Art & science professional development
Advanced clinical practitioner role in the emergency department Fawdon H, Adams J (2013) Advanced clinical practitioner role in the emergency department. Nursing Standard. 28, 16-18, 48-51. Date of submission: September 10 2013; date of acceptance: October 14 2013.
Abstract The advanced clinical practitioner role in emergency departments in the UK has developed in an ad hoc manner, without a national framework of registration requirements. This article describes the structure adopted by one NHS trust in England to certify the clinical competence of advanced clinical practitioners in emergency departments through the completion of two portfolios, with a third portfolio to record professional development. The portfolios cover history taking, clinical examination, and interpretation of information and basic investigations to enable the practitioner to undertake medical clerking of a patient attending the emergency department. The portfolios contain evidence of learning and observation of practitioners by middle-grade doctors and consultants.
Authors Helen Fawdon Advanced clinical practitioner lead, Kettering General Hospital NHS Foundation Trust, Northamptonshire. John Adams Temporary lecturer, Anglia Ruskin University, Peterborough. Correspondence to: [email protected]
Keywords Advanced clinical practitioner, competence, education, emergency department, independent prescribing, nursing role
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
HOSPITAL CARE IN the UK has been facing challenges over the last few years, with budgetary, regulatory and organisational pressures. One response to these challenges has been the creation of the advanced clinical practitioner (ACP) role in a range of specialties. However, regulatory and educational frameworks in the UK have yet to be
developed in a manner that keeps pace with these developments (Livesley et al 2009, Shearer and Adams 2012). In the absence of clear role definitions and agreed terminology, new nursing roles have developed in an ad hoc manner to meet local needs (Lee 2008, Swann et al 2013). In the emergency department, nurse practitioner roles have been developed with a focus on minor illnesses and injuries (Norris and Melby 2006). These roles have been expanded in some departments to encompass advanced nursing practice in assessing a wide variety of acute illnesses and injuries (Melby et al 2011).
Reorganising the emergency department Kettering General Hospital NHS Foundation Trust in Northamptonshire, implemented the ACP role in the clinical decision unit, an area where GP patient referrals to acute medicine were seen and assessed, and either discharged or admitted to hospital. At this time, ACPs were included in the staffing rota for nursing rather than for medicine. However, experience showed that the effectiveness of the unit was impaired by the pressure created by large numbers of inappropriate patient transfers from the emergency department. It was soon recognised that the patient experience could be improved if the ACP role was developed in the emergency department, where patients could be identified for immediate treatment and discharge and for whom further transfer within the hospital was inappropriate. Following this reorganisation in which the clinical decision unit was closed, ACPs were assigned to the medical rather than the nursing rota. On admission to the emergency department, patients are booked in and an experienced nurse assesses their need for treatment via one of three routes: minor injury, minor illness or the rapid assessment and treatment stream (RATS). The majority of patients admitted via ambulance transfer enter the RATS. ACPs work exclusively in this stream, where they are regarded as equivalent to Foundation Year 2 (FY2) junior doctors (senior house officers). The RATS operates under the supervision of a consultant or middle-grade doctor, who can provide advice and support. ACPs can refer
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patients directly to other specialties, are independent prescribers and can order tests or scans, with the exception of computed tomography scans of the head and magnetic resonance imaging scans. The ACP will see the next person waiting, take a history, undertake medical clerking with appropriate physical examination, order investigations and provide first-line treatments, such as analgesics, intravenous fluids and antibiotics. The ACP will then interpret the investigation results and refer the patient to a specialist team or discharge him or her. The use of ACPs in the emergency department has reduced staffing costs because the need to employ agency medical staff is reduced, and efficiency and continuity of care is improved because ACPs work 12-hour shifts and are familiar with all aspects of the hospital’s operation and the availability of local services.
