Clarification of Emergency Department NP Role and Scope in Alberta: A Narrative Review

Christie Brulhart^*
*Correspondence: Christie Brulhart, Department of Nursing, University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3, Canada, Email:

Keywords

Nurse practitioners • Emergency room • Emergency department • Trauma centre • Trauma center • Accident and emergency • Urgent care • Triag • Role • Duty • Duties of responsible • Scope of practice

Introduction

Benefits of nurse practitioners

Nurse Practitioners (NP) are an asset to Emergency Department (ED) healthcare teams. EDs that employ NPs demonstrate a reduction in the time to initially see a provider, overall reduced length of stay, and decreased frequency of clients leaving the department prior to being seen by a provider [1]. Integrating NPs into an ED is further supported by Alberta’s struggling healthcare climate, which is highlighted by mounting length of stay and inaccessibility to healthcare [2,3].

Alberta’s ED’s are congested. The average time a client spends in ED until discharge has increased from 8.6 hours to 9.5 hours [2,4]. Prolonged length of stay leads to congestion, as there are no available care spaces to see new clients [5]. Unfortunately, admitted clients that are deemed too ill to be discharged, require admission into non-existent beds [5]. The length of stay for clients awaiting inpatient beds skyrocketed, from 27 hours to 36.4 hours [2,4]. Further adding to the congestion, an alarming number of patients are being seen in emergency rooms for non-urgent issues, leading to a downstream effect on wait times [6]. Limited accessibility to care may be the root of why clients go to the ED for non-urgent concerns.

Introducing NPs in the ED can drastically improve accessibility to care. Clients who leave without being seen are often in underserved and marginalized communities, with limited access to healthcare [7,8]. At-risk individuals often have more complex socioeconomic needs, such as unstable or vagrant living situations and difficulties arranging transportation to attend follow-up appointments. Shand W, et al. demonstrated that NPs can follow-up with microbiology/diagnostic imaging results and phone clients who left without being seen to ensure their health needs are met [9]. Furthermore, NPs excel in interpersonal care, and when compared to physicians, clients report being more satisfied with the NPs’ approach [1,10]. NPs spend a longer amount of time with clients, providing education and promoting health, which have a positive impact on health outcomes [7]. Despite the dire need for emergency healthcare providers within Alberta, there are still barriers preventing widespread integration of NPs in EDs.

Barriers to NP integration

Although NPs are recognized as primary care providers in Canada, their introduction into emergency care is relatively new, thus, the literature exploring the scope of practice is limited. In Alberta, NPs who have graduated from a recognized master’s program in Alberta can autonomously assess, order and interpret diagnostics, prescribe pharmacotherapy and arrange follow-up [11]. Unfortunately, the restrictions regarding what skills NPs can perform autonomously in the ED are not specific [12]. Therefore, it’s not surprising that the role and scope of practice of the NP practicing in an ED is widely unknown.

A prominent barrier to NP integration is interdisciplinary confusion about the role and scope of practice, including their level of autonomy [13,14]. In primary care settings, role ambiguity stems from staff and management inexperience working alongside an NP [15,16]. The issues that NP practicing in primary care settings parallels the issues in emergency departments. Role ambiguity can lead to loss of autonomy and a narrowing of the scope of practice [17]. All NPs have a RN license, as it’s a prerequisite for NP practice, and level of autonomy is the defining difference between the roles. NPs can practice restricted activities like prescribing Schedule I drugs and setting a fractured bone [4]. Restricting scope of practice and limiting autonomy is counterproductive because NPs are largely present in ED setting to cope with high volumes of clients. For example, when NPs practice autonomously, wait times and lengths of stay were shorter than when a patient was seen by both a NP and a physician (39 and 77 minutes; 65 and 174 minutes, respectively) [1]. Limited clarity regarding scope of practice has a ripple effect on how NPs are utilized.

