms were plotted to ensure

that the data were normally distributed. Two-tailed t-tests

were applied to continuous variables. For categorical varia-

bles the chi-squared test for independent samples was used,

or Fisher’s exact test if values were less than 5 in any cell. The

Mann–Whitney U-test was used in the analysis of the ordinal

data from patient satisfaction questionnaires.

Analysis was undertaken comparing patients in the groups

to which they were originally assigned. Any patient who was

not seen initially by the clinician to whom they were

randomized was excluded from the final analysis.

Results

Recruitment

A total of 214 minor injury patients were invited to

participate in the trial, and 95% of these took part

M.A. Cooper et al.


(n ¼ 204). Five patients were subsequently withdrawn as

they were not seen in the clinician group to which they were

randomized (see Fig. 1). Patients were recruited into the trial

over 28 days during December 1998 and January 1999 (no

recruitment was conducted during the Christmas and New

Year period). Approximately 215 hours were spent in the

department recruiting patients. Eight ENPs and 12 SHOs

took part in the study. Seven of the eight ENPs had been

practising for 1 year at the time of the study. The eighth had

completed her training 3 months previously. All SHOs were

in their fifth and sixth months of their 6-month A & E

posting, and the majority were in their first SHO post.

Demographic information and types of injury

The average age of patients in the study was 36Æ3 years and

just over half were male (56Æ4%). Demographic characteris-

tics and the injuries treated in both the ENP and SHO groups

were compared and no statistical differences were found

between for age, sex, deprivation score and type of injury

(Table 1).

Consultation and referral

The average waiting time to see an SHO was significantly

longer than that for an ENP (SHO 70Æ1 minutes, ENP

48Æ6 minutes, P < 0Æ001; 95% CI, 11Æ2–31Æ8 minutes).

However, there was no significant difference in the total

consultation time (including the time for treatment) (ENP

30Æ0 minutes, SHO 24Æ9 minutes, P ¼ 0Æ115; 95% CI, �1Æ3

to 11Æ5 minutes).

ENPs and SHOs were able to seek advice from senior

medical staff for a variety of reasons including diagnosis,

X-ray interpretation and management. At the time of the trial

ENPs had to request advice on interpreting X-rays. They

sought advice on patients more often than SHOs (64Æ6%

compared with 21Æ2%, P < 0Æ001). However, when patients

who had been X-rayed were excluded, there was no

difference between the two groups (ENP 20Æ9%, SHO

11Æ5%, P ¼ 0Æ21). There was also no difference between

the groups in the numbers of X-rays requested (ENP 56Æ6%,

SHO 47Æ5%, P ¼ 0Æ2).

There was no difference between the groups in patients

admitted (ENP 2Æ0%, SHO 6Æ0%, P ¼ 0Æ279) or between

those referred to follow-up clinics (ENPs 33Æ3%, SHOs

27Æ5%, P ¼ 0Æ358). The percentage of ‘Clinic Referral Forms’

returned by the various follow-up clinics varied considerably

from 17Æ4% to 100% (Table 2). No statistical difference

was detected between the two groups in appropriateness of

referral or clinical management (Table 3). However two

patients in the ENP group were considered to have received

unsatisfactory clinical management. The first case involved a

patient with a suspected ulna collateral ligament injury to the

metacarpal-phalangeal joint of the right thumb. The patient

had been correctly diagnosed and referred to the appropri-

ate follow-up clinic. The thumb had also, correctly, been

immobilized in a thumb spica; however, the patient had not

been given a sling, which the reviewing doctor felt was

Eligible patients (n = 214)

Declined to praticipate (n = 10) Did not want to see an ENP (n = 6) Did not have time (n = 1) Did not want to participate in research (n = 2) No reason given (n =1)

SHO-led careAllocated to control intervention (n = 102)

Did not receive control allocation & withdrawn (n = 2) Seen by Middle grade Dr (n = 1) Seen by Consultant (n = 1)

ENP-led careAllocated to test intervention (n = 102)

Did not receive test allocation &withdrawn (n = 3) Seen by SHO (n = 1) Seen by Middle grade Dr (n = 2)

Returned patient satisfaction questionnaire (n = 81) following consultation

Returned follow-up questionnaire (n = 65) at one month

Clinic refenal form returned (n = 10/28)

Unexpectedly returned to department (n = 4)

Returned patient satisfaction questionnaire(n = 87) following consultation

Returned follow-up questionnaire (n = 63) at one month

Clinic refenal form returned (n = 17/34)

Unexpectedly returned to department (n = 2)

R

Figure 1 Flowchart of trial. ‘R’ indicates

randomization.



unsatisfactory. At the review clinic the hand was still swollen

and thorough examination was not possible until the swelling

had subsided. The second case involved a toe fracture, which

had been correctly diagnosed and managed by strapping the

toes together; however, the reviewing doctor noticed that a

piece of gauze which should have been placed between the toes

prior to strapping was missing. This was felt to have been

unsatisfactory management which could, if not corrected, lead

to an adverse outcome. The piece of gauze is used to help

prevent the skin between the toes from becoming macerated.

