Advanced nursing roles

Published on 14/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 3053 times

Chapter 45 Advanced nursing roles

Barbara Daly, Sarah Hoy, Gordian W.O. Fulde, Kirsty McLeod

Advancing nursing practice is a global phenomenon: in the context of the Australian experience, this has evolved over the past three and a half decades. The evolution of advance nurse practice is an ongoing process moving nursing practice forward for the benefit of the patient.¹ This change of practice is directly related to changes in the delivery of healthcare services and the implementation of new models of patient-focused care. An important driver in the development of the advance practice nurse is the political demand to meet government-set performance indicators and benchmarks aimed to reduce emergency department waiting times and patient length of stay and to increase patient satisfaction.² Another factor that has contributed to evolving advance practice is medical and nursing workforce shortages and skill mix problems. These developments have provided the impetus for emergency nurses to take on new opportunities to develop and increase their scope and complexity of practice in the field of emergency medicine. These advance nursing roles are now core roles that work with and support the medical and clerical staff to expedite the patient’s journey through the emergency department.

THE TRIAGE NURSE

The patient’s journey in the emergency department begins at triage. Triage is an essential function in the delivery of care in all emergency departments. It is the point at which emergency care begins. Triage is a brief clinical assessment that determines the urgency of treatment and the time sequence in which patients should be seen in the emergency department. The purpose of the triage system is to ensure safe quality of care and equity of access to health services. In all healthcare environments, the triage process is underpinned by the premise that a reduction in the time taken to access definitive medical care will improve patient outcomes.³

Most importantly, triage is a dynamic and ongoing process in which patients are continually reassessed. Their clinical urgency and triage category may be changed as a result, depending on parameters such as changes in level of pain and haemodynamic stability. For example, if a patient’s level of pain increases compared to initial triage assessment, or they become tachycardic or hypotensive, the patient will be re-triaged to a higher category.

In Australasian emergency departments a standardised triage system known as the Australasian Triage Scale (ATS) is the primary clinical tool for ensuring patients are seen in a timely manner, commensurate with their clinical urgency. The practical application of the ATS is the process by which the triage nurse assesses a patient’s presenting complaint, which is identified by a brief history of the presenting illness or injury. Triage decisions using the scale are made on the basis of observation of general appearance, focused clinical history and physiological data.⁴ This decision-making process may also require consultation and discussion with medical staff.

In practical terms triage refers to two domains, which are:

Domain 1. The ATS has five levels of acuity that categorise patients according to a rating scale from 1 to 5. (Also see Chapter 39, ‘Psychiatric presentations’, Table 39.1 Mental health triage.)

Table 45.1 ATS categories for treatment acuity, performance thresholds and examples of possible presenting problems

Domain 2. Time-to-treatment criteria attached to the ATS.

Time-to-treatment criteria attached to the ATS categories identify the maximum time a patient can safely wait for medical assessment and treatment.

Please refer to Table 45.1 for triage examples.

There are five core components for a nurse undertaking the role of triage nurse:

1. patient assessment

2. initiation of nursing interventions

3. ensuring continuous reassessment/management of`waiting room patients

4. provision of public education

5. acting as a liaison for members of the public and other health care professionals.⁵

The ability to undertake effective and efficient triage is dependent on extensive knowledge of and experience with a wide range of illness and injury patterns. Therefore, it is essential that the triage nurse is appropriately prepared through education and experience.

The triage nurse will perform a seven step triage assessment, which identifies the following key points as physiological predicators underpinning the allocation of urgency using the ATS.

Step 1. Identify and manage risks to self, patients and the environment is the first principle of a safe triage practice.

Step 2. First impressions of general appearance should always be considered when making a triage decision.

Step 3. Always ask the question: ‘Does this person look sick?’

Step 4. The primary survey approach is used to identify and correct life-threatening conditions at triage.

Step 5. Other conditions in which timely intervention may significantly influence outcomes (such as thrombolysis, an antidote or management of acid or alkali splash to eye) must also be detected at triage.

Step 6. Timely access to emergency care can improve patient outcomes.

Step 7. Early identification of physiological abnormality at triage can inform focused ongoing medical assessment and investigation.⁶

Once the triage assessment is complete, the patient may follow a variety of treatment paths and interact with any of the following emergency department staff and teams:

• clinical initiatives nurse (CIN)

• aged care services team (ASET)

• rapid assessment team (RAT)/immediate initiation of care (IIOC)

• nurse practitioner (NP).

