Factors influencing the decision to use nurse practitioners in the emergency department.

Abstract

Emergency department overcrowding is a serious problem nationwide. Of an estimated 14 million visits to hospital emergency departments, only 12.9% are considered emergent. Many emergency departments, however, employ only physicians despite the fact that nurse practitioners have a proven record of providing high quality, cost-effective care in the emergency department. The purpose of the study was to determine factors that influence the decision to use nurse practitioners in the emergency department.
Interviews were conducted with ED managers in hospitals that both employ and do not employ nurse practitioners in the emergency department.
In this study, the primary reason that nurse practitioners were not employed by emergency departments was that physician groups with whom the hospitals contract refuse to use nurse practitioners. Emergency department managers of facilities with nurse practitioners reported high levels of satisfaction with the nurse practitioners performance. The 2 ED managers without nurse practitioners in their facility were highly supportive of having nurse practitioners in the emergency department and have advocated for hiring nurse practitioners.
Education needs to occur with emergency departments regarding the value of the nurse practitioner's role to the facility. Research is needed to investigate why emergency department physician groups resist hiring nurse practitioners. Increased staffing with nurse practitioners in the emergency department can serve to reduce overcrowding, reduce waiting times, and increase patient satisfaction.

Full text

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Authors: Laurie A. McGee, MN, ARNP, and Louise Kaplan,
PhD, ARNP, Centralia, and Vancouver, Wash
Laurie A. McGee is Family Nurse Practitioner, Washington
Orthopaedic Center, Centralia, Wash.
Louise Kaplan is Assistant Professor, Washington State University,
Vancouver, Wash.
For correspondence, write: Louise Kaplan, PhD, ARNP, 14204 NE
Salmon Creek Ave, Washington State University, Vancouver, WA
98686; E-mail: kaplanla@wsu.edu.
J Emerg Nurs 2007;33:441-6.
0099-1767/$32.00
Copyright n 2007 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2006.10.019
Earn Up to 8 CE Hours. See page 518.
Introduction: Emergency department overcrowding is a serious
problem nationwide. Of an estimated 14 million visits to hos-
pital emergency departments, only 12.9% are considered emer-
gent. Many emergency departments, however, employ only
physicians despite the fact that nurse practitioners have a
proven record of providing high quality, cost-effective care in
the emergency department. The purpose of the study was to
determine factors that influence the decision to use nurse prac-
titioners in the emergency department.
Methods: Interviews were conducted with ED managers in hos-
pitals that both employ and do not employ nurse practitioners
in the emergency department.
Results: In this study, the primary reason that nurse practi-
tioners were not employed by emergency departments was
that physician groups with whom the hospitals contract refuse
to use nurse practitioners. Emergency department managers of
facilities with nurse practitioners reported high levels of satis-
faction with the nurse practitioners performance. The 2 ED man-
agers without nurse practitioners in their facility were highly
supportive of having nurse practitioners in the emergency de-
partment and have advocated for hiring nurse practitioners.
Discussion: Education needs to occur with emergency depart-
ments regarding the value of the nurse practitioner’s role to
the facility. Research is needed to investigate why emergency
department physician groups resist hiring nurse practitioners.
Increased staffing with nurse practitioners in the emergency de-
partment can serve to reduce overcrowding, reduce waiting times,
and increase patient satisfaction.
Factors Influencing the
Decision to Use Nurse Practitioners in the
Emergency Department
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E
exceeds the ability of a department to provide quality care
within acceptable time frames.1A number of commonly
held definitions for overcrowding have been identified.
These include all ED beds occupied for more than 6 hours
a day, patients placed in hallways, a full ED waiting room
for 6 hours or more per day, physicians feeling rushed for
6 hours or more a day, and acutely ill patients who wait
more than 60 minutes to be seen by a physician.2Emer-
gency department overcrowding is a matter of patient safety
when there is a delay in providing care as well as an issue
with patient satisfaction. The Joint Commission on Ac-
creditation of Healthcare Organizations’ review of senti-
nel events has attributed patient deaths to delays in patient
care. In hospital emergency departments, delay of treatment
is the most common type of sentinel event.1
The 2004 National Hospital Ambulatory Medical Care
Survey (NHAMCS) reports an 18% increase in the number
of visits to emergency departments from 1994 to 2004.3
During the same period of time, there was a decrease of
about 12% in the number of hospital emergency departments
in the United States. In 2004, an estimated 110 million visits
were made to hospital emergency departments. The emer-
gency department, however, is being used by the public for
care of seriously ill or injured patients on a limited basis.
