EVALUATION doi: 10.1111/nicc.12133
The advance nurse practitioner in critical care: a workload evaluation Audrey Jackson and Martin Carberry ABSTRACT Background: The Advanced Nurse Practitioner in Critical Care role was developed to support the critical care team by undertaking specific roles traditionally associated with medical staff in the intensive care unit and high dependency unit. The rationale for the evaluation was to establish the specific tasks undertaken and scope of workload of these newly created posts. Aims: To report on an evaluation of the specific activities, workload and patterns of prescribing of advanced nursing practice posts within a critical care settings Methods: A data collection form was designed to capture clinically and patient-related activities of these post-holders. Data from 1 week were recorded on one post-holder and subsequently analysed. During the evaluation the nurse practitioners worked with the consultant anaesthetist. Data were entered into Microsoft Excel and analysed using descriptive statistics. Results: The intensive care and high dependency unit ward round attributed to 46% of the nurse practitioners weekly activity and mainly consisted of patient assessments and prescribing. The rest of the time was mainly split between documentation and unsupervised patient assessments. Discussion: The nurse practitioners contributed to the majority of interventions traditionally performed by anaesthetic trainees. Independent patient assessment was highlighted as a significant part of that workload (12%). The evaluation also highlighted the broad nature required of nurse practitioner prescribing and thus reinforced the strategic decision not to introduce a restricted formulary. Conclusion: Advanced nurse practitioners in critical care effectively carried out the traditional medical tasks in which they were trained. As already experienced nurses with new enhanced skills they successfully contributed to and enhanced the delivery of care to the critically ill. Key words: Advanced nursing roles • Developing/evaluating nursing roles • Evaluation studies • Intensive care nurses • New roles in practice
BACKGROUND It is now widely accepted that the European Working Time Directive (Council Directive, 2000) and Modernising Medical Careers (Scottish Executive Health Department (SEHD), 2005a) have resulted in a reduction in the availability of all levels of trainee doctors for service provision. This and positive research findings from other countries have paved the way for the introduction of innovative advanced nursing roles (Stetler et al., 1998). Advanced roles for nurses have been supported by professional and government bodies alike, and were recognized as an important aspect of health service contribution (Nursing and Midwifery Council (NMC), 2005; SEHD, 2005b; Department of Health
Authors: A Jackson, RGN, MSc, PG Certificate Advanced Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital, Glasgow, UK; M Carberry, RGN, DCC, BSc, MSc, Critical Care Nurse Consultant, NHS Lanarkshire, HECT Office, Hairmyres Hospital, Glasgow, UK Address for correspondence: A Jackson, Certificate Advanced Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital, Monks court Avenue, ML8 Glasgow, UK E-mail: [email protected]
© 2014 British Association of Critical Care Nurses
(DoH), 2006; Royal College of Nursing (RCN), 2007; National Education Scotland (NES), 2008; SEHD, 2010). In response to these national drivers NHS Lanarkshire set up an Advanced Nurse Practitioner in Critical Care (ANPCC) project board consisting of senior management, human resources and nursing and medical leads. The role of the project board was to examine the possible gaps in critical care service provision and a potential role for the new ANPCC. Trainee doctors were shadowed across three critical care units by the nurse consultant in order to establish their daily workload. Following this exercise it was accepted that the new ANPCC role would need to include: advanced clinical assessment and clinical decision making, documenting findings, independent non-medical prescribing (NMP) and advanced invasive procedures, such as central venous and arterial line placement. The project board subsequently addressed potential ANPCC education and training needs. The ANPCC role would also provide experienced critical care nurses with an alternative route of promotion that remained predominately clinical, a view 1
A workplace evaluation of ANPCC work balance
supported by Kleinpell’s (2005), five-year longitudinal study into nurse practitioner roles. As a result, NHS Lanarkshire funded the recruitment of nine ANPCCs between 2008 and 2009 in order to maintain critical care service provision across three district general hospitals’ critical care areas. The ANPCC selection process involved psychometric testing, objective structured clinical examination and competency-based interviews. This approach ensured that successful applicants could robustly demonstrate leadership and clinical skills (Fleming and Carberry, 2011). Those appointed undertook a locally devised educational programme, which consisted of a postgraduate certificate in advanced clinical practice, NMP course, a clinical competency framework and a programme of scheduled work shops and tutorials. The postgraduate certificate attributed points towards an MSc in nursing. ANPCCs were required to complete a university accredited masters degree in either advanced practice or critical care. Clinical supervision and coaching were provided by a designated consultant anaesthetist mentor with professional leadership provided by the nurse consultant. Aside from academic assessment, newly appointed ANPCCs were appraised through direct observation of procedures, multi source feedback forms which allowed the whole intensive care unit (ICU) and high dependency unit (HDU) team to subjectively evaluate individual performance. Case-based discussions were also used, supported by a reflective portfolio of evidence (Minarik, 2005). During the period of training, these posts had supernumerary status which lasted 2–3 years depending on exposure to clinical experience and competency completion. Two previous evaluations of trainee anaesthetic workload had been undertaken in the critical care areas of the three hospitals. An initial evaluation in 2005 set out to establish the potential ANPCC role, suitability and sustainability, workforce planning and a training needs analysis for post-holders. A further evaluation after 5 years identified further training needs included: • Attendance at cardiac arrest calls • Internal hospital transfer of ICU and HDU patients • Request for complicated radiological investigations • Insertion of chest drains • Reporting death to the procurator fiscal • Authorisation of blood and blood products • Prescribing unlicensed drugs. 2
These findings informed a professional, legal and clinical debate in order to establish what would be deemed appropriate for ANPCC development. A number of points were addressed prior to service evaluation of this role. A restricted ANPCC prescribing formulary was discussed but deemed too limiting to address the wide range of drugs prescribed in a typical day. Limited exposure to the insertion of chest drains also meant that these practitioners would be unable to undertake this procedure and maintain clinical competency so this task was removed from their training. Patients requiring a chest drain had it inserted by the consultant, which was normal practice before the development of these roles, unless the medical trainee was particularly senior. The project board considered it inappropriate that the ANPCCs attend cardiac arrests during the service evaluation for a number of reasons. Firstly, lack of exposure to advanced/difficult airway management at the stage of their training. Secondly, on examination, a significant number of cardiac arrest calls were peri-arrest calls requiring consultant-level decision making. Finally, in peri-arrest situations, the use of anaesthetic drugs is not uncommon, but these were prohibited for NMPs at the time of this evaluation (SEHD, 2009). Non-medical requests for any radiological investigation, such as chest radiographs, proved problematic owing to legislation, competence and governance of role development. Blood and blood product authorization was achieved through the provision of a collaborative educational programme and the formation of new clinical competencies (Green and Pirie, 2009). While the ANPCC role is not a new role, its implementation in NHS Scotland was new and hence evaluation was deemed necessary. It was also essential from a risk management and clinical effectiveness perspective that the appropriateness of post-holder’s workload should be examined as part of a wider role evaluation in NHS Lanarkshire’s three ICU and HDUs.
