ORIGINAL RESEARCH

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The population of the Republic of Ireland (ROI)has been increasing for almost 50 years after a100-year decline.1 It is expected that by 2020,

the population will have increased by at least 1 millionpeople.2 Ireland’s relatively young population, with 1 per-son in 10 over 65, is set to change considerably in thecoming years, and it is projected that, by 2036, 1 person in4 will be over 65. It is anticipated the Irish health servicewill be challenged to meet the rising needs.3

Emergency departments (EDs) throughout the ROIface the prospect of curtailing their opening hours oreven closing completely from a shortage of junior physi-cians.4 Reasons for shortages are multifaceted, includingemigration of newly qualified physicians and the diffi-culty for physicians who are not from the EuropeanUnion in obtaining work visas. Never has there beenmore need for the establishment and deployment ofANPs throughout EDs in the ROI.

The profession of nursing in the ROI is experiencingrapid change against this background of unprecedentedtransformation in the health service. Because of recom-mendations in the Report of The Commission on

Nursing5 and Review of the Scope of Nursing andMidwifery Practice6 and by the work of the NationalCouncil for the Professional Development of Nursing andMidwifery (NCNM), nurses are encouraged to undertakeeducation at higher diploma, master’s, and doctoral levels.This trend is particularly evident in the area of developingclinical nurse specialist and ANP roles.7

ANP roles are in the neophyte phase in the ROI incomparison to other jurisdictions, such as America and theUnited Kingdom. The development of advanced practiceroles in the ROI is part of the strategic development of theoverall health service.8 The first ANP post in emergencynursing was approved by the National Council in 2001,with the first ANP being accredited for that post in 2002.

Previous studies have focused on the qualitativeaspect of patient satisfaction with services provided bythe ANP.9-12 This study will provide empirical evidencearound the outcomes of ANP care in the emergency set-ting, which will complement other recent Irish studies.13

It is important to examine care outcomes to determinewhether they have an impact on quality and cost. Littleinformation is available on comparison of ANP outcomes

Evaluation of an Advanced Nurse Practitioner (Emergency Care)—An Irish PerspectiveWayne Thompson, RNP, and Pauline Meskell, RGN

ABSTRACTThe purpose of this audit was to provide empirical evidence for the outcomes of care ofadvanced nurse practitioners (ANPs) within the emergency department (ED). In addi-tion, the audit permitted the comparison of ANPs with other medical clinicians work-ing in the ED setting in relation to results of radiology investigations, analgesia adminis-tration, and waiting times. Results show that ANPs have equivalent if not better radiolo-gy diagnostic skills, evidence of increased awareness of pain management practices, and agreater impact on reducing patient waiting times compared to other grades of clinician.

Keywords: Advanced nurse practice, analgesia, emergency, radiology, waiting times© 2012 American College of Nurse Practitioners

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of care in the ED to medical colleagues. Given the cur-rent concerns about the shortage of medical coverage inEDs, it is timely to examine measurable outcomes such asimpact of ANPs on waiting times, efficacy of pain control(identified as a key performance indicator by theNCNM),14 and X-ray prescribing practices.

METHODSA retrospective, comparative audit was undertaken in anED of a general hospital, looking at the monthly censusof July and August 2010. The records of 1,366 patientsattending the ED who met identified inclusion andexclusion criteria were selected. Of these 1,366 records,402 were unavailable, leaving an actual sample size of 964patient records, which represented 18.11% of all EDattendances for the 2-month period.

The audit’s inclusion criteria were that the patient: • Was at least 3 years old, as the scope of the ANP

within the hospital does not include children underthis age

• Presented with a non-complex injury or illness thatmet the ANP’s scope of practice

• Presented to the ED between the hours of 0900 and2100

Patients who did not meet the above criteria wereexcluded as their conditions were deemed to be outsidethe scope of practice of the ANP, such as patients withback pain, abdominal pain, chest pain, respiratory prob-lems, head injuries with loss of consciousness, and thoserequiring admission.

Patients were treated by different grades of clinicians,including consultant in emergency medicine (EM), regis-trar in EM, senior house officer (SHO) in EM, and othernonconsultant hospital doctors (NCHDs; ie, locum coverand surgical on-call SHOs), and ANPs.

• Consultants (EM) are senior physicians who havecompleted all training in their chosen speciality,such as EM (equivalent US grade: attend-ing/attending physician). They have overall responsi-bility for the treatment of patients under their care.

• Registrars are physicians who are receivingadvanced training in a specialist field of medicine inpreparation for a consultant role (equivalent USgrade: resident/resident physician).

