For what its worth, I'm quite happy with most ENPs I have worked with.
Some are good, some bad but then so are SHOs, SpRs, SGs and consultants.
A few years back some colleagues and I did a study looking at education
for ENPs and organised an OSCE etc for them. To 'pilot' it we tried it
out on a bunch of our SHOs. Later, just because we had the data, we
compared the SHOs scores to those of the ENPs and found no significant
difference in the results. Well of course, we thought, that's what
studies show, ENPs and SHOs are comparable. A little later we realised
that these ENPs had been qualified for up to 5-6 years (and ED nursing
for a long time prior to that) and most of the SHOs were fresh out of
house jobs or maybe a year in to training rotations, with little prior
ED training.
Now obviously this was not the object of the study and as such the
'results' need to be looked at with caution but the indication was that
the ENPs appeared not to have moved on much in their time (?restrained
by protocols) beyond the care provided by a relatively junior SHO.
Simon
-----Original Message-----
From: Dunn Matthew Dr. (RJC) A & E - SwarkHosp-TR
[mailto:[log in to unmask]]
Sent: 17 August 2006 09:50
To: [log in to unmask]
Subject: Re: I think we have this all wrong - final thoughts
If I may address the somewhat one sided nature of this debate by
mentioning issues from the other side.
Where research has looked at equivalence of care between ENPs and SHOs
it has tended to judge outcomes by a scientific paradigm. Engebretson,
J. (1997). A multiparadigm approach to nursing. Advances in Nursing
Science, 20(1), 21-33 makes some worthwhile points in that nurses
expanding their practice move away from a pure scientific paradigm to a
multiparadigm approach incorporating science within an holistic
approach. ("Holistic theories are global, espouse a transcendental view
of humans, and are committed to not viewing subject matter as an
accumulation of parts").
If patients are seen as the carrier of a condition requiring diagnosis
and treatment of that diagnosis then based purely on diagnosis and
treatment SHOs and ENPs are equivalent but ENPs are more expensive
because of increased length of consultations. If however you take the
attitude that the extra length of consultation adds value by allowing a
deeper understanding of the person as a whole then ENPs could be said to
be more cost effective. Bear in mind that a significant number of ED
attendees (in some departments possibly the majority) do not have a
disease that medical treatment will significantly affect. In these
patients an holistic approach to them as a person will obviously be of
more benefit than a pure diagnosis centred approach.
This way of looking at it also moves away from the idea of "ENPs work to
protocols". ENPs incorporate protocols but their holistic approach moves
further away from the disease/ pathway/ protocol driven way of working
than the usual way of doctors working does.
F. C Donald and C. McCurdy. Review: nurse practitioner primary care
improves patient satisfaction and quality of care with no difference in
health outcomes. Evid. Based Nurs., October 1, 2002; 5(4): 121 - 121. at
first seems to have a strange title (how can you claim to improve
quality of care if you don't improve outcomes- surely to a patient it is
outcome not process that matters) but if you move to judging quality of
care by its effect on the patient as a whole rather than by its effect
on the disease it is more understandable.
Going back to a pure scientific paradigm, several studies have shown
statistically significant improved patient satisfaction with NPs. This
is fairly weak evidence though- it is not generally found in studies in
EDs. A criticism of it is that the studies have tended to be in settings
where NPs have had longer consultation times than doctors and have had
relatively low return rates. It would be reasonable to suspect a
selection bias in these cases with patients with the time to fill in
satisfaction forms tending to be those who preferred longer
consultations. Again, though, this is thing worth putting into your
cost/ benefit analyses.
Another point worth considering is the effect on doctors of use of NPs.
There is almost an assumption that use of NPs will reduce the workload
of doctors with total workload remaining the same. If this is the case
and you take a disease centred approach to quality, then you could argue
that use of NPs costs slightly more for the same service. Some studies
however have shown an increase in total workload with the use of NPs. It
could be argued in these cases that NPs are meeting a previously unmet
need and increasing quality.
Overall the idea that switching from SHOs to ENPs results in a similar
service at higher cost is over simplistic.
Matt Dunn
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