AIMS The aim of this paper is to report two key areas of the evaluation and to determine ANPCC: • specific activities and workload • prescribing practice
EVALUATION METHODS Evaluation of the new service model was planned after 2 years of training as this period of time was considered to be an appropriate duration to fully prepare © 2014 British Association of Critical Care Nurses
A workplace evaluation of ANPCC work balance
the ANPCC to participate in the service and evaluate their workload. In one unit, the ANPCCs were involved with both ICU and HDU patients and so chosen for detailed review of their workload. In this unit the staffing model changed from a traditional medical model, including: one anaesthetic consultant and one trainee per day with varying experience from level Specialist Training 1 (ST) to ST7, to one which included anaesthetic consultant and an ANPCC (Royal College of Anaesthetists, 2014). The evaluation was undertaken over five, 10.5 h day shifts, covering Monday to Friday from 8 a.m. until 6.30 pm in March 2011. Data were collected by the ANPCC on duty (total 52.5 h/week). ANPCCs work 4 days/week, so the full 5 days data were collected as the unit would have one ANPCC on duty every weekday. A data collection form was developed to capture clinical tasks, ward round workload and all drugs prescribed undertaken by ANPCCs. Data entry included every task and prescription and its duration throughout their shift and over 5 days. Common tasks included: insertion of central lines and arterial lines, intravenous fluid prescriptions and blood product authorization. Data collection forms were stored in accordance with data protection law, kept in a locked drawer within a secure office. No forms contained patient or staff information (Data Protection Act, 1998).
Ethics Following discussion with the local Research and Development committee, this project was deemed to be a service evaluation and therefore did not require research or ethics approval. All three lead consultant anaesthetists, nurse managers and lead for ANPCCs were informed of the pending evaluation.
Results The results presented have been broken down into three emerging categories. Firstly, week workload by one ANPCC in one ICU and HDU (Figure 1), secondly ward round activity (Figure 2) and finally prescribing activity (Figure 3). The data were collated, uncoded onto an Excel® spreadsheet for analysis. Following data entry, results were allocated to specific categories described above.
Week workload Figure 1 illustrates the tasks the ANPCC performed independently and unsupervised after their training period and competency framework completion, Activities undertaken related to independent patient assessments on all HDU patients. Around one fifth of the time was devoted to clinical documentation such as: © 2014 British Association of Critical Care Nurses
• Patient assessments and subsequent management plans. • Admission, transfer and discharge documentation. • Routine investigation paperwork namely laboratory investigations. A total of 10% of the working week encompassed data collection and data input, for example, maintaining the Scottish Intensive Care Society (SICS) national database WardWatcher. Combined invasive lines and phlebotomy accounted for 6% of ANPCC workload
Ward rounds Of the working week, 46% was spent participating in the ICU and HDU ward round. The ward round consisted of a complete patient assessment and detailed treatment and management plan. In view of this being the largest component of the week it was deemed appropriate that more in-depth analysis was required. Data were subsequently subcategorized into core activities namely patient assessments, prescribing, documentation and finally specialist ward rounds such as microbiology and surgeons’ reviews (see Figure 2).
Ward round activity The following data reported percentages of the ANPPC time attributed to tasks conducted on the ICU and HDU ward round specifically 46% of the ANPCC working week (Figure 1). The ICU ward round consumed 35% of that time which entailed conducting supervised patient assessments, examining and presenting patients and reporting clinical findings. ANPCC documentation time was low during the ward round accounting for 4% of workload. Prescribing was an essential and substantial part of ANPCC workload at 59% of ward round activity (Figure 2). This result merited further analysis of prescribing activity in order to elaborate professional and legal prescribing challenges. Prescriptions for antimicrobials contributed to 25% of all requests (Figure 3). Blood, fluid and electrolyte prescriptions accounted for 27% of those made by ANPCCs. While analgesia and sedation prescriptions contributed to 11% (Figure 3) of the total ANPCCs’ prescribing activity, the majority of which consisted related postoperative analgesia. The gastrointestinal drug section totalled 6% of prescriptions. These drugs included anti-emetics and laxatives. Ranitidine prescriptions were categorized in the DVT/Ulcer prophylaxis section. Cardiac protective drugs included aspirin, beta blockers and calcium channel blockers accounted for 6% of ANPCC 3
A workplace evaluation of ANPCC work balance
Week Workload Assessments Unsupervised 12%
All Documentation (Excl Wd Round) 19%
Airway / Arrest 4%
All Data Input 10%
Others 3% Ward Round 46%
All Lines 3% All Bloods 3%
Figure 1 Week workload.