Training for the advanced clinical practitioner role To be appointed to the initial development ACP role, applicants must have a nursing or other relevant degree and experience in the acute assessment area. The Kettering General Hospital NHS Foundation Trust has consistently taken the view that the MSc degree in autonomous practice offered at a local university, provides the required educational preparation for the ACP role. One ACP in the emergency department has completed the MSc degree and four ACPs are undertaking it at present. Since the programme takes at least three years to complete part time and only one member of staff can be released at any given time, it will be several years before all members of the ACP team possess the qualification. In the interim, the trust requires assurance that all those undertaking the ACP role have been assessed as competent and this has been achieved through the introduction of a formal system of competency-based portfolios. The development programme involves the completion of the prescribing qualification at master’s level and two portfolios of clinical skills signed as complete by the clinical lead consultant. Development ACPs have no less than one year and no more than two years to complete this programme. Once these aspects are complete, they are given the title ACP, and they are expected to complete the MSc degree while in post. ACPs are contracted for 37.5 hours per week and work three 12-hour shifts each week, with the remaining six hours per month being used to assist activities such as observation in specialist clinics during the first six months, before reverting to clinical hours. There is an ACP on duty from 8am to 8pm seven days per week.
Portfolio one skills are evidenced with short reflective pieces, researched articles and signed statements from senior doctors within the emergency department that they have observed competent practice from the development ACPs. There are also some study days where development ACPs attend emergency department training for junior doctors. Nurses are guided through integral requirements of the role, mostly in clinical practice working alongside senior doctors, by attending lectures with junior doctors and some locally arranged sessions with middle-grade doctors within emergency department or acute medicine. These sessions include history taking, general survey, abdominal examination, clinical investigations, and information on the respiratory and cardiovascular systems. Completion of portfolio one is self-directed, and nurses are required to complete skills evidence sheets to sign off the relevant sections. The skills evidence sheets cover history taking, general survey, respiratory, cardiac, abdominal and basic neurological examination, requesting investigations such as blood tests, X-rays, scans and interpretation of these. The development ACP’s practice is observed by a middle-grade doctor or consultant, who signs the skills evidence sheets to confirm the ACP’s competence. The ACPs are also encouraged to read articles that relate to particular areas of clinical interest. Once portfolio one has been completed, the nurse is required to present it to the lead medical consultant, who signs it off as complete if the required standard has been achieved. The independent prescribing course must also be completed within two years. Portfolio two includes more specialised areas of emergency department practice mainly involving supervised clinical practice alongside senior doctors, continuing with the MSc degree, and including modules in clinical examination and history taking. The ACP team is also developing a sharing programme, where ACPs complete case studies and share any lessons learned. The online programme includes coverage of musculoskeletal problems, advanced abdominal assessment, and assessment of patients with urological, vascular, obstetric and gynaecological, maxillofacial, ophthalmic, and ear, nose and throat problems. Clinical skills include undertaking arterial blood gases and mid-line insertion. Training on using the Manchester Triage System must be undertaken, and the Advanced Trauma Life Support (ATLS) course must be completed at observer level. Nurses undertaking ACP training also undertake the accident and emergency radiology survival course at Northwick Park Hospital, Middlesex. Completion of portfolio two is signed off by the lead consultant. The intention is that portfolio two should be
Journal Club #NursingJC Join a discussion on Twitter about this article on Friday January 3 12.30-1.30 Using #NursingJC
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Art & science professional development completed within one year, and while it is linked to the Knowledge and Skills Framework, it has no grading implications. At this point, the nurse is recognised as an ACP. On successful completion of the independent prescribing course and the first two portfolios, nurses move automatically to band 7. Portfolio three is a lifelong portfolio of continual learning. It is completed opportunistically and consists of reflective accounts of critical incidents organised according to the systems of the body. In the emergency department, the ACP role has an element of leadership and these individuals are viewed as senior nurses. They are expected to champion good practice and challenge poor practice, and teach and develop more junior staff. However, they have no formal management role within the emergency department.
TABLE 1 Presenting complaints of patients seen by advanced clinical practitioners in the emergency department (January-June 2012) Presenting complaint
Number of patients
Percentage (rounded)
Chest pain
138
20
Shortness of breath
97
14
Abdominal pain in adults
70
10
Limb problems
66
10
Urinary problems
59
9
Unwell adult
51
8
Collapsed adult
38
6
Falls
37
5
Headache
31
5
Diarrhoea and vomiting
23
3
Overdose and poisoning
15
2
Gastrointestinal bleeding
8
1
Eye problems
7
1
Palpitations
7
1
Back pain
6
Advanced clinical practitioner role in the emergency department Fawdon H, Adams J (2013) Advanced clinical practitioner role in the emergency department. Nursing Standard. 28, 16-18, 48-51. Date of submission: September 10 2013; date of acceptance: October 14 2013.
