The work of an advanced nurse practitioner in an emergency department in the UK.

Kate Dear qualified as a Paramedic in 2001 and up until April 2013 continued her work as a Paramedic, completing one shift per week, alongside her other roles. After qualifying as a registered Nurse in 2006, Kate worked in coronary care and various Emergency departments (EDs) and in 2008 became a Paediatric Resuscitation Practitioner. In 2010 whilst working as a Senior Sister in an ED, Kate began her Master of Science Advanced Practitioner training at Rochdale and Oldham A&E, which she completed in 2012. She qualified in Non-Medical Prescribing in January 2013.

What does a typical day look like for you?

Bild– A typical day for me is actually a night shift. I work in a District General Emergency Department called Stepping Hill Hospital and this sees on average 97,000 pts a year, including children. We are a trauma unit so we receive trauma in the daytime and only limited trauma at night time. The staffing at night consists of a Middle Grade or senior Emergency medicine trainee, two junior doctors and either a 3 rd junior doctor or me. I arrive at work, sign onto my iPad ( as we are fully paperless) and speak to the nursing coordinator and the middle grade doctor and we plan the work depending on the needs of the department.

The last few months have been extremely busy so I either go to the paediatric part of the ED and clear all the patients from there or I start seeing the really sick patients that are scoring on the Early Warning Scoring system. I often go to the paeds Ed and there are 10 children waiting to be seen, sometimes they are poorly and need lots doing but often they are primary care patients who can be reassured and sent home. If a paediatric standby is given to us I would go to the Resuscitation area and see the child on arrival either with or without the Middle Grade doctor.

I basically see patients, take a history, organize investigations, prescribe appropriate medications and have a plan for the patient. I can have a quick chat with the Middle Grade if they are a complex medical patient, and sometimes I will also ask them to check certain X-rays with me as I am still learning limb and spine X-rays. Often though I work fairly independently and see the more sick patients. I will run the cardiac arrests and can take patients with airway problems, but I always have the back up of the Middle Grade doctor if required which is really nice. I am currently learning how to insert chest drains and re-locate shoulders and I am going on the level 1 Ultra sound course later in the year.

What is the difference in training of an Advanced Nurse Practitioner compared to a regular Registered Nurse?

– As a nurse in the ED you develop lots off emergency care skills such as suturing, catheterising, nasogastric tubes, setting up and caring for chest drains and ventilators. However these are all tasks that have been given to you to do, you are only responsible for getting the task completed correctly, not for making the decision to initiate the chest drain or prescribe the fluids. The AP course gives you the depth of understanding to actually make the decisions based on a good history and examination of the patient added to a deeper level of understanding of A&E and core emergency conditions. The training consist of 2 years studying A&E, clinical conditions, supervised clinical practice with set competences and also OSCE examinations.

It’s also worth noting that every Advanced Nurse Practitioner (ANP) works differently and they each have a variable scope of practice and set of competences. My background as a paramedic allowed me an enhanced range of resuscitation skills and the ability to make clinical decisions as that was what I was used to doing, so for me the advanced practitioner course just built upon my existing skills and was a natural progression. Finally the prescribing course allowed me to fully transition from an ED nurse to an ED ANP.

That sounds like highly qualified work. Could you staff an ED with only ANPs and consultant doctors?

– Short answer….probably not. The ANP competences are extremely variable. We have tried several times to recruit more ANPs to my ED but each time the ANPs have not been able to meet the competences. Also there are lots of gaps in my knowledge and skill set that are currently met by the Middle Grades/Registrars. Basically my role supports the ED Registrar as I can see sick patients, take standbys, manage really sick patients together with the Registrar. That gives them some support as they don’t feel so vulnerable on the night shifts as often the junior doctors are well out of their depth and really struggle, they often don’t like to see children or resus patients and they often take a long time to see each patient. Whereas I work more like the registrars but with the added comfort that I can ask them for help.

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