Ward Round Activity Ward Round Documentation 4% Specialist wd rd 2% Supervised Patient Assessment 35% Prescribing 59%
Figure 2 Ward round activity. Prescribing Activity Analgesia/ Sedation 11%
Others 3%
Antimicrobials 25%
Meds Reconciliation 13% DVT / Ulcer Prophylaxis 6%
Steroids 3% Cardiac Protection 6%
Blood/ IV Fluids/ Electrolytes 27%
GI Drugs 6%
Figure 3 Prescribing activity.
prescriptions. Perhaps most noteworthy was the significant time spent with medicines reconciliation. Thirteen percent of ANPCC prescribing time was used to discontinue drugs, change drugs, doses or rewrite drug cardexes; this was recorded as medicines reconciliation.
DISCUSSION The available literature surrounding nurse practitioners in ICU is varied and extensive; however, the majority of studies have shown favourable or 4
equivocal results for the role of the nurse practitioner when compared with senior trainee medical staff or physicians assistants (Rudy et al., 1998; Burns et al., 2003; Hoffman et al., 2003; Kleinpell, 2005). The completion of this audit revealed key issues that addressed the aims of the project, namely three key areas of the ANPCC workload, daily activities, workload and prescribing practice. Independent patient assessment was highlighted as a significant part of ANPCC workload (12%). Moreover, the ANPCCs’ independent patient assessments and action plans allowed prompt review by the consultant, informed decision making, prioritization of patient reviews and discharge planning. The consultants in general documented assessments and treatment plans for ICU patients; this may explain the low percentage of ANPCC documentation time during the ward rounds of 4%. Data collection and input were seen as a valuable use of ANPCC time (10%) and may have impacted on data collection standards into various databases such as Ward Watcher by the Scottish Intensive Care Society Audit Group (SICSAG, 2012). Rudy et al., (1998) also demonstrated that nurse practitioners spent more time in administrative and research tasks than their medical counterparts. The ANPCCs were qualified independent NMPs as of July 2010. In Scotland, NMPs can prescribe any drug within their field of competence including off-license drugs (SEHD, 2009). Off-license prescribing refers to prescribing a drug out with its licensed indication for use, e.g. using intravenous paracetamol for longer than 48 hrs. NMPs in Scotland were not permitted to prescribe unlicensed drugs at the time of the evaluation. NHS Lanarkshire has since allowed NMPs to prescribe unlicensed medicines and opiate infusions. These changes came in © 2014 British Association of Critical Care Nurses
A workplace evaluation of ANPCC work balance
the years 2011 and 2012 (SEHD, 2006). Any unlicensed medicines were prescribed by the consultant during the evaluation period. The evaluation highlighted the broad nature required of ANPCC prescribing and thus reinforced the strategic decision not to introduce a restricted formulary. Although the ANPCCs were independent NMPs, they were also supervised at consultant level and all prescriptions were written in accordance with a documented treatment plan, enhancing safety for the patient and the novice NMPs. Competence to authorize blood and blood products was an important aspect of the ANPCC role adding to seamless and consistent care delivery (Green and Pirie, 2009; SEHD, 2006). ANPCCs were the first critical care nurses in Scotland trained to authorize blood and blood products. Blood product prescribing was included within the 27% of time needed for all IV fluids. Antimicrobial prescribing was a significant workload issue within critical care, a task which was carefully considered when developing the ANPCC role (Lawrence and Kollef, 2009). Many critically ill patients presented with severe infections requiring a multitude of complex antimicrobial therapies. The ANPCCs attended additional intensive pharmacy led training sessions in antimicrobial prescribing in order to support their prescribing practice. It should be noted that NMPs were not legally permitted to prescribe continuous intravenous opiate infusions or anaesthetic drugs at the time of the service evaluation (SEHD, 2009). These restrictions meant that the consultant had to prescribe these drugs. These shortfalls in prescribing have recently been resolved, and ANPCCs can prescribe any drug including unlicensed medicines within the scope of their competence. During the service evaluation only a few tasks had to be performed by the consultant for example: advanced radiological investigations such as CT scans and difficult airway skills. These tasks were decided upon at the ward round and so incorporated within it. It was decided that owing to a limited exposure to experience the insertion of chest drains would remain a medical procedure. Certification of death was solely a medical task, unremarkable in terms of workload during the service evaluation. Medical staff continued to report appropriate deaths to the Procurator Fiscal (Coroner). Fleming and Carberry (2011) interviewed ANPCCs before their training to examine if expectations of their new role matched the reality 1 year later. It was originally anticipated by ANPCCs at the beginning of their training that a significant part of their role would be inserting invasive lines such as arterial © 2014 British Association of Critical Care Nurses
and central lines and intubating patients. Results, as demonstrated here showed this was not the case, and that after 2 years training only 6% of the ANPCC weekly workload consisted of invasive line insertions or phlebotomy. Advanced airway management was also a rare occurrence (4%). During the evaluation, ANPCCs had not been yet been trained to insert dialysis lines or use the subclavian vein as a route for central lines, which may have accounted for the lower than anticipated result. Infrequent exposure of ANPCCs to advanced or difficult airway procedures made maintaining these competencies difficult. Airway training was included in the ANPCC programme and it would appear from the results that the decision to make it a long-term plan was indeed appropriate due to the infrequency of experiences (DoH, 2008). ANPCCs did not attend cardiac arrests as the anaesthetic trainee carried the on-call pager in theatre and always attended alone. ANPCCs were not trained to request radiological investigations of any kind; this was due to changes in the regulation and monitoring of the legislation of The Ionising Radiation (Medical Exposure) Regulations (Statutory Instrument 1059, 2000) in NHS Scotland. These issues were resolved shortly after the completion of this evaluation in late 2011, ANPCCs can now request simple X-rays, e.g. chest, abdomen bones. Complex studies such as computed tomography (CT) scans remain consultant to consultant requests as before. It appeared from the service evaluation results that ANPCCs delivered a significant and important role in critical care service provision. There were no adverse patient events reported during the evaluation period, although rates of adverse events were not recorded pre-evaluation.