The 2004 NHAMCS reports contusion with intact skin
was the leading ED diagnosis followed by abdominal pain,
open wound excluding the head, chest pain, and acute up-
per respiratory infection excluding pharyngitis.
The 2004 NHAMCS also provides insight into the
acuity of care being provided in emergency departments.
Only 12.9% of ED visits were classified as emergent with
37.8% urgent, 21.8% semi-urgent, and 12.5% non-urgent.
The triage status of the remaining 15.1% was unknown.3
This small percentage of ED visits classified as emergent
suggests that nurse practitioners are suited ideally to pro-
viding care to the majority of ED patients. One national
survey of hospitals, however, found that only 17% of re-
spondents employed nurse practitioners in the emergency
department and only an additional 9% were planning to
hire new nurse practitioners.4This low level of employ-
ment of nurse practitioners in emergency departments occurs
mergency department overcrowding is a serious
problem nationwide. Overcrowding is defined as a
situation in which demand for emergency services
despite nurse practitioners having a proven record of pro-
fessional performance and effectiveness in their ED roles.5-8
There is no literature that discusses why nurse practi-
tioners are not being used in emergency departments when
their education, skills, and ability may reduce ED over-
crowding, improve patient satisfaction, and improve access
to care. This pilot study examines the factors that contrib-
ute to the decision to employ or not employ nurse practi-
tioners in the emergency department.
Care Provided in the Emergency Departments
The primary role of the emergency department is treat-
ment of seriously ill and injured patients. The emergency
department, however, provides a significant amount of un-
scheduled primary and urgent care often because there is
inadequate capacity for this care in other parts of the health
care system. The emergency department is the only seg-
ment of the health care system that is mandated by federal
law to screen and, if necessary, treat all patients who pres-
ent to the emergency department for care. The Emergency
Medical Treatment and Labor Act ensures that the public
has access to a medical screening exam in the emergency
department regardless of the ability to pay.9In the absence
of a national universal health benefits program, hospital
emergency departments are essentially the only place in
our current health system where all patients are guaranteed
medical care.10
Unable to turn non-urgent patients away, ED over-
crowding has emerged as a pressing health care issue over
the last decade. The top 10 visits to the emergency de-
partments (Table) include only a few symptoms or problems
that can be characterized as emergent. The 3 leading
complaints among ED patients were for abdominal pain,
chest pain, and fever.3
Emergency Department Nurse Practitioner
There are currently only 4 nurse practitioner programs in
the United States that specifically prepare emergency nurse
practitioners (ENPs). As there is no national certification
for ENPs, graduates of these programs are also educated to
qualify for national certification in other nurse practitioner
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areas. At Emory University, for example, graduates are eli-
gible to become certified as family nurse practitioners.11
Although there are few programs educating emergency
nurse practitioners, many primary care nurse practitioners
are well suited to care for the majority of patients with
non-emergent problems who present to the emergency de-
partment. The use of nurse practitioners in the emergency
department, which began in the 1970s, can complement
the care of the emergency department physician and im-
prove ED efficiency.12The responsibilities of the ED
nurse practitioner should be consistent with her or his edu-
cational preparation, area of certification, and state scope
of practice.
The Emergency Nurses Association (ENA) Scope of
Practice Statement for Nurse Practitioners in the Emer-
gency Department concludes that knowledge in advanced
physical assessment, the ability to triage and prioritize care
in an uncontrolled environment, and skill in providing a
continuum of care as essential competencies for this role.13
The ENA recognizes that nurse practitioners have a breadth
of knowledge and expertise in their specialty area and are
capable of managing complex clinical issues.
Cole and Ramirez14developed a profile of nurse prac-
titioners employed in emergency departments. The ma-
jority (69.9%) of nurse practitioners in ED settings were
nationally certified family nurse practitioners with another
15% educated in emergency nurse practitioner programs,
11.5% educated as adult nurse practitioners, and 3.6%
educated in another type of nurse practitioner program.
Emergency department nurse practitioners worked in fast
tracks, urgent care centers, and main emergency depart-
ments located mainly (81%) in urban settings. The range
of experience as a nurse practitioner in an emergency set-
ting was 1 to 21 years with an average of 4.45 years.
The number of nurse practitioners working in the
ED setting is unknown. A 2003 statewide survey of nurse
practitioners practicing in Washington State found that
4% (n = 69) of respondents reported a hospital emergency
department as their place of employment.15The survey
had a response rate of 73%. Although the number of nurse
practitioners employed in emergency departments nation-
wide is unknown, 1 study showed that nurse practitioners
provided 5.76 million ED patient visits between Decem-
ber 1996 and December 2000.16This figure represents only
1.4% of all ED patient visits during that 4-year period.
