First Experience with Advanced Nurse Practitioners and Physician Assistants in Dutch Emergency Departments; (Dis)Advantages to the Development

Abstract

Background: Emergency Departments (EDs) are confronted with progressive crowding. One of the main reasons is found in the growing number of “self-referrals” caused by a growing shortage in general practitioners. To cope with crowding, cost-effective solutions are being sought that preserve quality of care. Up to now, the most successful initiative is the development of Advanced Nurse Practitioners (ANPs) and Physician Assistants (PAs). Aim: The aim of this study is to compare the role and development of ANPs and PAs in Emergency Departments in the Netherlands and put it in a European perspective. Methods: An inventory concerning the first experiences with ANPs and PAs on Dutch EDs was performed. Attention was focused on the differences and similarities in responsibilities and scope of practice of both professions and the (dis)advantages observed with this development. Furthermore, information was obtained from educational institutes, national nurses' associations and governmental organisations in the Netherlands and other European countries to complete the picture, enabling the formulation of a perspective on the future. Results: In Europe (mainland), the development of ANP/PA programmes is still in a very early stage. In the Netherlands, the first year of experience with ANPs working on the ED has come to a close. In the past year, some PAs also graduated and are working in the ED as well. For both groups, liability is still an issue and legislation concerning the new professions has not yet passed. Apart from a significant overlap in job description, there are some differences to be addressed. The background of ANPs must be a masters degree in nursing, as for the PAs a different paramedical background is also allowed. The following can be said about the scope of practice and responsibilities: ANPs have a disease-focused approach, while PAs are being trained to have a speciality-focused approach. Furthermore, PAs purely do clinical work, whereas ANPs are also trained to investigate and improve the efficiency of delivered care. (Dis)advantages of ANPs/PAs: In Anglo-Saxon countries, ANPs and PAs have contributed to the relief of physician shortage and therefore it is likely that this will also be the case in the Netherlands. Furthermore, it is shown that the implementation of ANPs/PAs can occur with preservation of quality of care and patient satisfaction. However, in both professions the educational program is relatively long and expensive. Moreover, although basic medical issues are dealt with, the programmes are not aimed at preparing the trainees for specific (diagnostic) tasks. Another disadvantage concerns the loss of these practitioners for regular nursing tasks, contributing to the shortage in regular nurses. This is why an alternative is sought that maintains the benefits of ANPs and PAs and gets rid of the disadvantages. Alternative Solution: An alternative concept is to provide regular ED-nurses with short injury-specific courses, teaching them how to assess and treat specific injuries according to a protocol. Apart from regular nursing tasks, treatment of minor injuries could then be taken over from physicians. This creates flexible employees, and would help deliver cost-effective quality of care with prevention of further nurse shortage.

Key words

mid-level practitioners - advanced nurse practitioners - physician assistants - emergency department