LIMITATIONS This evaluation was limited by the following factors. This was a small evaluation which was confined to one centre in Scotland. The training package although drawn from other work and local experts was directed to the needs of the unit involved. Data collection was limited to 1 week and consequently the results may not be generalizable or representative to other critical care areas.
CONCLUSION The outcomes of this evaluation demonstrated that ANPCCs could be trained to match the roles of the trainee doctor in critical care with only a few tasks transferred to the consultant on duty. ANPCCs also 5
A workplace evaluation of ANPCC work balance
added to unit efficiency by taking over responsibility for and monitoring of national data input which was lacking in consistency before. ANPCCs and NHS Lanarkshire have addressed some of the issues raised by this service evaluation. ANPCCs can now request X-rays and prescribing of unlicensed medications and opiate infusions are now permitted (The Misuse of Drugs (Amendment No. 2) 2012).
FUTURE PLANS Future plans for ANPCCs included: working in unsupervised sessions in HDUs, ICU follow-up services and taking direct ICU referrals. ANPCCs have now begun to take ICU referrals and have provided regular unsupervised sessions in HDU. ANPCCs are now using their training and skills to teach junior doctors invasive line skills and critical care assessment and care planning.
IMPLICATIONS FOR PRACTICE This evaluation has several implications for clinical practice:
• Experienced critical care nurses can be trained to effectively perform the roles traditionally performed by medical trainees. • The ANPCC role has provided experienced critical care nurses with an alternative route of promotion that remains predominately clinical. ANPCCs could be utilized in any ICU/HDU setting to safely contribute to service provision.
ACKNOWLEDGEMENTS We wish to thank NHS Lanarkshire intensive care unit staff. We particularly acknowledge the contribution from the advanced nurse practitioners working in the intensive care units who gave their time in a busy work schedule to participate in this evaluation. This evaluation received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
WHAT IS KNOWN ABOUT THIS TOPIC? • •
The reduction in the number and experience of junior medical staff in critical care has led to new advanced role opportunities for critical care nurses. Roles to address the shortfall of junior medical staff have been developed but not frequently evaluated.
WHAT THIS PAPER ADDS •
This service evaluation provides analysis of the roles and tasks undertaken by ANPCC which could be used to inform service providers and prospective employers of the value of these posts in critical care.
REFERENCES Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, Truwit JD, Bleck TP. (2003). Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Critical Care Medicine; 31: 2752–2763. Council Directive. (2000). 2000/34/EC of the European Parliament and Council. Official Journal of the European Community; 195: 41–45. Data Protection Act. (1998). http://www.legislation.gov.uk/ ukpga/1998/29 (accessed 30/10/12). Department of Health (DoH). (2006). Modernising Nursing Careers – Setting the Direction. Norwich: Department of Health. Department of Health (DoH). (2008). The National Education and Competence Framework for Advanced Critical Care Practitioners. Norwich: Department of Health. Fleming E, Carberry M. (2011). Steering a course towards advanced nurse practitioner: a critical care perspective. Nursing in Critical Care; 16: 67–76.
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Green S, Pirie E. (2009). A framework to support nurses and
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providing the written instruction for blood component transfusion. NHS Blood and Transplant http://www. transfusionguidelines.org.uk/docs/pdfs/BTFramework-final 010909.pdf (last accessed 17/02/13). Hoffman LA, Tasota FJ, Scharfenberg C, Zullo TG, Donahoe MP. (2003). Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training. American Journal of Critical Care; 12: 436–443. Kleinpell RM. (2005). Acute care nurse practitioner practice: results of a 5-year longitudinal study. American Journal of Critical Care; 14: 211–219. Lawrence KL, Kollef MH. (2009). Antimicrobial Stewardship in the intensive care unit: advances and obstacles. American Journal of Respiratory Care and Critical Care Medicine; 179: 434–438.