When the role of the NP in the ED is ambiguous or misunderstood, underutilization and conflict may arise. A misunderstanding of the role has a negative impact on the team dynamics, including limited collaboration and conflict with physicians [18]. The NP’s ability to practice autonomously is dependent on interdisciplinary collaboration with physicians [19]. In the Canadian context, NPs are not yet widely present in ED client care, and physicians may not acknowledge the full scope of practice of the NP [17]. Blurred boundaries between the scope of medicine and nursing practice also causes frustration in nursing staff and impacts nursing views of the role [20]. For example, when nurses were unsure of the NPs scope, they were underutilized in the main ED and primarily saw non-urgent or stable clients in the fast-track area. Nurses also expressed frustration about NPs not performing traditional nursing jobs, such as initiating IVs and administering medications [20]. When nursing staff have clarity surrounding the role, NPs can be utilized to their full scope of practice, rather than being isolated to caring for non-urgent clients [20].

As a response to the ongoing detrimental impacts of poor role clarity on NP utilization, an infographic was created to clarify scope of practice and address role ambiguity. As instruments of these nature are complex and require assessment of many variables, using a framework to guide the development process is necessary to ensure success. The Knowledge-to-Action (KTA) framework is a conceptual model that guides the synthesis and implementation of evidence into practice. This framework has been chosen as it offers many benefits, such as an emphasis on stakeholder involvement and tailoring of knowledge for the end-users [21]. Additionally, KTA offers an opportunity to critically assess barriers to implementation [21].

Purpose

The purpose of this capstone was to develop an evidence-based infographic that assists ED NPs to communicate their role and scope of practice to physicians.

Methodology

Source of information

Through the University of Alberta Library, the following databases were searched based on the recommendations from a University of Alberta Health Sciences librarian in March 2023: CINAHL, Scopus, and Medline. Grey literature sources such as the Canadian Nurses Association and the College of Registered Nurses of Alberta were utilized. As NPs’ scope of practice widely varies between provinces, grey literature documents were limited to only those written by Alberta-based organizations. A narrative literature review has been conducted based on the framework proposed by Green BN, et al. [22] (Figure 1).

Selection criteria

Inclusion criteria:

Date range and language: The search was limited to academic journals published during 2000-2023 and written in English. Grey literature was obtained from the College of Registered Nurses of Alberta website.

Literature content: Given the limited available research on emergency NPs in Alberta, all article types and methodologies were included. Qualitative, quantitative, mixed-methods research, and literature reviews were screened for both ED settings and focused primarily on NPs.

Exclusion criteria: Reasons for exclusion included inappropriate setting, such as inpatient units, NPs working within subspecialties in the ED, such as Pediatrics or mental health, or articles discussing aspects of NP practice other than role and scope of practice. Duplicates were removed.

Screening

A manual screening of article titles and abstracts was completed using the pre-determined inclusion and exclusion criteria.

Results

The initial search identified a total of 753 articles; 25 duplicates were removed prior to screening, leaving 728 titles and abstracts to be screened. Using the inclusion and exclusion criteria, 56 articles remained for retrieval. Of the 56 articles, a total of 29 articles written in English were included for analysis (Figure 2).

Four themes were identified: role confusion, insufficient emergency education, a lack of a national standard of NP scope of practice, and challenges with the existing pay structure (Table 1).

Role confusion

NP role confusion amongst physicians was a prominent theme that emerged from the literature, with multiple authors identifying it as a barrier to autonomous practice and interdisciplinary collaboration [16,17,19,20,23-25]. Some literature notes that managers are hesitant or do not hire NPs at all because they fear that physician groups are unfamiliar with the role and will be resistant to its development [23]. Frustration can grow amongst NPs and staff (physicians and nurses) if the role and responsibilities are not clearly defined and communicated to staff upon hiring a NP [7]. Physicians were often cited as being unsure about what the job of the NP was–provider or nurse [16]. Other studies support this finding, also suggesting that nursing staff too expressed confusion about NPs role. For example, nurses were found to be annoyed that the NP was not completing the orders, such as inserting an IV [25]. As previously discussed, this lack of awareness of the NP role can have unintended consequences on autonomous practice [18,19].

