Very good Matt (I tend to save your emails up for my VERY LONG coffee
breaks!)
But seriously, I too could be very holistic with my patients if I spent
30-60 minutes on each minor case. I'm utilitarian these days. What you might
gain in quality (of process) for some patients will ultimately result in
longer waits for all the others. So, I'm not sure we can afford such
luxuries in Emergency Medicine these days. The greatest good for the
greatest number, and all that... Rather, give me a fast middle grader any
day.
A
----- Original Message -----
From: "Dunn Matthew Dr. (RJC) A & E - SwarkHosp-TR"
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, August 17, 2006 9:50 AM
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
This email has been scanned for viruses by NAI AVD, however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicity stated.
If you have received this email in error please notify the sender.
The information contained in this email may be subject to public disclosure
under the NHS Code of Openness or the Freedom of Information Act 2000.
Unless the information is legally exempt from disclosure, the
confidentiality of this e-mail and your reply cannot be guaranteed.
|