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Minarik PA. (2005). Issue: Competence assessment and competency assurance of healthcare professionals. Clinical Nurse Specialist; 19: 180–183. NHS Education Scotland. (2008). Supporting the Development of Advanced Nursing Practice. A Toolkit Approach. Edinburgh: NES Publication. Nursing and Midwifery Council. (2005). Implementation of a framework for the standard for post registration nursing decision. Agendum 27.1 December 2005/c/05/160. London: NMC. Royal College of Anaesthetists. (2014). http://www.rcoa.ac.uk/ careers-training/considering-career-anaesthesia/types-ofcareers-anaesthesia (last accessed 24/05/14). Royal College of Nursing. (2007). Advanced Nurse Practice Domains and Competencies. London: RCN. Rudy EB, Davidson LJ, Daly B, Clochesy JM, Sereika S, Baldisseri M, Hravnak M, Ross T, Ryan C. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. American Journal of Critical Care; 7: 267–281. Scottish Executive Health Department. (2005a). Modernising Medical Careers. Edinburgh: Scottish Executive Health Department. Scottish Executive Health Department. (2005b). Framework for Developing Nursing Roles. Edinburgh: Scottish Executive
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Health Department. www.scotland.gov.uk/Publications/ 2005/07/08144657/46584 (last accessed 17/02/12). Scottish Executive Health Department. (2006). Non Medical Prescribing in Scotland. http://www.scotland.gov.uk/Resource/ Doc/145797/0038160.pdf (last accessed 17/02/12). Scottish Executive Health Department. (2009). A safe prescription: developing nurse midwife and allied health profession (NMAHP) in NHSScotland. Edinburgh: Scottish Executive Health Department. Scottish Executive Health Department. (2010). Advanced Nursing Practice Roles Guidance for NHS Boards. Edinburgh: Scottish Government Publication. SICSAG. (2012). www.sicsag.scot.nhs.uk/Data/WardWatcher.html (accessed 30/10/13). Statutory Instrument 2000 No. 1059. 2000. The Ionising Radiation (Medical Exposure) Regulations, The Stationery Office, London. Stetler C, Effken J, Frigon L, Tiernan C, Zwaingman-Bugley C. (1998). Utilization-focused evaluation of ACNP role. Outcomes Management in Nursing Practice; 2: 152–160. The Misuse of Drugs (Amendment No. 2) (England, Wales and Scotland) Regulations 2012. http://www.legislation. gov.uk/uksi/2012/973/made (accessed 30/05/13).
7
The advance nurse practitioner in critical care: a workload evaluation Audrey Jackson and Martin Carberry ABSTRACT Background: The Advanced Nurse Practitioner in Critical Care role was developed to support the critical care team by undertaking specific roles traditionally associated with medical staff in the intensive care unit and high dependency unit. The rationale for the evaluation was to establish the specific tasks undertaken and scope of workload of these newly created posts. Aims: To report on an evaluation of the specific activities, workload and patterns of prescribing of advanced nursing practice posts within a critical care settings Methods: A data collection form was designed to capture clinically and patient-related activities of these post-holders. Data from 1 week were recorded on one post-holder and subsequently analysed. During the evaluation the nurse practitioners worked with the consultant anaesthetist. Data were entered into Microsoft Excel and analysed using descriptive statistics. Results: The intensive care and high dependency unit ward round attributed to 46% of the nurse practitioners weekly activity and mainly consisted of patient assessments and prescribing. The rest of the time was mainly split between documentation and unsupervised patient assessments. Discussion: The nurse practitioners contributed to the majority of interventions traditionally performed by anaesthetic trainees. Independent patient assessment was highlighted as a significant part of that workload (12%). The evaluation also highlighted the broad nature required of nurse practitioner prescribing and thus reinforced the strategic decision not to introduce a restricted formulary. Conclusion: Advanced nurse practitioners in critical care effectively carried out the traditional medical tasks in which they were trained. As already experienced nurses with new enhanced skills they successfully contributed to and enhanced the delivery of care to the critically ill. Key words: Advanced nursing roles • Developing/evaluating nursing roles • Evaluation studies • Intensive care nurses • New roles in practice
BACKGROUND It is now widely accepted that the European Working Time Directive (Council Directive, 2000) and Modernising Medical Careers (Scottish Executive Health Department (SEHD), 2005a) have resulted in a reduction in the availability of all levels of trainee doctors for service provision. This and positive research findings from other countries have paved the way for the introduction of innovative advanced nursing roles (Stetler et al., 1998). Advanced roles for nurses have been supported by professional and government bodies alike, and were recognized as an important aspect of health service contribution (Nursing and Midwifery Council (NMC), 2005; SEHD, 2005b; Department of Health
Authors: A Jackson, RGN, MSc, PG Certificate Advanced Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital, Glasgow, UK; M Carberry, RGN, DCC, BSc, MSc, Critical Care Nurse Consultant, NHS Lanarkshire, HECT Office, Hairmyres Hospital, Glasgow, UK Address for correspondence: A Jackson, Certificate Advanced Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital, Monks court Avenue, ML8 Glasgow, UK E-mail: [email protected]
© 2014 British Association of Critical Care Nurses
(DoH), 2006; Royal College of Nursing (RCN), 2007; National Education Scotland (NES), 2008; SEHD, 2010). In response to these national drivers NHS Lanarkshire set up an Advanced Nurse Practitioner in Critical Care (ANPCC) project board consisting of senior management, human resources and nursing and medical leads. The role of the project board was to examine the possible gaps in critical care service provision and a potential role for the new ANPCC. Trainee doctors were shadowed across three critical care units by the nurse consultant in order to establish their daily workload. Following this exercise it was accepted that the new ANPCC role would need to include: advanced clinical assessment and clinical decision making, documenting findings, independent non-medical prescribing (NMP) and advanced invasive procedures, such as central venous and arterial line placement. The project board subsequently addressed potential ANPCC education and training needs. The ANPCC role would also provide experienced critical care nurses with an alternative route of promotion that remained predominately clinical, a view 1
A workplace evaluation of ANPCC work balance