• SHOs are junior physicians undergoing trainingwithin a certain speciality under supervision of con-sultant or registrar (equivalent US grade: intern).

• NCHDs within this context relates to locumSHO/registrar cover and on-call surgical SHOs.

• ANP is an umbrella term that encompasses the spe-cific roles of nurses who practice at more advancedlevels than that of traditional nurses (equivalent USgrade: APN/nurse practitioner [NP]).

The specific objectives of the study were to compareANPs with their medical counterparts in relation to thefollowing:

• Numbers of X-rays diagnosed as false negative(missed fracture)

• Numbers of X-rays diagnosed as false positive (inap-propriate referral)

• Typical lengths of waiting times for patients in the ED• Pattern of analgesia administration to patients in

the EDThe data were retrieved manually from patient records,

and statistical and descriptive analyses were undertaken.Formal approval for audit in the service was provided bysenior management. Because the study was classified asaudit, ethical approval from the regional health service ethicscommittee was not required. However, audit governancewas followed, and no personal data were collated that wouldidentify individuals or breach confidentiality.

RESULTSFindings showed that of the 964 patient records audited,54.7% (n � 527) were male patients and 45.3% were female(n � 437). Patients’ ages ranged from 3 to 89 years. Childrenunder 16 accounted for just over one third (34.3%) of atten-dances, while the most common category by age and gen-der was male, age 29. The most common reasons forattending the ED were upper limb injuries (46%), withlower limb injuries being the next most prevalent (Figure 1).

Numbers by clinician type were as follows: 14patients (1.45%) were seen by the consultant (EM), 401(41.6%) were seen by registrars (EM), 239 (24.79%) wereseen by ED SHOs, and 76 (7.88%) were seen by otherNCHDs. The ANP saw 231 (23.96%) patients. The con-sultant (EM) works between 2 hospital bases and withina review clinic and undertakes nonclinical work, whichmay explain the relatively low number of patients thatwere seen by the consultant (Figure 2).

Radiology InvestigationsThe majority of patients within the audit (n � 820, 85%)were X-rayed during their visit. Of these, 615 (75%)

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were thought to have shown no fracture when, in fact,28 (4.6%) were deemed to have a false negative result. Afalse negative result indicates that the X-ray was inter-preted as no evident fracture but in fact a fracture waspresent. To enable a like with like comparison of clini-cian, a ratio percentage of false negative and positiveresults were calculated. The registrar (EM) had the high-est number (11, 1.8%) of false negative results, followedby ED SHO (9, 1.5%) and other NCHDs (7, 1.1%). TheANP had the lowest rate of false negative results at 0.2%(n � 1). The consultant (EM) did not provide any falsenegative result on an X-ray (Figure 3).

Of the 215 patient X-rays thought to indicate a frac-ture, 23 provided a false positive result. The registrar(EM) had 9 (4.4%), while the SHO (EM) had 8 patients(3.9%) with a false positive result. Other NCHDs had 2patients (1%) with false positive result. The ANP recorded5 (2.4%) false positive results, while the consultant (EM)did not record any false positive results (Figure 4).

Analgesia AdministrationCurrent practice within the site hospital ED is that thepatient is triaged on presentation, and their pain is assessedusing a pain ruler scale (scale of 0 to 10, where 0 is no painand 10 is very severe pain).15 This pain is reassessed by treat-ment clinician on initial assessment and documented. Anexamination of this pain assessment and analgesia prescrip-tion showed that, of the 964 patient records examined, 322patients (33.4%) with an average pain score rating of 3declined the offer of analgesia, 390 patients (40.45%) withan average pain score rating of 6 had analgesia administered,and 252 patients (26.14%) with an average pain score ratingof 4 were not offered analgesia at all.

Of these 252 patients, the consultant (EM) had thelowest rate of not offering analgesia, with 2 patients

(0.79%) not being offered analgesia. This was followed bythe ANP with 23 (9.12%), other NCHDs with 30 (11.9%),ED SHOs with 83 (32.9%), and registrars (EM) having thehighest rate—114 patients (45.23%; Figure 5).

Waiting TimesThe mean length of stay from first being seen to eventualdischarge in the ED was 1 hour and 23 minutes. Theaverage waiting time as per specialty was as follows: theconsultant (EM) and the ANP had equal times of 51minutes. Other NCHDs had the longest length of wait-ing time, with patients waiting an average 1 hour and 56minutes. This was followed by the registrar (EM), with amean waiting time of 1 hour and 34 minutes. The EDSHO had an average of 1 hour and 28 minutes from firstseeing a patient to discharge (Figure 6).