Almost two-thirds of the reasons for the ED visits
of patients seen by nurse practitioners were injuries of
specific types and locations and symptoms related to the
musculoskeletal system, general symptoms, and respiratory
symptoms.16A study of invasive and diagnostic skills
performed by 72 nurse practitioners in emergency depart-
ments determined the 5 procedures carried out most fre-
quently were fluorescein staining, removal of a foreign
body from the eye, interpretation of 12-lead EKG, single
layer closure of an extremity or trunk wound, and removal
of a foreign body from soft tissues.17
Use of the Nurse Practitioner in the Emergency Department
Nurse practitioners are successfully fulfilling a vital role
in the delivery of non-urgent, urgent, and emergency care.
A high degree of patient satisfaction and the delivery
of quality care are well documented. More facilities are
beginning to consider the employment of nurse practi-
tioners in emergency departments. One emergency facility
in Missouri created a fast track program staffed by nurse
practitioners for non-urgent patients. The facility found
this was an effective system of care for patients with non-
urgent rather than emergent problems. The most common
types of patient problems were for complaints of upper and
TABLE
Top 10 reasons for visits to the emergency department
1. Stomach and abdominal pain, cramps, and spasms
2. Chest pain and related symptoms
3. Fever
4. Back symptoms
5. Headache, pain in head
6. Cough
7. Shortness of breath
8. Vomiting
9. Pain, site not referable to a specific body part
10. Lacerations and cuts–upper extremity
Modified from McCaig LF, Nawar EW. National hospital ambulatory medical care
survey: 2004 emergency department summary. Hyattsville, MD: National Center
for Health Statistics 2006. Available at: http://www.cdc.gov/nchs/data/ad/
ad372.pdf.3
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lower respiratory problems, injured extremities, and simple,
single-system complaints.18
Several studies in support of the role of nurse prac-
titioners delivering ED care come from Great Britain and
Australia.5,19-21These studies conclude that not only are
patients satisfied with nurse practitioner care, they also
report that nurse practitioner interpersonal skills are better
than those of physicians. In one of the studies, emergency
nurse practitioners were better than junior doctors at
recording the medical history and fewer patients seen by a
nurse practitioner had to seek unplanned follow-up advice
about their injury.19Another study documented that with
the addition of nurse practitioners in the emergency de-
partment there was a reduction in waiting times and an
improvement in the quality of care.21
Although nurse practitioners are educationally pre-
pared, nationally certified, and experienced providers of
quality care, only a small percentage of nurse practitioners
are being employed in ED settings. With the emergency
care system in the United States providing care to many
who are uninsured or who lack access to primary care, it is
documented that nurse practitioners can serve a vital role
in improving the efficiency and lowering the cost of care in
emergency departments. The purpose of this study was to
investigate factors that influence the decision to employ or
not employ nurse practitioners in the emergency department.
Methods
A qualitative exploratory study was conducted to investi-
gate factors influencing the decision to use nurse practitioners
in the emergency department. A convenience sample of ED
managers from hospitals in southwest Washington that do
and do not employ nurse practitioners in their emergency
department and hospital was used.
After approval from the Institutional Review Board, a
cover letter requesting an interview was sent to 5 ED man-
agers at their place of employment. If no response was re-
ceivedwithin7days,afollow-upphonecallwasmade.Those
ED managers interested in participating were scheduled for
interviews at a time and place of their choosing. Four ED
managers participated. Before the interviews, informed con-
sent was obtained. The interviews were conducted using a
semi-structured interview guide and were tape-recorded. The
audio tapes were transcribed verbatim and transcripts were
analyzed using content analysis.
In addition to the interviews study participants were
asked to share other data. This included the number of
emergencydepartmentvisitsperyearintheirfacilityandthe
percentage of ED visits that were for primary care problems
or non-life threatening problems that did not require ED
care. All 4 managers shared this data.
Results
The number of ED visits in the 4 hospitals ranged from
27,000 to 65,000 visits per year. Emergency department
managers reported that the percentage of level 1 emergent
visits ranged from 4% to 13% of the total ED visits. On the
other hand, 25% to 40% of ED visits were non-emergent
or level 4 to level 5 visits, or as one manager stated: ‘‘...visits
for problems that can be handled by an NP–chronic pain
patients, lacerations, sprains, strains, more minor kinds
of things.’’