supported by Kleinpell’s (2005), five-year longitudinal study into nurse practitioner roles. As a result, NHS Lanarkshire funded the recruitment of nine ANPCCs between 2008 and 2009 in order to maintain critical care service provision across three district general hospitals’ critical care areas. The ANPCC selection process involved psychometric testing, objective structured clinical examination and competency-based interviews. This approach ensured that successful applicants could robustly demonstrate leadership and clinical skills (Fleming and Carberry, 2011). Those appointed undertook a locally devised educational programme, which consisted of a postgraduate certificate in advanced clinical practice, NMP course, a clinical competency framework and a programme of scheduled work shops and tutorials. The postgraduate certificate attributed points towards an MSc in nursing. ANPCCs were required to complete a university accredited masters degree in either advanced practice or critical care. Clinical supervision and coaching were provided by a designated consultant anaesthetist mentor with professional leadership provided by the nurse consultant. Aside from academic assessment, newly appointed ANPCCs were appraised through direct observation of procedures, multi source feedback forms which allowed the whole intensive care unit (ICU) and high dependency unit (HDU) team to subjectively evaluate individual performance. Case-based discussions were also used, supported by a reflective portfolio of evidence (Minarik, 2005). During the period of training, these posts had supernumerary status which lasted 2–3 years depending on exposure to clinical experience and competency completion. Two previous evaluations of trainee anaesthetic workload had been undertaken in the critical care areas of the three hospitals. An initial evaluation in 2005 set out to establish the potential ANPCC role, suitability and sustainability, workforce planning and a training needs analysis for post-holders. A further evaluation after 5 years identified further training needs included: • Attendance at cardiac arrest calls • Internal hospital transfer of ICU and HDU patients • Request for complicated radiological investigations • Insertion of chest drains • Reporting death to the procurator fiscal • Authorisation of blood and blood products • Prescribing unlicensed drugs. 2
These findings informed a professional, legal and clinical debate in order to establish what would be deemed appropriate for ANPCC development. A number of points were addressed prior to service evaluation of this role. A restricted ANPCC prescribing formulary was discussed but deemed too limiting to address the wide range of drugs prescribed in a typical day. Limited exposure to the insertion of chest drains also meant that these practitioners would be unable to undertake this procedure and maintain clinical competency so this task was removed from their training. Patients requiring a chest drain had it inserted by the consultant, which was normal practice before the development of these roles, unless the medical trainee was particularly senior. The project board considered it inappropriate that the ANPCCs attend cardiac arrests during the service evaluation for a number of reasons. Firstly, lack of exposure to advanced/difficult airway management at the stage of their training. Secondly, on examination, a significant number of cardiac arrest calls were peri-arrest calls requiring consultant-level decision making. Finally, in peri-arrest situations, the use of anaesthetic drugs is not uncommon, but these were prohibited for NMPs at the time of this evaluation (SEHD, 2009). Non-medical requests for any radiological investigation, such as chest radiographs, proved problematic owing to legislation, competence and governance of role development. Blood and blood product authorization was achieved through the provision of a collaborative educational programme and the formation of new clinical competencies (Green and Pirie, 2009). While the ANPCC role is not a new role, its implementation in NHS Scotland was new and hence evaluation was deemed necessary. It was also essential from a risk management and clinical effectiveness perspective that the appropriateness of post-holder’s workload should be examined as part of a wider role evaluation in NHS Lanarkshire’s three ICU and HDUs.
AIMS The aim of this paper is to report two key areas of the evaluation and to determine ANPCC: • specific activities and workload • prescribing practice
EVALUATION METHODS Evaluation of the new service model was planned after 2 years of training as this period of time was considered to be an appropriate duration to fully prepare © 2014 British Association of Critical Care Nurses
A workplace evaluation of ANPCC work balance
the ANPCC to participate in the service and evaluate their workload. In one unit, the ANPCCs were involved with both ICU and HDU patients and so chosen for detailed review of their workload. In this unit the staffing model changed from a traditional medical model, including: one anaesthetic consultant and one trainee per day with varying experience from level Specialist Training 1 (ST) to ST7, to one which included anaesthetic consultant and an ANPCC (Royal College of Anaesthetists, 2014). The evaluation was undertaken over five, 10.5 h day shifts, covering Monday to Friday from 8 a.m. until 6.30 pm in March 2011. Data were collected by the ANPCC on duty (total 52.5 h/week). ANPCCs work 4 days/week, so the full 5 days data were collected as the unit would have one ANPCC on duty every weekday. A data collection form was developed to capture clinical tasks, ward round workload and all drugs prescribed undertaken by ANPCCs. Data entry included every task and prescription and its duration throughout their shift and over 5 days. Common tasks included: insertion of central lines and arterial lines, intravenous fluid prescriptions and blood product authorization. Data collection forms were stored in accordance with data protection law, kept in a locked drawer within a secure office. No forms contained patient or staff information (Data Protection Act, 1998).
Ethics Following discussion with the local Research and Development committee, this project was deemed to be a service evaluation and therefore did not require research or ethics approval. All three lead consultant anaesthetists, nurse managers and lead for ANPCCs were informed of the pending evaluation.
Results The results presented have been broken down into three emerging categories. Firstly, week workload by one ANPCC in one ICU and HDU (Figure 1), secondly ward round activity (Figure 2) and finally prescribing activity (Figure 3). The data were collated, uncoded onto an Excel® spreadsheet for analysis. Following data entry, results were allocated to specific categories described above.
Week workload Figure 1 illustrates the tasks the ANPCC performed independently and unsupervised after their training period and competency framework completion, Activities undertaken related to independent patient assessments on all HDU patients. Around one fifth of the time was devoted to clinical documentation such as: © 2014 British Association of Critical Care Nurses
• Patient assessments and subsequent management plans. • Admission, transfer and discharge documentation. • Routine investigation paperwork namely laboratory investigations. A total of 10% of the working week encompassed data collection and data input, for example, maintaining the Scottish Intensive Care Society (SICS) national database WardWatcher. Combined invasive lines and phlebotomy accounted for 6% of ANPCC workload
Ward rounds Of the working week, 46% was spent participating in the ICU and HDU ward round. The ward round consisted of a complete patient assessment and detailed treatment and management plan. In view of this being the largest component of the week it was deemed appropriate that more in-depth analysis was required. Data were subsequently subcategorized into core activities namely patient assessments, prescribing, documentation and finally specialist ward rounds such as microbiology and surgeons’ reviews (see Figure 2).