Abstract The advanced clinical practitioner role in emergency departments in the UK has developed in an ad hoc manner, without a national framework of registration requirements. This article describes the structure adopted by one NHS trust in England to certify the clinical competence of advanced clinical practitioners in emergency departments through the completion of two portfolios, with a third portfolio to record professional development. The portfolios cover history taking, clinical examination, and interpretation of information and basic investigations to enable the practitioner to undertake medical clerking of a patient attending the emergency department. The portfolios contain evidence of learning and observation of practitioners by middle-grade doctors and consultants.
Authors Helen Fawdon Advanced clinical practitioner lead, Kettering General Hospital NHS Foundation Trust, Northamptonshire. John Adams Temporary lecturer, Anglia Ruskin University, Peterborough. Correspondence to: [email protected]
Keywords Advanced clinical practitioner, competence, education, emergency department, independent prescribing, nursing role
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
HOSPITAL CARE IN the UK has been facing challenges over the last few years, with budgetary, regulatory and organisational pressures. One response to these challenges has been the creation of the advanced clinical practitioner (ACP) role in a range of specialties. However, regulatory and educational frameworks in the UK have yet to be
developed in a manner that keeps pace with these developments (Livesley et al 2009, Shearer and Adams 2012). In the absence of clear role definitions and agreed terminology, new nursing roles have developed in an ad hoc manner to meet local needs (Lee 2008, Swann et al 2013). In the emergency department, nurse practitioner roles have been developed with a focus on minor illnesses and injuries (Norris and Melby 2006). These roles have been expanded in some departments to encompass advanced nursing practice in assessing a wide variety of acute illnesses and injuries (Melby et al 2011).
Reorganising the emergency department Kettering General Hospital NHS Foundation Trust in Northamptonshire, implemented the ACP role in the clinical decision unit, an area where GP patient referrals to acute medicine were seen and assessed, and either discharged or admitted to hospital. At this time, ACPs were included in the staffing rota for nursing rather than for medicine. However, experience showed that the effectiveness of the unit was impaired by the pressure created by large numbers of inappropriate patient transfers from the emergency department. It was soon recognised that the patient experience could be improved if the ACP role was developed in the emergency department, where patients could be identified for immediate treatment and discharge and for whom further transfer within the hospital was inappropriate. Following this reorganisation in which the clinical decision unit was closed, ACPs were assigned to the medical rather than the nursing rota. On admission to the emergency department, patients are booked in and an experienced nurse assesses their need for treatment via one of three routes: minor injury, minor illness or the rapid assessment and treatment stream (RATS). The majority of patients admitted via ambulance transfer enter the RATS. ACPs work exclusively in this stream, where they are regarded as equivalent to Foundation Year 2 (FY2) junior doctors (senior house officers). The RATS operates under the supervision of a consultant or middle-grade doctor, who can provide advice and support. ACPs can refer
48 december 18from :: volRCNi.com 28 no 16-18 :: 2013 NURSING STANDARD / RCN Downloaded by ${individualUser.displayName} on Oct 23, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
patients directly to other specialties, are independent prescribers and can order tests or scans, with the exception of computed tomography scans of the head and magnetic resonance imaging scans. The ACP will see the next person waiting, take a history, undertake medical clerking with appropriate physical examination, order investigations and provide first-line treatments, such as analgesics, intravenous fluids and antibiotics. The ACP will then interpret the investigation results and refer the patient to a specialist team or discharge him or her. The use of ACPs in the emergency department has reduced staffing costs because the need to employ agency medical staff is reduced, and efficiency and continuity of care is improved because ACPs work 12-hour shifts and are familiar with all aspects of the hospital’s operation and the availability of local services.