All of these advanced practice roles assist in expediting treatment and initiation of care and will now be discussed in terms of how they interact with the patient during their emergency department journey.

CLINICAL INITIATIVES NURSE (CIN)

The CIN role works as an adjunct to the triage position, initiating care of patients in the waiting room once they have been assessed by the triage nurse. The CIN is able to fast-track the care of patients with a variety of presenting problems prior to receiving medical care. This may be as a result of established clinical pathways, local standing orders or CIN guidelines. The CIN is not able to discharge patients and hands over care of the patient to another nurse once treatment has been initiated.

Nurses working at CIN level should have:

• significant triage experience

• high level clinical skills

• advanced practice skills, or ready to be trained to an advanced practice level

• well-developed conflict resolution and negotiation skills with focus on customer satisfaction.

Initiated care may include:

• ordering radiological tests

• insertion of peripheral intravenous cannulae

• withdrawal of venous blood for pathology

• initiation of medication such as oral analgesia, anti-emetic agents and intravenous narcotic analgesics

• fracture management such as application of ‘back slab’ plaster

• wound management, including suturing

• referral to other hospital services, for example outpatient’s clinics or social worker.⁷

The CIN role enables the nurse to commence patient treatment via pre-approved standing orders for specific presentations under the supervision of an emergency department registrar or consultant.

Box 45.1 Example 1. Patient presenting with an ankle fracture

Patient presents to emergency department with painful left ankle following a simple trip and fall.

Triage assessment indicates pain and tenderness at posterior edge of lateral malleolus, ankle is swollen and deformed, and the patient is unable to weight bear. The left ankle is neurovascularly intact, and the patient describes pain severity as 6/10. Vital signs are within normal limits, Glasgow Coma Score 15, nil known allergies.

Triage category 3 is allocated by triage nurse.

Patient is referred to CIN nurse who orders left ankle X-ray according to Ottawa ankle rules, application of rest/ice/elevation. Due to level of pain, CIN inserts IV cannula, places patient on oxygen saturation monitoring and initiates administration of IV morphine 2.5 mg bolus as per nurse initiated protocol.

Patient’s ankle X-ray attended.

CIN nurse views X-ray with emergency department registrar. X-ray shows fracture to left lateral malleolus.

CIN applies back slab plaster as per standing order.

Ongoing medical treatment by emergency department registrar as required.

Patient is referred to orthopaedic team.

AGED SERVICE EMERGENCY TEAM (ASET)

ASET is led by a clinical nurse consultant, specialising in aged care. ASET is a multidisciplinary team including a nurse, physiotherapist, social worker and, in some areas, an occupational therapist.

The specific objectives of this team include:

• undertaking a comprehensive assessment of elderly patients over 70 years of age presenting to emergency department.

• aiming to prevent avoidable admissions by setting up services or accessing respite.

• identifying potential admission for patients who are considered at risk.

• commencing treatment for patients being admitted by providing physiotherapy and social work input while in the emergency department.

• encouraging health promotion by providing information on social and educational activities available for older people in the community.

• improving communication between hospital and community workers and hospital and residential care staff regarding patients presenting to emergency department.

An example of how the ASET functions is described in Box 45.2.

Box 45.2 Example 2. 80-year-old female presenting with recurrent falls

Patient presents via ambulance to emergency department with recurrent falls. Patient found on the floor by neighbour with painful right hip, unable to weight bear.

Triage assessment indicates painful right hip, shortening and external rotation of right leg. Patient is confused regarding day/date/time. Unable to confirm past medical history. Vital signs within normal limits. Triage category 3 is allocated. Referral made to CIN and ASET nurse.

CIN orders right hip X-ray, chest X-ray, IV cannula inserted, bloods taken for pathology (FBC, renal profile, group-and-hold), analgesia given as per nurse initiated narcotic protocol, ECG, intravenous fluids, pressure risk assessment, patient remains nil by mouth.

ASET nurse undertakes comprehensive assessment including:

• Pre-morbid mobility assessment to identify level of independence. This also includes history of falls and potential causes. This may lead to a referral to other specialty teams, e.g. dizziness may require investigation by neurology team.

• Ability to perform activities of daily living (ADL).

• Community services usage and frequency of services.

• Current home support, e.g. family, contact numbers, need for respite care.