Ward round activity The following data reported percentages of the ANPPC time attributed to tasks conducted on the ICU and HDU ward round specifically 46% of the ANPCC working week (Figure 1). The ICU ward round consumed 35% of that time which entailed conducting supervised patient assessments, examining and presenting patients and reporting clinical findings. ANPCC documentation time was low during the ward round accounting for 4% of workload. Prescribing was an essential and substantial part of ANPCC workload at 59% of ward round activity (Figure 2). This result merited further analysis of prescribing activity in order to elaborate professional and legal prescribing challenges. Prescriptions for antimicrobials contributed to 25% of all requests (Figure 3). Blood, fluid and electrolyte prescriptions accounted for 27% of those made by ANPCCs. While analgesia and sedation prescriptions contributed to 11% (Figure 3) of the total ANPCCs’ prescribing activity, the majority of which consisted related postoperative analgesia. The gastrointestinal drug section totalled 6% of prescriptions. These drugs included anti-emetics and laxatives. Ranitidine prescriptions were categorized in the DVT/Ulcer prophylaxis section. Cardiac protective drugs included aspirin, beta blockers and calcium channel blockers accounted for 6% of ANPCC 3
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Week Workload Assessments Unsupervised 12%
All Documentation (Excl Wd Round) 19%
Airway / Arrest 4%
All Data Input 10%
Others 3% Ward Round 46%
All Lines 3% All Bloods 3%
Figure 1 Week workload.
Ward Round Activity Ward Round Documentation 4% Specialist wd rd 2% Supervised Patient Assessment 35% Prescribing 59%
Figure 2 Ward round activity. Prescribing Activity Analgesia/ Sedation 11%
Others 3%
Antimicrobials 25%
Meds Reconciliation 13% DVT / Ulcer Prophylaxis 6%
Steroids 3% Cardiac Protection 6%
Blood/ IV Fluids/ Electrolytes 27%
GI Drugs 6%
Figure 3 Prescribing activity.
prescriptions. Perhaps most noteworthy was the significant time spent with medicines reconciliation. Thirteen percent of ANPCC prescribing time was used to discontinue drugs, change drugs, doses or rewrite drug cardexes; this was recorded as medicines reconciliation.
DISCUSSION The available literature surrounding nurse practitioners in ICU is varied and extensive; however, the majority of studies have shown favourable or 4
equivocal results for the role of the nurse practitioner when compared with senior trainee medical staff or physicians assistants (Rudy et al., 1998; Burns et al., 2003; Hoffman et al., 2003; Kleinpell, 2005). The completion of this audit revealed key issues that addressed the aims of the project, namely three key areas of the ANPCC workload, daily activities, workload and prescribing practice. Independent patient assessment was highlighted as a significant part of ANPCC workload (12%). Moreover, the ANPCCs’ independent patient assessments and action plans allowed prompt review by the consultant, informed decision making, prioritization of patient reviews and discharge planning. The consultants in general documented assessments and treatment plans for ICU patients; this may explain the low percentage of ANPCC documentation time during the ward rounds of 4%. Data collection and input were seen as a valuable use of ANPCC time (10%) and may have impacted on data collection standards into various databases such as Ward Watcher by the Scottish Intensive Care Society Audit Group (SICSAG, 2012). Rudy et al., (1998) also demonstrated that nurse practitioners spent more time in administrative and research tasks than their medical counterparts. The ANPCCs were qualified independent NMPs as of July 2010. In Scotland, NMPs can prescribe any drug within their field of competence including off-license drugs (SEHD, 2009). Off-license prescribing refers to prescribing a drug out with its licensed indication for use, e.g. using intravenous paracetamol for longer than 48 hrs. NMPs in Scotland were not permitted to prescribe unlicensed drugs at the time of the evaluation. NHS Lanarkshire has since allowed NMPs to prescribe unlicensed medicines and opiate infusions. These changes came in © 2014 British Association of Critical Care Nurses
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the years 2011 and 2012 (SEHD, 2006). Any unlicensed medicines were prescribed by the consultant during the evaluation period. The evaluation highlighted the broad nature required of ANPCC prescribing and thus reinforced the strategic decision not to introduce a restricted formulary. Although the ANPCCs were independent NMPs, they were also supervised at consultant level and all prescriptions were written in accordance with a documented treatment plan, enhancing safety for the patient and the novice NMPs. Competence to authorize blood and blood products was an important aspect of the ANPCC role adding to seamless and consistent care delivery (Green and Pirie, 2009; SEHD, 2006). ANPCCs were the first critical care nurses in Scotland trained to authorize blood and blood products. Blood product prescribing was included within the 27% of time needed for all IV fluids. Antimicrobial prescribing was a significant workload issue within critical care, a task which was carefully considered when developing the ANPCC role (Lawrence and Kollef, 2009). Many critically ill patients presented with severe infections requiring a multitude of complex antimicrobial therapies. The ANPCCs attended additional intensive pharmacy led training sessions in antimicrobial prescribing in order to support their prescribing practice. It should be noted that NMPs were not legally permitted to prescribe continuous intravenous opiate infusions or anaesthetic drugs at the time of the service evaluation (SEHD, 2009). These restrictions meant that the consultant had to prescribe these drugs. These shortfalls in prescribing have recently been resolved, and ANPCCs can prescribe any drug including unlicensed medicines within the scope of their competence. During the service evaluation only a few tasks had to be performed by the consultant for example: advanced radiological investigations such as CT scans and difficult airway skills. These tasks were decided upon at the ward round and so incorporated within it. It was decided that owing to a limited exposure to experience the insertion of chest drains would remain a medical procedure. Certification of death was solely a medical task, unremarkable in terms of workload during the service evaluation. Medical staff continued to report appropriate deaths to the Procurator Fiscal (Coroner). Fleming and Carberry (2011) interviewed ANPCCs before their training to examine if expectations of their new role matched the reality 1 year later. It was originally anticipated by ANPCCs at the beginning of their training that a significant part of their role would be inserting invasive lines such as arterial © 2014 British Association of Critical Care Nurses