Lack of national standard of np scope of practice

In Canada and the USA, the lack of standardization of scope of NP practice contributes to role confusion and negatively impacts interdisciplinary collaboration between physicians and NPs [23,24,26,27]. Scope of practice regulations are created for each individual province and state, allowing for considerable variations in NP practice [20]. For example, in Alberta, NPs can issue a Form 1 for involuntary admission for those at risk of harm to themselves or others, whereas in New Brunswick, British Columbia, and Ontario, this action is out of the NP’s scope [14]. Furthermore, physicians, managers and local institutions have the power to restrict NPs clinical autonomy, despite provincial scope of practice [17-19,28,29]. When autonomous practice is restricted, it can result in NP job dissatisfaction, turnover, and a negative impact on recruitment [19].

Insufficient emergency education and preparedness

The educational preparedness for NPs practicing in EDs is insufficient [18,29]. One study in the USA suggested that 65% of NPs practicing in EDs have Family NP degrees with no formal emergency education [28]. Furthermore, NP fellowship programs are scarce in Canada, requiring the NP seek out-of-country education [30]. Without formal education, many NPs learn ED specific skills through on-the-job orientation or through self-study methods [26,28,29,31]. Campo T, et al. [31] study reviewed NPs’ confidence and knowledge base when performing common skills. The top five most performed procedures by NPs are fluorescein staining, single-layer closure of extremity or trunk, incise and drainage, injecting local anaesthetics, and removal of a foreign body from soft tissue [31]. Out of these five skills, four of them were learnt while on-the-job rather than in a formal institute [31]. The lack of foundational ED education can be hazardous to clients as insidious, life-threatening conditions may be missed or mismanaged [26,28]. Unfortunately, upon graduating, a staggering 51% of NPs felt ill-prepared to venture into independent practice [31]. Despite this, NPs have potential to become competent in emergency care if properly mentored.

Lack of ED-specific education is evident when comparing NPs with the current standard of practice, which is an ED physician. Steiner IP, et al. [29] found that NPs make substantially different clinical decisions when compared to ED physicians, but with consistent mentorship and teaching, NPs were able to improve their practice. For example, the plan of care for follow-up of microbiology results was consistent between an NP and an emergency physician (87% of NP care was all equivalent to emergency physician care); however, NPs management of palpitations was substantially different than the plan of care proposed by the ED physician (20% of NP care was all equivalent to emergency physician care) [29]. Following a 6-month internship with a physician, the NP’s plan of care generally improved from 25% to 56.2%, which is considered an acceptable standard [29].

Pay structure challenges

Adding further strain, the existing pay structure in Alberta also contributes to physician opposition. NPs are paid either by annual salary or a set hourly rate, whereas physicians operate under a fee-for-service model [23]. Fee-forservice means that the physician bills insurance companies for the services they provide. Physicians cannot bill for a visit when a salaried NP has seen the patient, which can result in friction between the two disciplines [7,23]. Other provinces, such as Ontario, have sought to amend the problem by aligning both NPs and physicians with a salary model [7].

Discussion

Alberta emergency nurse practitioners: A reference for physicians infographic

Interdisciplinary collaboration is a staple in emergency care. NPs have the potential to be excellent additions to ED teams but face barriers that make successful integration difficult [7,29]. Contributing factors identified were role confusion, lack of national standards of scope of practice, insufficient emergency education programs and pay structure differences. However, the literature suggests that when physicians are familiar with NP practice, they are more likely to become “champions of the role” [7]. As previously mentioned, new NPs are more likely to succeed if they have physician support and mentorship [7]. Frankly, given the lack of formal emergency NP programs in Canada, without physician mentorship, NP integration into an ED setting is futile. Therefore, efforts needed to be made to encourage physician support [32].