All 4 ED managers reported that ED overcrowding
was a problem in their hospital. One manager reported
overcrowding as being a ‘‘huge problem,’’ others answered
‘‘definitely.’’ One ED manager stated: ‘‘Last year we saw
65,000 patients, 2 years ago it was 45,000.’’ Another stated:
‘‘We have designated hall beds already. We have actually
reached the numbers projected for this year in March, which
is what has driven the construction in the emergency
department to add 14 beds.’’
All of the ED managers reported that their hospitals
contracted with an outside group of emergency medicine
physicians to provide medical care in the emergency de-
partment. The decision as to whether or not to employ nurse
practitioners was therefore up to the contracted physicians
group. The factors that influenced the physician groups
as to whether or not to employ nurse practitioners were
not clear to the ED managers, although they surmised it
was due to several issues. One ED manager commented:
‘‘I think the only challenge of using nurse practitioners in
the emergency setting is getting past the medical model
from the physicians. Once they learn that they work just
as well hand-in-hand with them [NPs] as anybody else does
we’ll be by that.’’ Another ED manager reported discussing
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the addition of a nurse practitioner-staffed fast-track. The
ED medical director was concerned about liability issues if
he could not observe the nurse practitioners even though
Washington nurse practitioners are licensed independently.
The ED managers whose facilities did not employ
nurse practitioners stated that there had been recent dis-
cussion about adding nurse practitioners to the physician
group. A factor contributing to increased willingness to con-
sider hiring nurse practitioners relates to a 2005 legislative
change in Washington State. This law grants nurse practi-
tioners prescriptive authority for all controlled substances
without physician involvement making Washington nurse
practitioners fully autonomous.
Two of the four emergency departments currently had
a minor ED/urgent care area staffed by nurse practitioners.
The 2 emergency departments that employed nurse practi-
tioners used a 4 or 5 level triage system with level 1 being
considered emergent and level 4 and 5 being non-urgent.
Level 4 and 5 patients were triaged to the nurse practitioner
rather than physician.
The 2 ED managers that had experience with nurse
practitioners in the emergency department reported it as
a positive experience. One manager stated that the nurse
practitioners had ‘‘excellent clinical skills.’’ The other man-
ager reported her experience as ‘‘great–no problems!’’ There
has been no negativity from patients regarding the use of
nurse practitioners.
The ED managers had other illuminating comments
regarding factors that they saw contributing to ED over-
crowding as well as employing nurse practitioners in the
emergency department. ‘‘In some places the overcrowding
is worsened by the fact that we have a huge psychiatric
population that has no place to go so the overcrowding gets
worse. At some of the campuses we have it’s not unusual
for them to be boarding 6, 7, or 8 psych patients for 3, 4,
or 5 days so that takes up one-third of your emergency
department.’’ One manager reported that there is a lack
of community providers taking new patients or Medicare
and Medicaid patients. ‘‘So where do they come? They
come here.’’ One ED manager had an ED employee who
had returnedto schooltobecome a nurse practitioner.There
had been discussion of the physician ED group hiring him,
and the ED manager was disappointed when he was hired
by another facility. ‘‘This was unfortunate as it would
have been a great way to break a NP into the system since
the physicians were familiar and comfortable with this per-
son’s skills.’’
Discussion
In all 4 facilities, ED provider staffing is controlled by
a contracted physician group. As a result, whether or not
nurse practitioners are used in the emergency department
was up to the physician group rather than the facility.
There is no definitive national data regarding the percent-
age of emergency departments staffed by contracted phy-
sician groups. Estimates vary from 14% to about 50%.10
Physician groups may be more comfortable working with
nurse practitioners if they have had past experience work-
ing with a nurse practitioner in another capacity. Review of
the literature showed there were no studies that evaluated
or explored physician perspectives on hiring nurse practi-
tioners in emergency departments.
Emergency department managers of facilities with nurse
practitioners reported high levels of satisfaction with the
nursepractitioners’performance.The2EDmanagerswithout
nurse practitioners in their facility were highly supportive
of having nurse practitioners in the emergency department
and have advocated for hiring nurse practitioners. Despite
greater than 50% of ED visits falling into the category of
non-emergent, facilities have not reconfigured the way
they provide care to this population of patients who pres-
ent to their emergency department. Instead, they are add-
ing beds and capacity.
Limitations
This study is limited by being a pilot study, having a
small sample size, and being limited geographically to a
specific area of Washington State. It may not reflect the
use of nurse practitioners in emergency departments across
the state or nationwide.
Implications for Emergency Nurses
Education needs to occur with emergency departments re-
garding the value of the nurse practitioner role to the fa-
cility. Research is needed to investigate why ED physician
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