and central lines and intubating patients. Results, as demonstrated here showed this was not the case, and that after 2 years training only 6% of the ANPCC weekly workload consisted of invasive line insertions or phlebotomy. Advanced airway management was also a rare occurrence (4%). During the evaluation, ANPCCs had not been yet been trained to insert dialysis lines or use the subclavian vein as a route for central lines, which may have accounted for the lower than anticipated result. Infrequent exposure of ANPCCs to advanced or difficult airway procedures made maintaining these competencies difficult. Airway training was included in the ANPCC programme and it would appear from the results that the decision to make it a long-term plan was indeed appropriate due to the infrequency of experiences (DoH, 2008). ANPCCs did not attend cardiac arrests as the anaesthetic trainee carried the on-call pager in theatre and always attended alone. ANPCCs were not trained to request radiological investigations of any kind; this was due to changes in the regulation and monitoring of the legislation of The Ionising Radiation (Medical Exposure) Regulations (Statutory Instrument 1059, 2000) in NHS Scotland. These issues were resolved shortly after the completion of this evaluation in late 2011, ANPCCs can now request simple X-rays, e.g. chest, abdomen bones. Complex studies such as computed tomography (CT) scans remain consultant to consultant requests as before. It appeared from the service evaluation results that ANPCCs delivered a significant and important role in critical care service provision. There were no adverse patient events reported during the evaluation period, although rates of adverse events were not recorded pre-evaluation.
LIMITATIONS This evaluation was limited by the following factors. This was a small evaluation which was confined to one centre in Scotland. The training package although drawn from other work and local experts was directed to the needs of the unit involved. Data collection was limited to 1 week and consequently the results may not be generalizable or representative to other critical care areas.
CONCLUSION The outcomes of this evaluation demonstrated that ANPCCs could be trained to match the roles of the trainee doctor in critical care with only a few tasks transferred to the consultant on duty. ANPCCs also 5
A workplace evaluation of ANPCC work balance
added to unit efficiency by taking over responsibility for and monitoring of national data input which was lacking in consistency before. ANPCCs and NHS Lanarkshire have addressed some of the issues raised by this service evaluation. ANPCCs can now request X-rays and prescribing of unlicensed medications and opiate infusions are now permitted (The Misuse of Drugs (Amendment No. 2) 2012).
FUTURE PLANS Future plans for ANPCCs included: working in unsupervised sessions in HDUs, ICU follow-up services and taking direct ICU referrals. ANPCCs have now begun to take ICU referrals and have provided regular unsupervised sessions in HDU. ANPCCs are now using their training and skills to teach junior doctors invasive line skills and critical care assessment and care planning.
IMPLICATIONS FOR PRACTICE This evaluation has several implications for clinical practice:
• Experienced critical care nurses can be trained to effectively perform the roles traditionally performed by medical trainees. • The ANPCC role has provided experienced critical care nurses with an alternative route of promotion that remains predominately clinical. ANPCCs could be utilized in any ICU/HDU setting to safely contribute to service provision.
ACKNOWLEDGEMENTS We wish to thank NHS Lanarkshire intensive care unit staff. We particularly acknowledge the contribution from the advanced nurse practitioners working in the intensive care units who gave their time in a busy work schedule to participate in this evaluation. This evaluation received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
WHAT IS KNOWN ABOUT THIS TOPIC? • •
The reduction in the number and experience of junior medical staff in critical care has led to new advanced role opportunities for critical care nurses. Roles to address the shortfall of junior medical staff have been developed but not frequently evaluated.
WHAT THIS PAPER ADDS •
This service evaluation provides analysis of the roles and tasks undertaken by ANPCC which could be used to inform service providers and prospective employers of the value of these posts in critical care.
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Minarik PA. (2005). Issue: Competence assessment and competency assurance of healthcare professionals. Clinical Nurse Specialist; 19: 180–183. NHS Education Scotland. (2008). Supporting the Development of Advanced Nursing Practice. A Toolkit Approach. Edinburgh: NES Publication. Nursing and Midwifery Council. (2005). Implementation of a framework for the standard for post registration nursing decision. Agendum 27.1 December 2005/c/05/160. London: NMC. Royal College of Anaesthetists. (2014). http://www.rcoa.ac.uk/ careers-training/considering-career-anaesthesia/types-ofcareers-anaesthesia (last accessed 24/05/14). Royal College of Nursing. (2007). Advanced Nurse Practice Domains and Competencies. London: RCN. Rudy EB, Davidson LJ, Daly B, Clochesy JM, Sereika S, Baldisseri M, Hravnak M, Ross T, Ryan C. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. American Journal of Critical Care; 7: 267–281. Scottish Executive Health Department. (2005a). Modernising Medical Careers. Edinburgh: Scottish Executive Health Department. Scottish Executive Health Department. (2005b). Framework for Developing Nursing Roles. Edinburgh: Scottish Executive
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