Patient satisfaction

One hundred and sixty-eight patients returned satisfaction

questionnaires immediately after their treatment, giving a

response rate of 84% (ENP n ¼ 87, SHO n ¼ 81). Patients

appeared very satisfied with the level of care they received

Characteristic

ENP-led care

n ¼ 102

SHO-led care

n ¼ 102 Significance

Age, years (mean) 35Æ85 36Æ80 P ¼ 0Æ648

Sex

Male 59 56 P ¼ 0Æ672

Female 43 46

Deprivation score (Carstairs Index)

(McLoone 1997)

(Least deprived)

1 2 1 P ¼ 0Æ612

2 2 5

3 12 16

4 13 10

5 11 6

6 16 20

(Most deprived)

7 43 43

Type of injury (primary complaint)

Ankle/foot sprain 18 11 P ¼ 0Æ196

Wrist/hand sprain 9 8

Wound inc. burns and scalds 34 36

Contusion injury 8 8

Hand/wrist fracture 11 15

Ankle/foot fracture 12 10

Minor head injury 0 1

Other 7 10

Table 1 Demographic information and

types of injury of patients entered into trial

Table 2 Response rates for the clinic referral form

Clinic

No. of

patients referred

Proformas

recovered

Response

rate percentage

Soft tissue clinic 20 20 100

Fracture clinic 23 4 17Æ4Hand clinic 18 10 55Æ6Burns clinic 1 1 100

ENP-led care SHO-led care Significance

Patients referred to follow-up clinics 34 28 P ¼ 0Æ358

Patient who failed to attend clinics 4 4

Patients who attended clinic 30 24

Completed clinic forms returned 17 10 N/A

Inappropriate or borderline referrals 3 1 P ¼ 0Æ596

Unsatisfactory management 2 0 P ¼ 0Æ254

Adverse effect on clinical outcome likely,

where management was considered unsatisfactory

1 0 N/A

Table 3 Results from follow-up clinics

(clinic referral form)

M.A. Cooper et al.


from both the SHOs and the ENPs. However, they reported

that ENPs were easier to talk to; they were given information

on accident and illness prevention; they were given enough

information on their injury. Overall they were more satisfied

with the treatment provided by ENPs than they were with that

by SHOs (Table 4). Not all patients answered every question.

Quality of clinical documentation

The clinical documentation was audited 4 months after the

trial ended, using the previously validated Documentation

Audit Tool (Cooper et al. 2000). A total of 186 clinical notes

were audited (93Æ5%) (ENP n ¼ 94, SHO n ¼ 92), and 13

could not be found. ENPs were found to have written notes

of higher quality than SHOs (ENP 28Æ0 of 30, SHO 26Æ6 of

30 P < 0Æ001).

One-month follow-up

The patient 1-month follow-up questionnaire yielded a 64%

(ENP n ¼ 63, SHO n ¼ 65) response rate following one postal

reminder. Patients were asked how long it had taken them to

recover fully from their injury. There was no difference in time

to recovery (P ¼ 0Æ96), level of symptoms (swelling, P ¼ 0Æ92

and stiffness, P ¼ 0Æ80), level of activity (looking after

themselves, P ¼ 0Æ58; ability to go to work/school, P ¼ 0Æ40;

sleep pattern, P ¼ 0Æ87), and time off work (P ¼ 0Æ14).

Patients were asked if they required further medical or

nursing advice in the month following their attendance in

A & E, excluding any follow-up appointments made or

suggestions to visit with their GP (i.e. unplanned follow-up).

A fifth of patients (20Æ0%) who replied reported the need to

seek this (ENP 18Æ3%, SHO 21Æ5% P ¼ 0Æ654). No statistical

difference was found between the groups.