DISCUSSIONThe purpose of this audit was to provide empirical evi-dence for the outcomes of care of ANPs within the ED.Additionally, the audit permitted the comparison ofANPs with other medical counterparts. Overall, theresults show that ANPs have equal if not better radiologydiagnostic skills and recognize the need for analgesiaadministration, and their patients wait considerably lesstime than their medical colleagues.

Radiology InvestigationsThe majority of patients with minor injuries that attendedthe ED required radiological intervention, so it is imperativethat an ANP has the ability and authority to request X-raysto make the position viable. ANPs within the ROI must suc-cessfully complete a certificate in nurse/midwife prescribing(ionising radiation) before they can request and interpret X-rays independently. This expansion of practice was facilitated

Figure 1. Types of trauma seen in ED Figure 2. Patient percentages as treated by clinician grade

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by new legislation introduced in 2007, which amended thedefinition of prescribers of medical ionising radiation toincorporate nurses who completed this certificate.3

Earlier studies regarding X-ray interpretation tended tocenter on comparisons between ANPs and SHOs.16,17

Comparison at this level has been criticized because thelength of experience in the ED is not comparable betweenANPs and SHOs, largely because of the frequent SHOrotation practices.18 Authors now suggest that ANPs’ accu-racy in interpreting X-rays should be compared with that ofemergency physicians.19 Therefore, this study compared theANPs diagnostic accuracy in interpreting X-rays with thatof emergency registrars and the emergency consultant inaddition to SHOs.

False Positive Fracture ReportsIn total over the 2-month period, 820 X-rays wererequested. Of these, 205 (25%) were deemed to showfractures. This is inline with previous studies with per-centages ranging from 25% to 31%.18,20,21 All 205patients returned for review, either to the fracture clinicor emergency review clinic; 23 of these 205 patients ontheir return were noted to have no fracture, thereby con-tradicting the initial diagnosis. This therefore led to a falsepositive rate of 11.2%. This percentage is well below falsepositive rates obtained in other studies.18, 22 On an indi-vidual basis, the emergency registrar has a rate of 4.4 %,ED SHO 3.9 %, ANP 2.4 %, and other NCHDs havethe lowest rate of 1%.

False Negative Fracture ReportsOf the 615 X-rays deemed to show no fractures, 28(4.6%) were seen to have fractures after the radiologyreport. These patients were contacted by telephone andasked to return to the ED for further treatment. This false

negative rate is commensurate with the study completedby Willis and Sur,20 which cited false negative rate aver-ages of between 0.5% to 5.0%. In this audit, the emer-gency registrar has the highest rate of false negatives(1.8%), with the ANP having the lowest rate (0.2%).

These findings suggest that ANPs have an equal if notbetter diagnostic accuracy rate compared with their medicalcolleagues. This finding corresponds with previous studiesthat show NPs have similar accuracy in the interpretation ofradiographs with no statistical difference between them andphysicians regarding missed injuries.17,23,24,25

Puckridge et al26 declare that nurses can accuratelyand safely order X-rays for patients with extremityinjuries as long as there is appropriate training and sup-port. These results, with the ANP having 1 of the lowestmisdiagnosis rates compared to their medical colleagues,give support to the radiology training currently availablefor ANPs within the ROI.

Administering AnalgesiaThe introduction of nurse prescribing of medicinal prod-ucts in the ROI was a result of 2 documents: “Report ofThe Commission on Nursing—A Blueprint for theFuture”5 and “Review of the Scope of Practice forNursing and Midwifery.”6 These reports identified thatnurses were constrained in delivering optimal patient carein a coherent and efficient way from the lack of prescrip-tive authority. Their justification and rationale for theextension of prescriptive authority to nurses and mid-wifes was to improve service to patients, reduce healthservice delays, and deploy the education and expertise ofnurses and midwives more efficiently. International expe-rience of nurse prescribing from other jurisdictions, suchas the US, UK, Canada, New Zealand, Australia, andSweden, highlights the associated benefits, in terms of

Figure 3. X-rays with false negative results per clinician grade Figure 4. X-rays with false positive results per clinician grade

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increased patient satisfaction with provided services and agreater adherence with medication regimens.