• Mental status is assessed via Abbreviated Mental Test Score (AMTS) and Confusion Assessment Method (CAM) diagnostic algorithm. Both these tests are performed with involvement of the patient’s family.

Early linkage to community care packages is made to ensure safe and timely discharge of the patient back to the community after acute admission. Early involvement of the general practitioner (GP) is an important aspect of the discharge planning process.

Medical staff continue treatment and management of the patient in conjunction with emergency department nurses and ASET.

Once clinical work-up is complete, referral to ortho-geriatric team for admission for fractured right neck of femur.

Medical officer decides the need for further investigations in emergency department—e.g. if head injury present or if the patient is on warfarin, need to consider CT of the brain.

RAPID ASSESSMENT TEAM (RAT)/IMMEDIATE INITIATION OF CARE (IIOC)

There are a variety of names and abbreviations, such as RAT and IIOC, which describe models of rapid assessment and treatment within the emergency department. These models involve having a team of a senior doctor and nurse meeting patients as they arrive. What they actually do for each patient will depend on the nature and seriousness of the problem, as well as the prevailing patient flow constraints at the time.

This is so that:

• Senior emergency department medical decision making is moved to the earliest point in the patient’s emergency department care, so as to streamline subsequent processes.

• Senior emergency department nurse involvement ensures the availability of advanced nursing skills, and streamlining of subsequent nursing care.

• Working in partnership, the team will leverage each other’s skills, making each more effective than working alone.

The concept for all these models is the same in that they move experienced medical and nursing staff to the front door so that the patient’s journey starts with them rather than ends with them, as is currently the case.

The specific objectives of these teams are to:

• provide senior medical decision making at the earliest point in the patient’s emergency department care, so as to streamline emergency department processes for the patient and for the department

• triage patients to the appropriate area for care

• organise appropriate investigations

• minimise unnecessary interventions

• initiate analgesia early

• provide a quick assessment, referral, fix and discharge from the front if appropriate.

All members of the team are capable of multitasking, according to their skills. Doctors and nurses will triage according to current guidelines. Nurses will provide definitive treatment using written guidelines, as well as being under the direct supervision of senior medical staff.

The two biggest dangers of these models are:

1. Trying to do too much at the front door. The senior doctors and nurses must be resolute in their efforts to avoid this.

2. Errors of omission or duplication due to inadequate handover as the patient moves from one area of the department to another. The written form should be utilised to avoid this.

An example of how the RAT/IIOC works is set out in Box 45.3.

Box 45.3 Example 3. Patient presenting with renal colic

Patient presents to emergency department with 1 hour history of severe loin pain radiating to groin.

Triage assessment indicates patient distressed and in severe pain, severity described as 10/10. The patient is observed to be diaphoretic, pale, hypertensive and feels nauseated. Nil past medical history, regular medications or allergies. Triage category 2 is allocated.

Patient is referred to RAT for ongoing management.

RAT doctor conducts a brief history and examination to confirm likelihood of diagnosis and then orders opioid and non-steroidal anti-inflammatory medication (e.g. morphine IV 5 mg and indomethacin 100 mg PR); nurse to perform basic pathology investigation, FBC, urea/electrolytes/creatinine (UEC) and mid-stream urine (MSU) and administer medications.

History and clinical examination with results reviewed by other emergency department staff to ascertain whether presentation is complicated or uncomplicated.

• Uncomplicated:

• Pathology results for FBC, UEC

• If all ‘nothing abnormal detected’ (NAD) and pain settles, discharge home with outpatient referral for CT-KUB and urology consult

• Complicated:

• Confirmed through pathology results, history of strictures, indwelling stents, abnormal urinary tract or evidence of fever or ongoing pain

• Investigation via CT-KUB and inpatient consultation/admission with the urology team

• Ongoing analgesia as required

THE NURSE PRACTITIONER (NP)

The nurse practitioner role is a relatively new advanced practice role within emergency departments, and as such there is variety in their clinical activities. This may depend on the setting the nurse practitioner is working in (e.g. rural, remote or metropolitan hospital). The nurse practitioner role in emergency department is currently focused on primary care; however, as the role evolves, more complex acute care management guidelines may be developed.

The nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of patients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other healthcare professionals, prescribing medications and ordering diagnostic investigations. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise and approval of nurse practitioner guidelines at the local level. The nurse practitioner will refer the patient to the medical officer if there is any evidence of symptoms outside their scope of practice.

The nurse practitioner role has been shown to have a positive impact on emergency department waiting times and has enhanced the collaborative clinical management of patients within the emergency department setting.