Returns and missed injuries

Ten patients (5Æ0%) re-attended the department, and they

returned for a variety of reasons including new injuries (ENP

n ¼ 1, SHO n ¼ 1), concern about their injury (ENP n ¼ 2,

SHO n ¼ 1), problems complying with treatment (ENP

n ¼ 2, SHO n ¼ 1) and problems with treatment (ENP

n ¼ 1, SHO n ¼ 1).

A total of three patients entered into the trial had injuries

missed by the reviewing clinician. There was one in each of the

treatment groups and a further one amongst the five patients

withdrawn from the study. No formal complaints were

received by the hospital about any patient entered into the trial.

Discussion

The study has demonstrated that using the tools it has tested,

it is possible to evaluate patient satisfaction with ENP-led

care and to measure the quality of documentation in the real

life situation of an A & E department.

This study has also demonstrated that patients, when they

leave A & E, were more satisfied with the treatment provided

by ENPs. In particular, they were more satisfied with how

easy it was to discuss their injury with the ENP, the amount

of information ENPs gave them concerning their injury, and

the advice ENPs gave them on avoiding injury or illness in the

future. The results also show that the quality of ENP

documentation was higher and, importantly, levels of missed

injuries appear to be very low; however, large numbers of

patients need to be monitored to determine the actual rate.

Only two other RCTs of ENP- compared with SHO-led

care have been published (Chang et al. 1999, Sakr et al. 1999)

and neither found a significant difference in patient satisfac-

tion. The larger trial (Sakr et al. 1999), involving 1453

Table 4 Patient satisfaction questionnaire results

Percentage agreeing or strongly

agreeing with statementStatistics

SignificanceStatement (Statistically significant statements in bold) ENP-led care SHO-led care

I feel the doctor/nurse practitioner listened to me 97Æ7 (n ¼ 87) 86Æ4 (n ¼ 81) P ¼ 0Æ089

I feel the doctor/nurse practitioner gave me enough information

about my injury/condition

95Æ2 (n ¼ 83) 82Æ5 (n ¼ 80) P ¼ 0Æ007

I felt able to ask questions about my injury/condition 94Æ0 (n ¼ 84) 83Æ8 (n ¼ 80) P ¼ 0Æ123

I feel the doctor/nurse practitioner gave me enough time 995Æ3 (n ¼ 86) 82Æ5 (n ¼ 80) P ¼ 0Æ12

The doctor/nurse practitioner gave me advice on how to avoid illness/injuries 75Æ3 (n ¼ 81) 45Æ2 (n ¼ 73) P ¼ 0Æ001

I felt it easy to tell the doctor/nurse practitioner about my injury/condition 97Æ6 (n ¼ 85) 84Æ0 (n ¼ 81) P ¼ 0Æ009

I understood the advice the doctor/nurse practitioner gave me 94Æ1 (n ¼ 85) 84Æ6 (n ¼ 78) P ¼ 0Æ080

I am satisfied with the treatment the doctor/nurse practitioner gave me 98Æ8 (n ¼ 85) 87Æ7 (n ¼ 81) P < 0Æ001

n ¼ Total number of responses to each statement in each group.



patients, only found a nonsignificant trend in favour of ENPs.

Neither trial specifically examined clinical documentation.

Byrne et al. (2000) conducted a study which examined

minor injury patients attending three different types of centre

(1) an A & E department, (2) a minor accident treatment

service (MATS) located within an A & E department, and (3)

a minor injuries unit (MIU). Patients received care from

junior doctors (SHOs) in the A & E department and from

ENPs in the MATS unit and MIU. One hundred and sixty-

three patients completed questionnaires (A & E department

n ¼ 43; MATS n ¼ 57; MIU n ¼ 63) and overall were

satisfied with their care. Those who were managed by ENPs

were: (1) more likely to have had health and first aid advice

(P ¼ 0Æ05); (2) more likely to have been told who to contact

for advice (P ¼ 0Æ01); (3) more likely to have been given

written instructions (P ¼ 0Æ01); and (4) less likely to be

worried about their health (P ¼ 0Æ05).

Whilst it is acknowledged that patient satisfaction surveys

tend to show uniformly high ratings (McColl et al. 1996), the

findings from Byrne et al. (2000) support our results and

suggest that ENPs are more likely to provide health education

advice and be better at providing information to patients than

SHOs.