In 2007, primary legislation was introduced in theform of the Irish Medicines Board (MiscellaneousProvisions) Act 2006 (Commencement) Order 2007. Thislegislation permits Irish nurses and midwives who haveobtained a certificate in nurse/midwife prescribing toprescribe medications under the guidance of collabora-tive practice agreements. The first independent evaluationreport on nurse and midwife prescribing found that theinitiative has been a benefit to patients and staff across thehealth care system.27

Having prescriptive authority is paramount in theprovision of optimum patient care, as analgesia wasrequired by over 50% of patients in this study. Resultsfrom this audit would suggest that there is a large dis-crepancy between pain assessment and analgesia adminis-tration across grades of clinicians for similar patientprofiles. Further research needs to be conducted in thearea of individual interpretation of pain scores to ensureconsistency of best practice for analgesia administrationin the emergency setting.

Dolan and Holt28 conclude that emergency nurseshave a responsibility to reduce patients’ pain and lessentheir suffering. However, studies have shown that painmanagement in EDs is rated poorly in patient satisfac-tion surveys. The National Council for Nursing &Midwifery highlights the importance of pain assess-ment and reassessment and appropriate intervention asa key performance indicator for ANPs in the emer-gency setting.14 It is therefore vital that furtherresearch is conducted into this aspect of patient care toensure optimum patient outcomes, regardless ofattending clinician grade.

Waiting TimesOvercrowding and extended waiting times in the ED havebecome an increasing reality for health services throughoutthe Western world. The 2003 National Hospital AmbulatoryMedical Care Survey reported 3.2 hours as an average wait-ing time in the ED, which included 46.5 minutes spentwaiting to be seen by a physician.29 Several studies haveshown that longer waiting times and overcrowding haveadverse effects on care and outcomes for patients30,31 andhave been cited as the most frequent reason patients leavebefore medical evaluation.32

This audit shows that the consultant (EM) and theANP had the shortest waiting times from first seeingthe patient to eventual discharge at 51 minutes. SHOshad waiting times of well over 1 hour; other NCHDshad a waiting time of just below 2 hours. While it isacknowledged that SHO patient caseload remitextended beyond that included in the audit, recordswere audited on a case-by-case basis to identify onlythose patients who met specific diagnostic criteria.Waiting times reflected the time from first assessment byspecialist clinician to discharge; it was not possible totake into account other concurrent role responsibilitiesfor each clinician.

This audit shows that ANPs significantly reduced thewaiting times of patients with minor injuries and illnesses inthe ED. Previous studies support this finding and concludethat the implementation of NPs in the ED has led to signif-icant reductions in waiting times and length of stay.9,33

Shorter waiting times are positively related to increasedpatient satisfaction. Researchers contend that a faster turn-around of patients through the ED can have a direct impacton quality outcomes and improve access to ED resources, aswell as decrease stress for patients and staff.31

Figure 5. Numbers of patients not offered analgesia per

clinician grade

Figure 6. Waiting time per clinician grade

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LIMITATIONSThe 2 main limitations of the audit were the number ofunavailable records and the comparatively low number ofpatients recorded as being seen by the consultant (EM).The number of unavailable records reflects current prac-tices at the site hospital, which depends on printed hardcopies. Computerized records and results will lessen thisissue for future audits. It is acknowledged that unavailablerecords may have affected overall results.

The consultant position reflects a joint appointmentwhere the role incumbent has responsibility for more than 1site. As a result time was divided between the audit site andanother similar geographically distant site, which obviouslyhad implications on number of patients seen. In addition,consultants are generally more involved in the review ofcomplex cases, which were outside of the criteria for thisaudit. The number of noncomplex cases seen by the con-sultant is therefore not a true reflection of workload.

CONCLUSIONEvaluation of the ANP role in the Irish context is in itsinfancy. Previous research has highlighted the need todescribe the precise interventions of advanced practitionersclearly in order to understand the process and outcomes oftheir practice.34 Results from this audit can add to theexisting body of knowledge in the area of emergency careand highlight the added value that the ANP provides topatient outcomes in the emergency setting.

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Wayne Thompson, RGN, RNP, DipHE (Nursing), Cert. inNursing (Nurse/Midwife Prescribing of Ionising Radiation),PGDip (Emerg), MSc, is a registered advanced nurse practi-tioner emergency in the emergency department at WexfordGeneral Hospital in Wexford, Ireland. He can be reached atwayne.thompson@hse.ie. Pauline Meskell, RGN, BSc,MSc, PhD, is a lecturer in the department of nursing and mid-wifery at the University of Limerick. In compliance withnational ethical guidelines, the authors report no relationshipswith business or industry that would pose a conflict of interest.

1555-4155/12/$ see front matter© 2012 American College of Nurse Practitionersdoi: 10.1016/j.nurpra.2011.09.002