Two examples of the nurse practitioner scope of practice are given in Boxes 45.4 and 45.5. The first example outlines the assessment and management of an acute sore throat. The second outlines the assessment and management of a patient with central chest pain.

Box 45.4 Example 4. Patient presenting with acute sore throat

The management of an acute sore throat will depend on the severity of symptoms, the presence of other signs and symptoms and the patient’s previous history.

Presenting complaint as stated by the patient or significant other:

• acute onset of a sore throat

• cervical lymphadenopathy.

Nurse practitioner assessment

The nurse practitioner will be continually assessing and initiating:

C. Circulation: BP (manual and bilaterally if possible), total peripheral resistance (TPR), PSatO₂

D. Differentials: a mildly sore throat may be a feature of most patient presentations with upper respiratory tract infections and may require no more than adequate pain relief

E. Evaluation or escalation? Do we continue independently or is their need for medical assistance? Can we use clinical directives to instigate blood sampling or morphine etc?

The nurse practitioner will also document the following as part of the clinical assessment:

• medications—current treatment, over-the-counter medications, recreational, missed medications

• past medical history—past medical history, instructions from past attendances to general practitioner/emergency department

• family medical history—family medical history (in summary, gained from the above)

• social history—e.g. housing status, lifestyle, recreational activities or support services

• risk factors.

The general assessment will consist of:

• vital signs

• appearance of throat

• tonsillar exudate

• petechia at junction of hard and soft palate

• lymphadenopathy

• splenomegaly

• hepatomegaly

• ear examination.

Management will consist of either a medical pathway or a nurse practitioner pathway.

Nurse practitioner management

Paracetamol/aspirin (may be gargle)

Adequate oral hydration

Antibiotic therapy if there is:

• tonsillar exudate

• bilateral cervical lymphadenopathy

• history of documented Group A beta-haemolytic streptococcal infection in a person with whom there has been close contact.

Review in 24–48 hours or at the request of the patient

Refer to medical officer if:

• history of rheumatic heart disease

• history of prosthetic valve

• immunocompromised patient

• presence of hepatomegaly or splenomegaly

• presence of peri-tonsillar abscess.⁸

Box 45.5 Example 5. Patient presenting with chest pain

The assessment of the patient presenting with central chest pain will vary according to the urgency of the situation, experience of the nurse practitioner and resources available, e.g. whether a doctor is immediately available. However, an expedient, logical and systematic appraisal of the patient’s condition is vital to patient safety and the timeliness of treatment.

Presenting complaint: as stated by the patient or significant other.

History of presenting complaint and assessment will include the following (mnemonic—CHEST PAIN ⁹);

C. Commenced when? Establish a timeframe and if there were any associated events such as exertion, activity, emotional distress.

H. History/risk factors? Any previous heart conditions or unexplained SOBOE, chest pain etc. Any first-degree relatives (parents/siblings) with heart complaints, stroke or raised blood pressure. Risk factors may include smoking, high-fat diet, diabetes, hypertension, obesity or a sedentary lifestyle.

E. Extra symptoms? Any complaints of feeling nervous, nauseated, sweating, palpitations, SOB, dizzy or weakness? Also remember ethnicity-associated increases in CVD.

S. Stays/radiates? Does the pain stay in one place, or does it move? If the pain radiates, where does it go? MI pain can present as toothache and neck/jaw pain and, in the elderly or diabetic neuropathy patient, symptoms can be deranged and not clearly detectable.

T. Timing? How long does the pain last? Any previous episodes, if so, how long did they last? When did the pain become continuous?

P. Place? Where is the pain? Check the point of tenderness with palpation.

A. Alleviating or aggravating factors? What makes the pain worse, or better?

I. Intensity? How intense is the pain, what does it stop you doing?

N. Nature? Ask the patient to describe their pain; do not suggest descriptors. Listen for key symptoms.

While going through the above, the nurse practitioner will be continually assessing and initiating:

C. Circulation: BP (manual and bilaterally if possible), total peripheral resistance (TPR), PSatO₂, signs of cyanosis

D. Differentials: chest pain can present from a myriad of pathologies—indigestion, musculo-skeletal (MSK) chest pain or aortic arch dissection for example. The nurse practitioner should be familiar with the main differentials for chest pain and their symptomatology along with appropriate assessment or diagnostic strategies to, as far as possible, exclude these differentials.