Chang et al. (1999) demonstrated that ‘appropriately

prepared emergency nurse practitioners can assist in the

management of nonurgent cases’. Sakr et al. (1999) conclu-

ded that ‘properly trained accident and emergency nurse

practitioners, who work within agreed guidelines can provide

care of patients with minor injuries that is equal or in some

ways better than that provided by junior doctors’. The results

from our study support both these conclusions.

Attempting to evaluate any form of longer-term outcome

following treatment in A & E for a minor injury was found to

be a complicated undertaking, as Read and George (1994) also

identified. Patients may be discharged with no anticipated

follow-up being thought necessary, advised to seek a consul-

tation with their GP or given an appointment to return to a

hospital follow-up clinic. However, they have a much wider

range of options: they can follow the advice about follow-up,

may decide to self-refer to another service provider, may return

to A & E, seek an appointment with their GP, go to another A

& E department, self-manage their condition, attend their

occupational health service, or seek a private consultation with

a physiotherapist or private doctor, for example.

Therefore, if an injury was missed at first presentation or

mismanaged, this ability to seek unplanned follow-up from a

large number of different health care providers often means

that it is unlikely for feedback to be forwarded to the initial A

& E department. This makes it difficult for departments to

monitor adverse outcomes in minor injury patients.

As the majority of patients are not expected to return to

hospital for any form of follow-up, it is difficult to evaluate

any longer term follow-up. As in Sakr et al.’s (1999) study,

we had to mainly rely on self-reported outcomes through a

postal questionnaire at 28 days.

Study limitations

Self-completion questionnaires have a number of limitations.

The key difficulty often involves the refusal of respondents to

complete or return the questionnaire (Barker 1991), leading to

bias if nonresponders differ from responders. Subjects may also

ask other people either to assist in completing the questionnaire

or even complete if on their behalf, prejudicing the sample

(Barker 1991). This may occur where subjects may have

injured their dominate hand and are unable to write without

help or in their haste have not brought reading glasses with

them to hospital and cannot read the questionnaire properly.

Lack of reading ability may also contribute to poor

completion or nonresponse. Whilst very few adults are

totally illiterate, approximately 23% of the Scottish popula-

tion would have difficulty identifying the correct amount of

medicine to give a child from the information given on the

medicine package (OECD and Statistics Canada 2000). This

may account for some of the nonresponders.

Analysis

In line with several other studies (Daoud et al. 1997, Fazekas

et al. 1997, Jacobson et al. 1997, Spruance et al. 1997),

patients who did not start the intended intervention were

excluded from the final analysis. This was felt unlikely to lead

to bias, as the intended effects of the intervention could only

occur if an ENP or SHO saw a patient.

This problem could perhaps have been avoided if random-

ization had occurred immediately before a patient was seen.

As the research was being conducted in a ‘real-life’ situation it

was necessary to randomize a patient whilst they were

waiting to be seen, and it was impossible to guarantee that

neither the ENP nor SHO would get called away or get

caught up with another case. Two of the five patients were

seen accidentally by more senior medical staff, and in both

these cases Clinical Assistants who were unaware or had

forgotten about the study saw patients randomized to the

SHOs. A second researcher, observing compliance with

randomization, may have been able to prevent this.

Recommendations for further research

Problems with initial mismanagement or missed injuries can

only be identified if reported to the A & E department.

M.A. Cooper et al.


However, patients can self-refer to many different places. In

this study one in five patients reported needing to seek

additional advice in the month after initial attendance.

Further research is needed to investigate the reasons for

seeking unplanned follow-up, where patients seek advice and

what measures could be taken to reduce this additional

burden on the health service.

In this study no difference was detected in missed injury

rates (one in each group); however, two patients in the

ENP-led care group were felt to have received unsatisfactory

management when reviewed in follow-up clinics. Therefore a

2% difference could be said to exist between the two groups.

Using Sampsize v2Æ0 (Machin et al. 1997), the sample size for

a full-scale trial was calculated. In order to detect a 2%

difference in the missed injury and mismanaged rates between

the two groups, with a power of 80% and at a 5% level of

significance, a trial would need to be undertaken with 1538

patients (769 patients in each arm).

Implications of the study for professional practice

Departments wishing to evaluate their own ENP services are

faced with many difficulties. Not least of which is the expense

and time-consuming nature of designing or replicating a

suitable study. The opportunity to use tools that have been

tested in a rigorous study design and are easy to administer

may allow more departments to evaluate and monitor their

services.

