Analysis

Advanced nurse practitioners may have general surgery role

A report by think tank the Nuffield Trust has called for advanced nurse practitioner (ANP) roles to be further developed to help plug the staffing gaps in emergency general surgery

A report by think tank the Nuffield Trust has called for advanced nurse practitioner (ANP) roles to be further developed to help plug the staffing gaps in emergency general surgery.

The report, entitled Emergency general surgery: challenges and opportunities, highlights unacceptable differences between hospitals in outcomes for patients undergoing emergency general surgery, with death rates for major operations being almost 12 times higher at some trusts than others.

Workforce shortages are cited as the main reason for these variations, due to reductions in numbers of junior doctors in training and a shift from generalist to more specialist practice in surgery.

Broader benefits

Advanced nurse practitioners, working in emergency departments (EDs) and surgical settings, are flagged in the report as one of the solutions to the problem. Evidence suggests these roles also have broader benefits for team working and quality of care. All hospitals should be considering the potential for these new roles, it states.

Although this report focuses on how the development of non-medical roles can benefit surgical wards, Candace Imison, report author and director of policy at the Nuffield Trust, says advanced nurse practitioners in emergency departments should have a growing role in alleviating staff pressures and providing a smoother pathway for patients. This includes patients who present at an ED and require emergency general surgery, she says.

‘In emergency departments you now have specialist nurses who are able to assess and appropriately triage patients and refer them to the surgical team,’ she says.

Compelling financial case

‘Demand for their skills is gathering pace because there are lots of pressures on junior doctor numbers and trusts not being able to fulfil junior doctor rotas and having to rely on locums, which makes a compelling financial case for developing these roles.’

Jason Lugg, lead nurse and emergency nurse practitioner at Bristol Royal Infirmary, says it is becoming more common for ANPs in emergency departments to have a direct dialogue with medics in emergency general surgery departments. This might be to discuss a case with a surgeon or request they come to see a patient, or referring directly to surgery.

‘This can be done autonomously,’ he says. ‘The main advantage of this pathway in terms of outcomes is speed, because patients could be waiting a little while to see a senior doctor to make a decision.’

Pathway

This is the case at Barnsley NHS Foundation Trust, which has introduced a pathway that allows ANPs who have undertaken the necessary specialist training to directly refer patients from the ED to surgery. Richard Jackson is one of four ANPs qualified to undertake these tasks.

‘I am now fully integrated into the middle grade rota,’ says Mr Jackson, who qualified as an ANP in 2012. His postgraduate training took two and a half years, and included gaining skills in clinical examinations and prescribing.

‘During my training I worked alongside consultants and discussed cases with them in a supernumerary role before being able to undertake my own consultations,’ he adds. This means he is able to cover shifts that would otherwise have been undertaken by junior doctors or locums, and means patients who require emergency surgery are quicker into theatre.

Clinical assessments

Mr Jackson supports the emergency general surgery team by being able to undertake thorough clinical assessments of patients with undifferentiated problems. This could be, he says, anything from stroke to stomach ache, ear nose and throat to cardiology. ‘I check that the condition isn’t life threatening and do a full clinical check, working through a list of differentials and, if required, I can refer to surgery,’ he explains.

By having an ANP carrying out these assessments, Mr Jackson believes he is able to spend more time with patients, provide more continuity than a stream of doctors and locums, and carry out more holistic assessments.

‘Nurses in this role bring good interpersonal skills. We can carry out our own investigations and full holistic assessments so patients need not be seen by lots of different people,’ he says. There is also the benefit of saving trusts sizeable amounts of money on what they would be paying locums to do the same shift.

Skill mix

Ms Imison argued the case for increasing the skill mix in EDs and in other emergency medicine settings in a blog published on the Nuffield Trust website last year. She advocates the Royal College of Emergency Medicine’s (RCEM) emergency care advanced clinical practitioner curriculum, endorsed by the RCN, to develop the ANP role in these settings. The RCEM is in the process of developing a formal process for demonstrating competencies.

She believes the continuing evolution of advanced scope nurses in emergency departments is an important step forward for improving patient pathways through EDs and into emergency surgery.

Ms Imison says: ‘I think it’s incredibly good and long overdue. It’s a huge opportunity for nursing career expansion and patients benefit from the valuable continuity of care. I would expect to see most emergency departments contemplating the development of these roles and that in five years there won’t be an emergency department without one.’

A report on skill mix, which will include further exploration of advanced nursing roles, is due to be published by the Nuffield Trust this month.

More information

Emergency general surgery: challenges and opportunities

The Royal College of Emergency Medicine’s advanced practice competencies

 

 

 

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