If we're going to have to get back to the original question (although advantages and disadvantages compared to what?):
Advantages:
Can see and manage certain groups of patients according to protocols
Work well to protocol
Tend to write extensive notes in legible handwriting
Have the flexibility to drop the ENP role and work as nurses if needed to do so
Can sometimes be recruited at times of shortage of medical staff
Relatively low turnover of staff (varies a bit though- I have seen some ENPs using it as a stepping stone to a management role)
It is possible to run a small nurse practitioner unit more cheaply than one where doctors see the patients (so possible to have minor injuries units in isolated areas)
Using a ENP as a triage nurse enables x-ray from triage for certain groups of patients (although interestingly our own initial data on this shows that it actually increases total time in the department. This is at odds with data from elsewhere)
Because of the way their pay works, UK ENPs are usually happy to work unsocial hours.
If considered as additional staff rather than as a replacement for junior doctors, they can potentially see between a quarter and a third of patients in a typical A and E department with similar quality of care and patient satisfaction to patients seen by SHOs.
Disadvantages
Generally not great at working outside protocols
In some cases will see only the simplest groups of patients
Training can be expensive if you are training up your own nurses rather than employing already trained ENPs particularly if they are paid a salary during ENP training
Most studies show ENPs refer more patients for follow up than SHOs do
If seen as a replacement for doctors, cost per case is higher for ENPs than for doctors
Rates of investigations are on a par with SHOs rather than middle grade A and E doctors.
If you are training up from your own department there is a risk that you will take the most able nurses away from traditional nursing
Bear in mind that most comparisons look at ENPs compared to SHOs. SHOs will largely disappear from EDs in the UK. FY2s will be there, but number of FY2s will be related to training not to service needs, so replacement of them by ENPs will become more complex. The question then is whether you spend your money on more senior (or possibly permanent middle grade doctors); whether you spend it on relatively low qualified staff to enable senior/ middle grade doctors or whether you spend it on ENPs. Different departments will need different solutions. But the evidence that is out there is mainly around a comparison that is no longer relevant with the real question being unanswered by any research.
There is also the issue that there is a much wider variation in training (in nurse practitioner/ traditional SHO work) between different nurse practitioners than between different junior doctors- some ENPs are very limited in the cases they can deal with, others are not. In the UK there is no standard length of a course to become a ENP.
At the moment, the summary in general would be that ENPs can see a proportion of your patients and provide a standard of care equivalent to having them seen by doctors but at a higher cost.
Now that that's over, to get back to the debate:
> 20 patients per hour is an easy throw away line that is not
> likely to ever
> be tested. The simple truth is that if one bottleneck in the
> system is
> removed - eg the unlikely event that a doctor is able to see
> 20 patients per
> hour - other bottlenecks will be revealed eg access to
> radiology, ability of
> clerical staff to generate paperwork etc.
The point made is that it has been tested. It can be done in selected minors. It is very much a sprint rate an not maintainable for a long time.
> Whilst it may be possible to physically see 20 patients per
> hour, I question
> whether:
> * this is possible for anything but the most 'minor'
> complaints (should they
> be in an ED in the first place?)
This stemmed from a discussion about ENPs. The patients who could be seen are the same sort of patient that are generally seen by ENPs. (Some departments ENPs have a more extended role)
> * this is possible to do across a whole shift - eg 180
> patients in a shift!
Probably not. It's a sprint rather than a marathon. However, hourly attendances at EDs fluctuate widely. If you aim to see patients within a relatively short period from their arrival you need to be able to alter your work rate. If you have 20 minors arriving within an hour (as many departments do from time to time) and you aim to your patients within an hour and a half of arrival, then someone who can see patients rapidly in short bursts
> * it is possible to practice high quality medicine in this manner - eg
> documentation, vigilance for low frequency / high morbidity conditions
>
Yes it is. Vigilance for low frequency/ high morbidity conditions takes very little time to an experienced practitioner.
> The US system is probably the best system to use for
> reference. They are
> set up so that the high cost individual (the doctor) has
> unimpeded access to
> patients. In this system, the usual across all shifts
> patient activity is
> around 3.5 pph.
>
Varies a lot, though. Up to 7 or 8 patients an hour in some departments. This is across the board. A single patient taking you 2 hours to deal with will distort this. It also includes slack periods- the usual equation is that you staff to deal with 85% of the variation. This means for most departments that if you are staffing at a level to see your patients within 90 minutes of arrival you will have some slack time when your staff aren't seeing patients. US hospitals are restricted by the necessity to provide the Medical Screening Exam (in the UK we have better primary care services so can use GP urgent follow up for more conditions). The idea of an equivalent to a MSE for the UK is debatable. There certainly are possible advantages to it. If it does come in, this would be a good role for ENPs.
> Now you're being disingenuous as well as patronising aren't
> you? Without wishing to state the obvious team work means
> everyone working together as a team.
Working as a team is not the same thing as doing the same job. It is playing to the abilities of each team member. Rugby is a team sport. Everyone has a valuable role to play. But you don't switch your wing three-quarter for your loose head prop.
--> Slower? You've hired the wrong ENPs then, or you've somehow managed to
find SHOs who see significantly more than 1-2 patients per hour.
Not found them. Trained them. Doesn't take long, but is intense.
ENPs on the whole work solidly at a standard pace (some don't); SHOs can up the pace if you teach them how.
> A&E and emergency care
> as a whole is
> one of the few areas where doctors and nurse have worked well together
> (often in interchangeable roles e.g. cardiac arrests)
I think this is a good example. Where the work involves working to protocols (as in cardiac arrests) doctors and nurses have interchangeable roles- although on the whole nurses stick to the protocols better than doctors. However doctors are usually more ready to work outside protocols. Whether this is a good or a bad thing for the patient is another question.
> But that's simply because I can't think of a single advantage
> of an ENP over a doctor. Not one.
They are better at following protocols. They are cheaper by the hour. They have the flexibility to do nursing tasks better than doctors. They are better at form filling.
Matt Dunn
Warwick
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