Conclusions

The study was sufficiently large to demonstrate higher levels

of satisfaction and clinical documentation quality with

ENP-led care. The patient satisfaction questionnaire and

Documentation Audit Tool are simple to use and sensitive

enough detect differences in the quality of care provided by

ENPs and SHOs. Both tools can be easily incorporated into

local evaluations to measure important aspects of the quality

of minor injury care. Monitoring recalls and other returns to

a department is an important measure of quality of care in A

& E; however, caution must be exercised in interpreting these

results as patients are at liberty to seek second opinions and

other unplanned follow-up from different health care pro-

viders. Further research is required to examine unplanned

follow-up in minor injury patients.

Acknowledgements

We would like to thank the ENPs and SHOs who took part in

the study, the Chief Scientist Office, Scottish Executive and

Glasgow Royal Infirmary for funding the study, and Dr Tracy

Ibbotson for her guidance on aspects of the study design. We

would also like to thank Dr M. Jenkins and Dr Sue Read for

kind permission to use and adapt their respective question-

naires.

References

Audit Commission (1995) Setting the Records Straight. HMSO,

London.

Audit Commission (1996) By Accident or Design: Improving A & E

Services in England and Wales. HMSO, London.

Audit Commission (2001) Acute Hospital Portfolio: Review of

National Findings – Accident and Emergency. Audit Commission

Publications, London.

Barker P.J. (1991) Questionnaire. In The Research Process in Nur-

sing (Cormack D.F.S. ed.), 2nd edn. Blackwell Scientific, Oxford,

pp. 215–227.

Byrne G., Richardson M., Brunsdon J. & Patel A. (2000) Patient

satisfaction with emergency nurse practitioners in A & E. Journal

of Clinical Nursing 9, 83–93.

Chang E., Daly J., Hawkins A., McGirr J., Fielding K., Hemmings L.,

O’Donoghue A. & Dennis M. (1999) An evaluation of the nurse

practitioner role in a major rural emergency department. Journal of

Advanced Nursing 30, 260–268.

Cooper M., Kinn S., Ibbotson T., Lindsay G. & Swann I. (2000)

Emergency nurse practitioner’s documentation: development of an

audit tool. Emergency Nurse 8, 34–39.

Cooper M.A., Hair S., Ibbotson T.R., Lindsay G.M. & Kinn S.

(2001) The extent and nature of emergency nurse practi-

tioner services in Scotland. Accident and Emergency Nursing 9,

123–129.

Daoud E.G., Strickberger S.A., Man K.C., Goyal R., Deeb G.M.,

Bolling S.F., Pagani F.D., Bitar C., Meissner M.D. & Morady F.

(1997) Preoperative amiodarone as prophylaxis against atrial

fibrillation after heart surgery. New England Journal of Medicine

337, 1785–1791.

Department of Health (1997) The New NHS Modern, Dependable.

HMSO, London.

Dickens P. (1994) Quality and Excellence in Human Services. John

Wiley & Sons, Chichester.

Dolan B., Dale J. & Morley V. (1997) Nurse practitioners: role in A

& E and primary care. Nursing Standard 11, 33–38.

Fazekas F., Deisenhammer F., Strasser-Fuchs S., Nahler G. &

Mamoli B. (1997) Randomised placebo controlled trial of monthly

intravenous immunoglobulin therapy in relapsing–remitting mul-

tiple sclerosis. Austrian Immunoglobulin in Multiple Sclerosis

Study Group. Lancet 349, 589–593.

Freij R.M., Duffy T., Hackett D., Cunningham D. & Fothergill J.

(1996) Radiographic interpretation by nurse practitioners in a

minor injuries unit. Journal of Accident and Emergency Medicine

13, 41–43.

Gwynne A., Barber P. & Tavener F. (1997) A review of 105 negli-

gence claims against accident and emergency departments. Journal

of Accident and Emergency Medicine 14, 243–245.

Head S. (1988) Nurse practitioners: the new pioneers. Nursing Times

84, 27–28.



Jacobson J.M., Greenspan J.S., Spritzler J., Ketter N., Fahey J.L.,

Jackson J.B., Fox L., Chernoff M., Wu A.W., MacPhail L.A.,

Vasquez G.J. & Wohl D.A. (1997) Thalidomide for the treatment

of oral aphthous ulcers in patients with human immunodeficiency

virus infection. National Institute of Allergy and Infectious

Diseases AIDS Clinical Trials Group. New England Journal of

Medicine 336, 1487–1493.

