The role of the Emergency Nurse Practitioner: An ethnographic study

Introduction: At the time of commencing this thesis there was a dearth of evidence-based information, especially from Australian studies, regarding the Emergency Nurse Practitioner (ENP) role and standardisation of the ENP scope of practice. The past eight years has seen a proliferation in the array of literature because of increased interest in ENP role, including patient satisfaction and other stakeholder perceptions of ENP clinical practice. There remains a deficit of literature focusing on what the role encompasses, from an incumbent’s perspective, as ENPs progress from the candidate to the post-endorsement ENP role.

Background: In Victoria, Australia, the introduction of the Emergency Nurse Practitioner role to the health care team in Emergency Departments has contributed to the care of patients presenting with minor injuries and illnesses. The Emergency Nurse Practitioner role has enabled experienced nurses to extend their scope of practice (SOP) to include ordering diagnostic investigations and prescribing medications for minor presentations, effectively allowing care from presentation through to disposition. Yet, because the role has not been clearly defined, either organisationally or in the literature, little is known of the ENP role post-endorsement. The aims of this study were threefold: first, to discover the role of the Victorian Emergency Nurse Practitioner, post-endorsement; second, to elucidate the complexities of the role; and third, to develop an informative framework to guide neophyte ENPs and prospective employers of ENPs regarding the complexities of implementing the role.

Method: This study was an ethnographic study of thirteen Emergency Nurse Practitioners practising in seven Victorian Emergency Departments, over a three-year period. Conducted across a variety of Emergency Department (ED) contexts, data collection included participant observation and interviews and was obtained from metropolitan, regional and rural health facilities. Data were analysed using the constant comparison method.

Findings: The overarching finding was that the Victorian Emergency Nurse Practitioner role, post-endorsement practice, was a blended model. As Emergency Nurse Practitioners became more expert in their clinical practice they appeared to practise virtually seamlessly, blending medical and nursing aspects of practice when assessing, treating and caring for their patients. More noticeable in rural emergency departments, ENP practice extended to include care for patients other than the minor injury and illness presentations seen by their metropolitan colleagues. It was further found that no two models of practice were the same, regardless of the number of Emergency Nurse Practitioners employed at the same health facility.

Discussion: The emergence of a clinical practice skill mix derived from both medicine and nursing has resulted in the addition of a new health care provider within the Emergency Department. In transitioning from an advanced emergency nursing role to that of Emergency Nurse Practitioner, participants experienced disruption from their previous well-understood roles. Application of Benner’s (1984) ‘Novice to Expert’ theory was examined in the context of the Emergency Nurse Practitioner participants as they developed their roles. From this, an informative framework was developed to enable the complexities of the Victorian Emergency Nurse Practitioner role to be more readily comprehended.

Conclusion: This study shows that lack of role clarity regarding the Emergency Nurse Practitioner role in Victoria still exists. Despite favourable reviews in the literature of the effectiveness and efficiencies of the role there remains a degree of ambiguity regarding how the role was developed and implemented. The findings of this study contribute to informing clinical governance and organisational support for the implementation of the Emergency Nurse Practitioner role. However, additional research focus is required for standardisation of clinical SOP, education and collaborative practices of the Emergency Nurse Practitioner.

This thesis has found that the role of the Victorian Emergency Nurse Practitioner, post-endorsement, is a blending of two practice paradigms. This study also demonstrates that the Emergency Nurse Practitioner role remains aligned to the traditional comportment of nursing.