As a result of the literature review an evidence-based infographic has been designed as a reference for physicians, that describe NPs’ scope of practice, the role, and that highlights physicians as mentors. Its aim is to clarify NP scope of practice and their role in an ED setting within Alberta (see Appendix I –Figure 1). The tool was designed to be utilized in Alberta only because scope of practice varies greatly between provinces.

Medical literature can be lengthy and daunting, deterring readers from engaging with the material [33,34]. An infographic was the chosen medium as it is concise, readily accessible, and draws the reader in [33,34]. Overall, many physicians prefer infographics to be delivered to them via smart phone or tablet, making it feasible to disperse to a large audience [21,33]. The infographic (see Figure 1) uses five headings: Education, Benefits of NPs, Scope of Practice and Advanced Interventions, Role in the ED, and Your Support Matters.

Education

General education requirements for various NP programs in Alberta were included in this section so that physicians can view NPs’ educational and professional backgrounds. The universities within Alberta that offer a Master of Nursing - NP program require their applicants to have minimum of 4,500 hours of RN clinical experience and a 4-year bachelor’s degree in nursing to be considered for acceptance (Athabasca University, 2023; University of Alberta, 2023). To practice in Alberta, following obtaining their MN-NP degree, graduates must pass the Canadian Nurse Practitioner Exam (CNPE) [35]. In Alberta, NP is a protected title, meaning that only those who have met the educational requirements and are a regulated member can practice under the title [12].

Benefits

As reflected in the literature, physicians may view NPs as competition for a various number of reasons [23,36]. This infographic section was created with the intention of addressing physician hesitancy, or rather, answering the question “what’s in it for me?” For a physician group to actively champion the NP role, they need to understand the intention or purpose of the role, as well as the benefits [16]. When NPs were introduced into various ED sites within Alberta, there was a decrease in the number of clients that left-without-being seen, shorter length of stay in the department, and a decrease in number of clients who revisited the ED within 72 hours of discharge when an NP was on shift [1,9]. These points are highlighted in the infographic to demonstrate the potential influence that the NP role has on the ED flow and volume. The role that the NP plays in the ED will determine how fruitful the rewards are, but it depends on physician understanding of scope of practice.

Scope of practice and advanced interventions

A frequently cited barrier to successful integration into an ED is role and scope of practice confusion [16,17,19,20,24,25]. Therefore, it’s vital that NPs’ scope of practice is described within the infographic to help provide role clarity. Although this information is easily accessible and opens to the public, the document is lengthy, and clinicians may not have the time to review it. The scope of practice of the Alberta NP is presented in point form, directly cited from the Scope of Practice of Nurse Practitioners by the College of Registered Nurses of Alberta [12]. Advanced interventions that are restricted to NP practice are also listed because these help to differentiate NP practice from that of an RN [12]. It’s also noted on the infographic that NPs are responsible for judging their own competency [12]. Competency is determined by the NPs self-reflection on their skills and ability to make critical, evidence-based judgements [12]. I chose to include the stipulation regarding competency on the infographic because individual NPs ultimately determine limitations of their practice. For example, although NPs can reset a fracture, it requires special education and hands-on learning to develop competency [12]. Working beyond scope of practice or competency has potential to cause harm to clients.

Role in the ED

Including the role of the NP in the infographic (see Appendix I–Figure 1) was paramount because role confusion strongly contributes to physician opposition. As the role of the NP is still being carved out in Alberta, I modelled this section after hospitals that had successfully created specific NP roles, such as Strathcona Community Hospital [9]. As Alberta’s healthcare climate is a current state of transition, these roles may be expanded in the future [37].

The “invisible work” of NPs described by Shand W, et al. [9] includes following up on all microbiology and diagnostic imaging results from ED providers (p.25). The impact of the behind-the-scenes work done by NPs is immense, as it reduces the number of clients returning to the department for potentially normal results, improves follow-up care, and avoids unnecessary ED visits [9]. Additionally, NPs can autonomously care for clients presenting with a variety of ailments.