Jenkins M. & Thomas A. (1996) The assessment of general practi-

tioner registrars’ consultations by a patient satisfaction question-

naire. Medical Teacher 18, 347–350.

Jones N.P., Hayward J.M., Khaw P.T., Claoue C.M.P. & Elkington

A.R. (1986) Function of an ophthalmic accident and emergency

department: results of a six month survey. British Medical Journal

292, 188–190.

Larsen D.E. & Rootman I. (1976) Physicians’ role performance and

patient satisfaction. Social Science Medicine 10, 29–32.

Machin D., Campbell M.J., Fayer P.M. & Pinol A.P.Y. (1997)

Sample Size Tables for Clinical Studies, 2nd edn. Blackwell

Science, Oxford.

Macleod A.J. & Freeland P. (1992) Should nurses be allowed to

request X-rays in an accident and emergency department? Archives

of Emergency Medicine 9, 19–22.

Marshall J., Edwards C. & Lambert M. (1997) Administration of

medicines by emergency nurse practitioners according to protocols

in an accident and emergency department. Emergency Medicine

Journal 14, 233–237.

McColl E., Thomas L. & Bond S. (1996) A study to determine

patient satisfaction with nursing care. Nursing Standard 10,

34–38.

McLoone P. (1997) Carstairs Scores for Scottish Postal Code Sectors

from the 1991 Census. Public Health Research Unit, University of

Glasgow, Glasgow.

Meek S.J., Ruffles G., Anderson J. & Ohiorenoya D. (1998) Can

A & E nurse practitioners interpret radiographs? A multicentre

study. Journal of Accident and Emergency Medicine 15, 105–107.

Montague A. (1996) Legal Problems in Emergency Medicine. Oxford

University Press, Oxford.

Munro J., Nicholl J., Webber L. & Paisley S. (2000) Walk-in Centres:

a Review of Existing Research. Medical Care Research Unit,

University of Sheffield, Sheffield.

NHS Management Executive (1992) Junior Doctors: the New Deal.

NHS Management Executive, London.

OECD and Statistics Canada (2000) Literacy in the Information

Age: Final Report of the International Adult Literacy Survey.

Organisation of Economic Co-operation and Development (and

Statistics Canada), Paris & Ottawa.

Overton-Brown P. & Anthony D. (1998) Towards a partnership in

care: nurses’ and doctors’ interpretation of extremity trauma

radiology. Journal of Advanced Nursing 27, 890–896.

Read H. (1999) Documentation in the outpatient setting. Nursing

Standard 13, 41–43.

Read S.M. & George S. (1994) Nurse practitioners in accident and

emergency departments: reflections on a pilot study. Journal of

Advanced Nursing 19, 705–716.

Read S.M., Jones N.M.B. & Williams B.T. (1992) Nurse practi-

tioners in accident and emergency departments: what do they do?

British Medical Journal 305, 1466–1469.

Sakr M., Angus J., Perrin J., Nixon C., Nicholl J. & Wardrope J.

(1999) Care of minor injuries by emergency nurse practitioners or

junior doctors: a randomised controlled trial. Lancet 354, 1319–

1326.

Scottish Executive Health Department (2001) Caring for Scotland:

the Strategy for Nursing and Midwifery in Scotland. The Station-

ary Office, Edinburgh.

Shaw C., Hurst M. & Stone S. (1988) Towards Good Practices in

Small Hospitals – Some Suggested Guidelines. National Associ-

ation of Health Authorities, Birmingham.

Spruance S.L., Rea T.L., Yhoming C., Tucker R., Saltzman R. &

Boon R. (1997) Penciclovir cream for the treatment of herpes

simplex labialis: a randomised, multicenter, double-blind, placebo-

controlled trial. Topical Penciclovir Collaborative Study Group.

JAMA 277, 1374–1379.

Tingle J. (1995) Why hospital medical record keeping must improve.

British Journal of Nursing 4, 982–983.

Tye C.C., Ross F. & Kerry S.M. (1998) Emergency nurse practitioner

services in major accident and emergency departments: a United

Kingdom postal survey. Journal of Accident and Emergency

Medicine 15, 31–34.

UKCC (1998) Guidelines for Records and Record-Keeping. United

Kingdom Central Council for Nursing, Midwifery and Health

Visiting, London.

Wallis L.A. & Guly H.R. (2001) Improving care in accident and

emergency departments. British Medical Journal 323, 39–42.

M.A. Cooper et al.


Evaluating Emergency Nurse Practitioner services: a randomized controlled trial

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