BENEFITS AND CHALLENGES OF ADVANCED PRACTITIONERS IN EMERGENCY DEPARTMENT 

BENEFITS AND CHALLENGES OF ADVANCED PRACTITIONERS IN EMERGENCY DEPARTMENT

Clinical care

he ANP role is described as having professional knowledge, skills and behaviours to a high level, being capable of safe and effective practice, (Council for Healthcare Regulatory Excellence, 2009). Utilising these core qualities with expert skills and knowledge, the ANP could be the lever to assist with the reduction of waiting times for patients. This would be achieved by way of identifying Urgent and non urgent patients from the ED, as suitable and  transferring to majors or resus, therefore keeping the unit to full capacity Arguably, one of the most significant benefits of ACPs is they improve the quality of services at the Emergency department  (McDevitt and Melby 2015) by increasing positive patient outcome satisfaction and safety McDonnell et al (2014). Additionally, Nieminen et al. (2011) note that the AP’s are well empowered with specialised skills and knowledge that are useful in performing highly skilled and complex decision making in familiar and unfamiliar situation using their expert clinical knowledge and expertise. AP’s in ED can recognize, initiate investigation, prescribe, refer to speciality  and liaise with the appropriate multi-disciplinary  by  recognizing and prioritizing  the urgent and non-urgent cases. Although waiting times are a key indicator of patient satisfaction in ED(NHS England,2018) evidence shows that physician and APs equally helps in   reducing the waiting time in acute setting. However according to (Seale et al,2005) emphasises  that patient satisfaction level by a AP’s are much higher compared to the  doctors ,the key factor been effective communication .According to Comiske ,Coyne ,Lalor and Begley (2014 )while doctors opt to take a problem based approach or likely a traditional medical approach of history taking  (Silvermann,2013), advanced nurse practitioners uses a hybrid style consultation using nursing ideology and holistic approach by expressing activities of daily life taking into account social, emotional and psychological factors and  clinical knowledge to  optimise therapeutic approach and shared decision making (Barrat ,2016) .APs working in  Ed can use this skill   by explaining in detail patients diagnosis ,results and management thereby effectively communicate to bring  a  desirable  outcome on patient satisfaction (Silverman,2013).

A study in Ireland by Begley et al. (2012) showed  that advanced practitioner provides improved service delivery, with increase autonomy and produces greater professional and clinical leadership if given proper support for education and clinical skills . Given this According to Scar (2010) autonomy is the ability to make or the authority to make decision and the freedom to act in a professional knowledge base.

Although the transition from nursing to Advanced practitioner is a complex and multidemsional process which is rarely easy and even the most positive experience could be stressful (Cusson and Viggins ,2002),increased support and knowledge and a smoot transition can provide safe patient care ,career satisfaction and sense of well being (Cusson and Strange,2008,Barnes . In my trust the concept of a new integrated urgent care center and new post  of an trainee Advanced clinical practitioner brought in a lot of chaos and uncertainity . The role transition ,lack of  job descriptions and the inability to prescribe after completing the prescribing course brought in a lot of confusion of what we can’t and what we can actually do. Although there was a  the lack of senior leadership and recognition of trainee Acp .However there is has been a new move  and there is recognition and support for the trainee ACP  eg we have a clear job description and upon completion of Pgdip in   Advanced clinical practitioner we are offered a band 8 A pay scale ,as per the DOH . There is a positive move among the Lead consultants in ED to  support us with Royal college of emergency medicine credentialing (RCEM ,      ) . It is important that leadership is shared between clinical and managers (Kings Fund ,2015). Enhancement of clinical leadership and professional leadership can play indispensable role in building To be able to perform and showcase both clinical and professional leadership should be supported in their role. Although , a smooth role transition and leadership quality along with confidence, patient management and an environment conducive to learn and good working relationship will make APs an autonomous provider. A study by       shows  that poor transition ,impact of  politics ,hostility among staffs and lack of support were some of the reasons new APs were left abandoned and demoralized . During this transition to develop their autonomy and make a place they need to have the quality of  negotiable skills ,resilience ,tenacity and resilience (MacLellan, Levett-Jones and Higgins, 2016)- Increase support from physician and managers or practice manager champion to educate them also improves the ability for a smooth transition. leadership classes ,attending teaching sessions ,releasing time from work to attend clinical lectures.

During this transition to develop their autonomy and makea place they need to have the quality of  negotiable skills ,resilience ,tenacity and re-silience (MacLellan, Levett-Jones and Higgins, 2016)-

Accountability and autonomy are the different side of the same coin . .Nursing and midwifery council   clearly suggest that we are responsible for our actions and omissions(NMC,2015).

Although the trust was placed into special measures in December 2013, effective leadership with open cultures staff engagements and stakeholder advocacy was used as  the drive to change to bring about such a massive change.In March 2015, a further inspection revealed encouraging signs, and  the trust came out of special measures in March 2017.     Although the trust was under CQC special measures and financial restrain ,it funded for the course  of master’s degree Advanced clinical practitioner program to develop aspiring nursing staff and other allied health group for carrier development and a resource for developing  to new workforce .however the university caters for academic knowledge and skills the trust lacked support in enhancing clinical and emergency skills . As a trainee ACP initially there was a  lack of inter professional acceptance ,with weak management and absence of effective leadership unable to adopt a planning strategy .Despite the sound Department of Health’s position statement (2010 )on advanced practice and relevant existing health education framework(Health Education of England multi proffessional ACP framework (2017),there continued to be misunderstanding on educational ,skills training ,level of autonomy ,job title and pay scale . The ANP working at an advanced level are at the forefront of their area of practice, and proactively generate practice innovations and redesign solutions to better meet the needs of patients’ and the service. (DH, 2010). The position extends beyond clinical skills to combine leadership, teaching, and a role model for support and advice. DeBourgh, (2001), portrays the ANP as an expert role model providing structure and support to staff. The position would be a valuable resource to the nursing staff , for example; having the ability to prescribe, the patient would not be delayed by having to wait for a doctor. Furthermore, in the case of the deteriorating patient, the AP is available for expert advice, therefore potentially improving patient outcomes. Dalton, (2013), states the AP are in a good position to initiate treatment. Effective and transformational leadership is crucial to the success of healthcare organisations, as nurses lead teams to provide quality care and deliver service improvement, (Govier and Nash, 2009).  The AP would be more involved in how the department works, evidenced by the permanency of the post, a familiar resource, a fusion of medicine and nursing. Begley et al, (2012), establish clear evidence that the AP demonstrated clinical leadership by being a positive role model in autonomous clinical decision making and acted as a resource for other members of the team. Strong leadership is fundamental to

IMPACT ON WORK COLLEAGUES – Due to the global shortage of doctors and the WTD rule in UK there has been a move to restructure and reengineering of clinical team (McDonnell et al ;2014).

Martínez-González et al. (2014) point out that there are several benefits that come with implementing advanced practitioners such as the positive impact they have on their colleagues. In their view, the authors assert that ACPs add to the existing pool of knowledge within the health facility by sharing their experiences with the co-workers. The Royal College of Nursing (RCN) (2009) identifies clinical leadership as one of the requirements vital for assuring and sustaining quality care through the supervisory role of a leader and the creation of an effective workplace culture. However APs can feel professionally isolated due to colleague been overly critically because of unfamiliarity to the scope of practice and clinical skills what the APs can bring to the team leading to a hostile work environment (Fitzpatrick and Gripshover, 2016)

There is a need for a multidisciplinary approach to the planning of advanced practitioner services. To achieve multiprotection acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries. (Griffin and Melby, 2006)