E. Evaluation or escalation? Do we continue independently or is their need for assistance? Can we use clinical directives to instigate GTN, blood sampling or morphine etc?

The nurse practitioner will also document the following as part of the clinical assessment:

• medications—current treatment, over-the-counter medications, recreational, missed medications

• past medical history—past medical history, instructions from past attendances to local general practitioner/emergency department

• family medical history—family medical history (in summary, gained from the above)

• social history—e.g. housing status, lifestyle, recreational activities or support services

• risk factors.

The general management of chest pain will consist of diagnosis and risk stratification and management as per local protocols and pathways for high, intermediate and low risk. (See Chapter 7, ‘Acute coronary syndromes’.)

CVD, cardiovascular disease; MI, myocardial infarction; SOBOE, shortness of breath on exertion

PEARLS OF WISDOM

The most crucial aspect of triage is effective communication to ensure accurate information to make well-informed decisions. That is why when triaging you must remain calm, listen to the patient, interpret and explain all your actions and check that the patient understands what you have said.

Teamwork is crucial in emergency department; everyone needs to communicate well, especially at handovers.

Make sure you know where your resources are, or ask where to find emergency department protocols, drug protocols, clinical pathways.

It is important to appreciate that approximately 75% of your diagnosis comes from information gained at history taking, leaving only approximately 25% originating from your physical examination, diagnostics tests etc.¹⁰

Remember: Triage is the first point at which a patient enters the emergency department and this experience will influence how the patient responds and evaluates the care and treatment they receive.

Remember to ask for help/advice readily if you need it—the medical, nursing, allied health and clerical staff will assist you.

EDITOR’S COMMENT

Future professional and career roles for nurses must continue to progress due to the enormous health needs of the community: for example, ultrasound examination (abdominal, FAST), intravenous line placement skills for nurses, 24-hour increased senior nurses and educator cover for busy emergency departments.

1 Por J. A critical engagement with concept of advancing nursing practice. Journal of Nursing Management. 2008;16:84-90.

2 Hudson P., Marshall A. Extending the nursing role in emergency departments: challenges for Australia. Australasian Emergency Nursing Journal. 2008;11:39-48.

3 Australian Government Department of Health and Ageing. Emergency Triage Education Kit. 2007; p 4. Online. Available: http://www.health.gov.au/publicat.html.

5 CENA. Position statement triage nurse. Australasian Emergency Nursing Journal. 2007;10:93-95.

6 Australian Government Department of Health and Ageing. Emergency Triage Education Kit. 2007:18.

7 NSW Health. Clinical initiatives nurse guidelines: the emergency nurses advisory group. 2002.

8 Dennis M., Waters W., Shanahan M. Emergency department nurse practitioner clinical practice guidelines. Greater Southern Area Health Service, NSW Department of Health. 2006.

9 Newberry L., Barret G.K., Ballard N. A new mnemonic for chest pain assessment. J Emerg Nurs. 2005;31(1):84-85.

10 Peterson M.C., Holbrook J.H., von Vales D., et al. Contributions of the history, physical examination and laboratory investigations in the medical diagnosis. West J Med. 1992;156:163-165.

ADDITIONAL RESOURCES

Australasian College for Emergency Medicine website: http://www.acem.org.au.

Australian Government Department of Health and Ageing. Emergency Triage Education Kit. Online. Available: http://www.health.gov.au/publicat.html.

College of Emergency Nursing Australasia website: http://www.cena.org.au.

Curtis K., Friendship J., Ramsden C. Emergency and trauma nursing. Elsevier Australia; 2007.

Dolan B., Holt L. Accident and emergency. Theory into practice. Elsevier Limited; 2000.

Fry M., Holdgate A. Nurse initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emergency Medicine Australasia. 2002;14(3):249-254.

Hodkinson H. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and Ageing. 1972;1:233-238.

Inouye S.K., et al. Clarifying confusion: the confusion assessment method. A new method for the detection of delirium. Ann Int Med. 1990;113(12):941-948.

National standards and competency for a nurse practitioner. Online. Available: http://www.anmc.org.au/docs/Competency_Standards_for_the_Nurse_Practitioner.pdf.

NSW Health. State authorisation. Requirements for nurse/mid-wife practitioners and the scope of practice/clinical guidelines. Online. Available: http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_556.pdf.

Prince of Wales Hospital. In their shoes (communication training DVD). 2005.

Related

Emergency Medicine