NPs in the ED can autonomously assess CTAS 2-5s (ranging from emergent to non-urgent) but may require physician consult for CTAS 2 and 3 (emergent and urgent) on a case-by-case basis [9]. It’s important to avoid narrowing the scope of practice of the NP, as doing so can have negative outcomes on retention and effectiveness of the role. Additionally, NPs are valuable in the role of triage liaison provider, where they can initiate laboratory and diagnostic imaging orders prior to the patient being place into a treatment bed [9]. Although the literature clearly reflects the positive impact that NPs have in the ED, it’s fruitless if there is minimal physician support.

Your support matters

The infographic briefly covers the importance of physician mentorship. As previously mentioned, without physician support, it’s extremely difficult for NPs to integrate into an ED [29]. This is especially true in Alberta as Canadian NP emergency post-degree programs are non-existent and most of the training is learned on the job [23,31]. A 12-week orientation in combination with a 6-month mentorship is recommended to ensure success and establish trust and comfort in the new NP [7,29]. NPs can be successfully trained and integrated into the ED when adequately supported by physicians [29]. It’s important to note that NPs who have had excellent mentorship, on-the-job training and orientation can be successful in an ED [7,9,28,31]. Physician mentorship can enhance NPs knowledge and skills [29,31]. For example, NPs who learnt how to perform an incision and drainage were later able to practice the skill autonomously and with confidence [31]. Once sufficient training has been completed under a physician, NPs practicing in an ED should begin in a minor treatment area.

In addition to physician mentorship and orientation, NPs new to the ED should initially be integrated into low acuity areas [36]. Areas suggested in the literature where NPs can practice autonomously include triage liaison provider, care for clients deemed a non-urgent and seek consultation when needed in the management of emergent cases [9,38]. It’s important to note that further studies are needed to assess whether NPs can safely provide autonomous care for the critically ill [28]. If given the right amount of support and mentorship, NPs can be successfully integrated into the ED; however, for physicians to be mentors and advocates, they need to understand the ‘who, what and why?’ of NPs.

Strengths and Limitations

This is the first infographic developed as a communication tool and reference for physicians in Alberta that describes the role of emergency NPs. As this method of knowledge translation has not been previously demonstrated in the literature, it could potentially be a catalyst in promoting physician understanding of NPs. Furthermore, the chosen instrument, an infographic, is strength. Infographics are considered a low-cognitive load tool, meaning they are likely to be read by busy medical professionals compared to in-text literature [33]. This ensures adaptability of the infographic [21]. Although efforts are made to minimize error and bias, there were some limitations of this capstone project.

Despite conducting a rigorous search, some grey literature may have been missed. Further limitations of this capstone project were that the narrative review and thematic analysis of the literature was not limited to Alberta, but the infographic’s target audience was physicians working in Alberta. Unfortunately, the literature was too limited to conduct a thematic analysis and competent narrative review exclusive to Alberta. Other limitations related to the time allotted for capstone completion. Ideally, the impact of the infographic should be studied to assess if it can help improve practice conditions. Future research should be conducted to assess whether the infographic would be successful in improving physician understanding of the role [39-47].

Conclusion

The current healthcare climate in Alberta is one in desperate need of emergency providers. With exponentially long wait times and soaring rates of left-without-being seen, the gap in accessibility to healthcare has expanded into a crevasse. The introduction of NPs into EDs is a starting point to alleviate this situation, however physician opposition and vague scope of practice erects barriers, limiting successful integration. The infographic titled, ‘Alberta Emergency Nurse Practitioners: A Reference for Physicians’ was developed in hopes of bridging this gap and providing clarity. The infographic is intended to be used as a means of communication regarding ENPs education, role, scope of practice, benefits, and need for physician support. The wider use of NPs into Alberta EDs may help swing the pendulum towards accessible healthcare for all.

Acknowledgement

None.

Conflict of Interest

None.

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