Table 3 Perceived impact of NPs on care delivery in the emergency department– representative quotes

Impact on ED Functioning

“working in here, the Nurse Practitioner sees a lot of patients and we see more patients – we get through the patients quicker having Nurse Practitioners here and often we don’t have a lot of staff; sometimes we’re down so Nurse Practitioners really help us out” Site 1 ACN

“it helps with our KPIs^* because they’re seeing patients quicker … we get a lot of [low acuity patients] so they can fast track a lot of patients. And that helps clear the waiting room; gets patients in and out quickly” Site 2 NUM

“at the moment we’ve got small numbers of people, they’re available for part of the day and they see a particular set of patients. I think, you know, in the UK where there’s a large number of people, they run an entire section of the department and they’re responsible for that entire group of patients, I could see that might be of benefit … it’s a bit tokenistic [here] at the moment, you know, we have a nurse practitioner, or two nurse practitioners in a department where we’ve got, I don’t know, two hundred and thirty staff in the department and we’ve got two nurse practitioners so it’s still such a tiny fraction of our population … I think if I take a global view, the overall impact is relatively small.” Site 2 ED Director

“Emergency Departments offer a lot more services for patients. We’re a bit of a one stop shop and we offer things where there are gaps so the gap might be related to time so “at ten o’clock at night where do I go with my problem, there’s not a GP” or “I’ve cut my hand and I need to have stitches and my GP doesn’t do stitches so where do I go?” so you come to the ED. I’ve broken my bone and my GP doesn’t put plasters on so where do I go? So the nature of ED and the service that we provide [has changed] … there’s a gap in service provision so you know the doctors were just seeing lots and lots of people coming through and you know one asks themself does it make good sense to have a person that’s got a cut leg that needs half a dozen stitches put in their leg, does that make sense to take a doctor away from a patient with high complex medical problems to stitch up a person with a leg. It certainly needs an advanced level of clinical thinking to examine the leg and make sure that there’s no underlying structures involved and that there’s no nerve damage or tendon or whatever so … it makes sense to have nurses who are trained and have these skills and ability to do that type of stuff, to do those sorts of things so the doctors can be freed and do other things” Site 1 NP

“they appear to have taken a second line role rather than a front line role in terms of patient care. Nurse practitioners would be rostered to a shift but they will base themselves, for significant portions of the shift, in an office area away from the floor and so they will come back down when they see or feel that there’s work to be done but it’s – they’re not there at the front line…it’s a nursing position so they’re still primarily responsible to the nurse manager of the department. They have clinical responsibilities to myself and to the other staff specialists because we are their clinical supervisors but their management line is the nurse manager … I think it’s going to require some intervention to get that to happen more the way I would like to see it” Site 2 ED Director

“yesterday, for example around eight o’clock the staff specialist gives me a call and says, “Look, the nurse practitioner was in the office til eight o’clock” and not a single patient was seen … I’m not very happy about it but administratively they come under the Director of Nursing in this hospital” Site 1 ED Director

“I think they’re actually going to hit an interesting crossroad because I think one of the big drivers for the role was the fact that there was a need and the need was for having more of decision makers and there was a relative shortage of junior doctors who were the traditional people filling that role, that’s the role that they have basically stepped into. But with university placement planning and all the rest we’re now actually hitting in fact what many people are describing an excess of junior doctors coming through … and so now there’s going to be a flood of these doctors. I think that’s going to threaten the viability of the nurse practitioner program because the hospitals are going to have to employ these people and I wonder if they’re going to have any interest in pursuing this alternate group of practitioners” Site 2 ED Director

Impact on other Clinical Roles

“they’ve freed the doctors that work in the Subacute area from seeing those patients to go on and see patients that are a little higher acuity” Site 1 Doctor

“the ones that we have have worked very well and they would definitely have up-skilled nurses around them and empowered them to do things usually otherwise they would not have done” Site 1 Doctor

“They’re very sharing with their knowledge, they’re great educators to the other nurses. You know, you learn so much from them; you often learn a lot more from them than you do the doctors because they’re willing to sit down and talk to you and take the time to explain things” Site 1 ACN

“I think role modelling, [NPs have] an opportunity to role model for other nurses starting out or nurses that have gone two thirds through their career and then thought, “Oh, I can do this”… I think other nurses will go along and say, “Well gee, hey I can do that. You know I could commit to that period of study and I could be as autonomous as this person” so that’s a goal so role modelling” Site 2 NUM

“it has an impact in terms of work relationships, because you’ve got someone who’s a nurse but now is not actually someone who you would task to do something that you would task the other nurses to do because they’re seeing their own patients so that sort of relationship is different” Site 2 ED Director

Impact on Care Delivery

“their interaction with the patient will be similar to the ones that would be from a doctor. Perhaps they might even spend more time and explain better or explain more than a doctor would given that he’s - we might be superficial about some things - they might spend more time talking to them about aftercare and so on because they’ve been through a nursing perspective and have in the past, dealt with patients. If anything these minor patients with these kind of problems might be better dealt with by people with nursing backgrounds than doctors for instance” Site 1 Doctor

“They bring expertise and continuative care and holistic care” Site 2 NUM

“the healthcare system will evolve. As it stands today, it’s not going to hold; we need to look for other solutions to how we look after our patients today, and I think that’s where the Nurse Practitioners will take a huge role … I think we just need to have a reform in the way we run the healthcare system - it’s still very hierarchical and it’s still very medically driven and I think we need to look for other solutions – it’s not necessarily medically driven healthcare that we need. I think you need to look at what patients want and need and let patients maybe drive it more; give the power back to the patients and see what they need. They don’t necessarily need a script for antibiotics every time they go to a doctor, they might need to get other things and start changing their lifestyles and get input from social workers and get other people to be [involved] rather than spending hours and hours with a doctor and I think Nurse Practitioners are really good at doing that. Being a nurse, you have a more holistic view – not that doctors don’t do that, but I think we do have more insight into other professions … they often use the doctor as the gold standard and my question would be, is that the gold standard? Why do you compare us to a doctor? It might not be the gold standard, [or] it might [be] in something else” Site 1 NP