References

• 1 American Academy of Physician Assistants .AAPA Physician Assistant Census Report 2003. Alexandria, Virginia 6-10-2003
• 2 Allerston J, Justham D. Nurse practitioners and the Ottawa ankle rules: comparisons with medical staff in requesting X-rays for ankle injured patients.  Accid Emerg Nurs. 2000;  8 110-115
• 3 American Academy of Physician Assistants .Physician Assistants in Emergency Medicine,. 2004
• 4 Berland Y. Transfert de compétences. Cooperation des professions des santes: le transfert de taches et de compétences. Report in request of the French government, 2003
• 5 Brenner R. Proposed revisions to Nurse Practitioner and Nurse-Midwifery Education Program Guidelines.  Federal Register. 2003;  68 2
• 6 Bruurs M, Brink G van den. Nurse Practitioners & Physician Assistants/Ondersteunend Geneeskundige. Notitie Hogeschool van Arnhem en Nijmegen, faculteit GGM, 2002
• 7 Busse R, Riesberg A. The European observatory on health systems and policies. Health care systems in transition. Germany 2004
• 8 Calling all gatekeepers: this is an emergency.  Lancet. 1994;  343 305-306
• 9 Cooper M A, Lindsay G M, Kinn S, Swann I J. Evaluating emergency nurse practitioner services: a randomized controlled trial.  J Adv Nurs. 2002;  40 721-730
• 10 Derlet R W, Richards J R. Overcrowding in the nation's emergency departments: complex causes and disturbing effects.  Ann Emerg Med. 2000;  35 63-68
• 11 Doan B D, Levy D, Pavot J. [Demographic forecasts of medical workforce supply in France (2000-2050). What numerus clausus for what future?].  Cah Sociol Demogr Med. 2004;  44 101-148
• 12 Ganapathy S, Zwemer F L. Coping with a crowded ED: an expanded unique role for midlevel providers.  Am J Emerg Med. 2003;  21 125-128
• 13 Hughes N. ACEP survey provides statistical information on utilization of PA's in Emergency Medicine.  AAPA News. 1999;  20 1
• 14 Hull S, Jones I R, Moser K, Fisher J. The use and overlap of AED and general practice services by patients registered at two inner London general practices.  Br J Gen Pract. 1998;  48 1575-1579
• 15 Janiszewski G H. The nursing shortage in the United States of America: an integrative review of the literature.  J Adv Nurs. 2003;  43 335-343
• 16 Kulu-Glasgow I, Delnoij D, de Bakker D. Self-referral in a gatekeeping system: patients' reasons for skipping the general practitioner.  Health Policy. 1998;  45 221-238
• 17 Lambe S, Washington D L, Fink A, Laouri M, Liu H, Scura F J. et al . Waiting times in California's emergency departments.  Ann Emerg Med. 2003;  41 35-44
• 18 Lindberg M, Ahlner J, Ekstrom T, Jonsson D, Moller M. Asthma nurse practice improves outcomes and reduces costs in primary health care.  Scand J Caring Sci. 2002;  16 73-78
• 19 Lindberg M, Ahlner J, Moller M, Ekstrom T. Asthma nurse practice - a resource-effective approach in asthma management.  Respir Med. 1999;  93 584-588
• 20 Lu H, While A E, Louise B K. Job satisfaction among nurses: a literature review.  Int J Nurs Stud. 2005;  42 211-227
• 21 Mann C J, Grant I, Guly H, Hughes P. Use of the Ottawa ankle rules by nurse practitioners.  J Accid Emerg Med. 1998;  15 315-316
• 22 Murray M K. The nursing shortage. Past, present, and future.  J Nurs Adm. 2002;  32 79-84
• 23 Nursing and Midwifery Unit of the WHO Regional Office for Europe, Belgium .Nursing and midwifery profile,. 2000
• 24 Richardson L D, Hwang U. Access to care: a review of the emergency medicine literature.  Acad Emerg Med. 2001;  8 1030-1036
• 25 Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial.  Lancet. 1999;  354 1321-1326
• 26 Sakr M, Kendall R, Angus J, Sanders A, Nicholl J, Wardrope J. et al . Emergency nurse practitioners: a three part study in clinical and cost effectiveness.  Emerg Med J. 2003;  20 158-163
• 27 Schneider S M, Gallery M E, Schafermeyer R, Zwemer F L. Emergency department crowding: a point in time.  Ann Emerg Med. 2003;  42 167-172
• 28 Schull M J, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction.  Ann Emerg Med. 2004;  44 577-585
• 29 .SEMPA guidelines for the utilization of Emergency Medicine Physician Assistants. 24-5-2003
• 30 Sheer B. Report of 3^rd ICN International Nurse Practitioner/Advanced Practice Nursing Network Conference. Issue 3, page 2. International Council of Nurses 2004
• 31 Singh S. Self referral to accident and emergency department: patients' perceptions.  BMJ. 1988;  297 1179-1180
• 32 Thorne S. In Italy, a medical degree often means unemployment or underemployment.  CMAJ. 1996;  154 889-890
• 33 Trzeciak S, Rivers E P. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.  Emerg Med J. 2003;  20 402-405
• 34 den Bussche H van. [The health care system in France and Germany].  Cah Sociol Demogr Med. 2004;  44 165-185
• 35 Geloven A A van, Luitse J S, Simons M P, Volker B S, Verbeek M J, Obertop H. Emergency medicine in the Netherlands, the necessity for changing the system: results from two questionnaires.  Eur J Emerg Med. 2003;  10 318-322
• 36 VDO opleidings en adviescentrum Hogeschool Arnhem en Nijmegen. Master Advanced Nursing Practice 2004
• 37 Zabalegui Y A. Nursing education in Spain - past, present and future.  Nurse Educ Today. 2002;  22 311-318