Training for the advanced clinical practitioner role To be appointed to the initial development ACP role, applicants must have a nursing or other relevant degree and experience in the acute assessment area. The Kettering General Hospital NHS Foundation Trust has consistently taken the view that the MSc degree in autonomous practice offered at a local university, provides the required educational preparation for the ACP role. One ACP in the emergency department has completed the MSc degree and four ACPs are undertaking it at present. Since the programme takes at least three years to complete part time and only one member of staff can be released at any given time, it will be several years before all members of the ACP team possess the qualification. In the interim, the trust requires assurance that all those undertaking the ACP role have been assessed as competent and this has been achieved through the introduction of a formal system of competency-based portfolios. The development programme involves the completion of the prescribing qualification at master’s level and two portfolios of clinical skills signed as complete by the clinical lead consultant. Development ACPs have no less than one year and no more than two years to complete this programme. Once these aspects are complete, they are given the title ACP, and they are expected to complete the MSc degree while in post. ACPs are contracted for 37.5 hours per week and work three 12-hour shifts each week, with the remaining six hours per month being used to assist activities such as observation in specialist clinics during the first six months, before reverting to clinical hours. There is an ACP on duty from 8am to 8pm seven days per week.
Portfolio one skills are evidenced with short reflective pieces, researched articles and signed statements from senior doctors within the emergency department that they have observed competent practice from the development ACPs. There are also some study days where development ACPs attend emergency department training for junior doctors. Nurses are guided through integral requirements of the role, mostly in clinical practice working alongside senior doctors, by attending lectures with junior doctors and some locally arranged sessions with middle-grade doctors within emergency department or acute medicine. These sessions include history taking, general survey, abdominal examination, clinical investigations, and information on the respiratory and cardiovascular systems. Completion of portfolio one is self-directed, and nurses are required to complete skills evidence sheets to sign off the relevant sections. The skills evidence sheets cover history taking, general survey, respiratory, cardiac, abdominal and basic neurological examination, requesting investigations such as blood tests, X-rays, scans and interpretation of these. The development ACP’s practice is observed by a middle-grade doctor or consultant, who signs the skills evidence sheets to confirm the ACP’s competence. The ACPs are also encouraged to read articles that relate to particular areas of clinical interest. Once portfolio one has been completed, the nurse is required to present it to the lead medical consultant, who signs it off as complete if the required standard has been achieved. The independent prescribing course must also be completed within two years. Portfolio two includes more specialised areas of emergency department practice mainly involving supervised clinical practice alongside senior doctors, continuing with the MSc degree, and including modules in clinical examination and history taking. The ACP team is also developing a sharing programme, where ACPs complete case studies and share any lessons learned. The online programme includes coverage of musculoskeletal problems, advanced abdominal assessment, and assessment of patients with urological, vascular, obstetric and gynaecological, maxillofacial, ophthalmic, and ear, nose and throat problems. Clinical skills include undertaking arterial blood gases and mid-line insertion. Training on using the Manchester Triage System must be undertaken, and the Advanced Trauma Life Support (ATLS) course must be completed at observer level. Nurses undertaking ACP training also undertake the accident and emergency radiology survival course at Northwick Park Hospital, Middlesex. Completion of portfolio two is signed off by the lead consultant. The intention is that portfolio two should be
Journal Club #NursingJC Join a discussion on Twitter about this article on Friday January 3 12.30-1.30 Using #NursingJC
©Downloaded NURSINGfrom STANDARD RCN PUBLISHING december 18 No :: vol 28uses no 16-18 2013 49 RCNi.com/ by ${individualUser.displayName} on Oct 23, 2015. For personal use only. other without:: permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science professional development completed within one year, and while it is linked to the Knowledge and Skills Framework, it has no grading implications. At this point, the nurse is recognised as an ACP. On successful completion of the independent prescribing course and the first two portfolios, nurses move automatically to band 7. Portfolio three is a lifelong portfolio of continual learning. It is completed opportunistically and consists of reflective accounts of critical incidents organised according to the systems of the body. In the emergency department, the ACP role has an element of leadership and these individuals are viewed as senior nurses. They are expected to champion good practice and challenge poor practice, and teach and develop more junior staff. However, they have no formal management role within the emergency department.
TABLE 1 Presenting complaints of patients seen by advanced clinical practitioners in the emergency department (January-June 2012) Presenting complaint
Number of patients
Percentage (rounded)
Chest pain
138
20
Shortness of breath
97
14
Abdominal pain in adults
70
10
Limb problems
66
10
Urinary problems
59
9
Unwell adult
51
8
Collapsed adult
38
6
Falls
37
5
Headache
31
5
Diarrhoea and vomiting
23
3
Overdose and poisoning
15
2
Gastrointestinal bleeding
8
1
Eye problems
7
1
Palpitations
7
1
Back pain
6
