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Winning them over

Sue Denham, an emergency nurse practitioner, shares her experience implementing the practitioner role into the ED of a regional public hospital, despite many initial objections.

It’s hard to believe I’m writing this and even harder to believe that only a few years ago [adding] emergency nurse practitioners in the department where I work was [an idea] not even any of the medical staff entertained.

About eight years ago, I was working as a clinical nurse and broached the subject with my nurse unit manager (NUM), who had worked with nurse practitioners in NSW. The discussion ended very quickly. Not that he was against the option; on the contrary, he believed NPs could have a vital role in the emergency department (ED) but he knew the attitude of the medical staff needed to be changed before the implementation of an NP service.

Our ED was, and in many ways still is, set in its ways. This department, maybe like many others, is antiquated. The emergency consultants like to have a firm hold on everything that happens and micromanage. That probably sounds familiar to many of you reading this.

If we were going to look at a new role, especially one that many believed was entering “medical territory”, we certainly had to tread softly and slowly.

In the background, the NUM worked extensively on the business case for financial support for the nurse practitioner positions. He believed we needed to have everything sorted and he knew he needed evidence to support the idea that an NP service would help achieve timely access to care, reach time-to-treatment targets and decrease ‘did-not-waits’.

Whilst this was happening, I believed the right time came for me to finally follow my dream. I had worked for over 20 years as a nurse and even though I had completed my emergency certificate and a management degree, my passion was always, and still is, about patients. After all, that is why I took up nursing in the first place. I never took it on to look at budgets and personnel.

I desperately wanted to return to what I considered real nursing and so I enrolled in the master’s of nursing science (nurse practitioner) course with the knowledge that:

• I would get clinical supervision from a consultant in one of the smaller EDs in the district.
• I may or may not get funding during my supervised NPC practice and if not, I would complete my clinical practice under a student deed – unpaid work.

Just after I commenced my studies, the district’s officials advertised for an NP. They were lucky to have one with experience apply from NSW. She got the position. She needed to work slowly and carefully on building up trust from both nursing and medical staff and luckily for us she persisted.

I was able to complete my final internship under her guidance and we made an unusual but formidable team. I was well known to the department, having worked as a CN for many years, so the medical staff was somewhat comfortable with me. Well, they were comfortable with me working as a nurse, but having my own patients and being able to discharge some without any discussion with them – now that’s a totally different story.

Despite having graduated and being endorsed as nurse practitioners, we both were required to complete a local credentialing process so the medical crew was [satisfied] we had acquired the skills and knowledge to be independent practitioners within a defined scope of practice in their department.

The NP [who guided me] was an outsider who gained their trust with her quiet resilience, persistence, knowledge and unending desire to do the best for the patient. But she and I both admit she had a harder time gaining the trust of the medical staff than I did, mainly because I was a known entity to them and was trusted for my nursing knowledge.

The district set up a steering committee and the scene was set. It was now inevitable that NPs would become a reality across the district. BUT work was still needed to ensure the medical staff was happy (albeit with reservations) about the NP role.

So work we did. We presented all of our patients to the senior medical officer on duty and discussed our options for management and discharge or admission. We worked on our relationship with other specialties from the allied health, registrars of all specialties, general practitioners, radiologists, pharmacists and visiting specialists.

The two of us have worked hard and at many times had to bite our tongues and swallow our pride but we both knew that it was all for the betterment of the nurse practitioner role and the care of our patients. Slowly we forged ahead. At times, we weren’t sure if we would ever get our wings, [such as] when the physicians had decided we were able to see and treat the few patients “they” decided were within our scope without consultation with them.

About two and a half years later, the EDNP role is firmly entrenched in the district’s departments.

There are five full-time nurse practitioners and three candidates across the three emergency departments. The initially reluctant medical staff now embrace the role and the NPs in their department.

We work independently and collaboratively within a dedicated fast track area. We attend both nursing and medical education sessions and are often requested by senior medical staff for assistance with education and guidance for junior personnel. From patient care and nursing education to medical student and intern education, we are a vital part of the senior ED team.

The initial limited scope (as deemed by the medical staff) is now constantly being expanded, often under the direct suggestion of the ED consultants.

We’ve gone from having to discuss the simple removal of sutures with the senior medical staff prior to discharging the patient, to the ED consultant group suggesting that the nurse practitioner should be able to perform biers blocks. We’ve certainly come a long way.

A staff satisfaction survey conducted in September 2012 showed that nearly all respondents – 97 per cent – would be happy for a member of their family to be treated by the ED nurse practitioner.

The survey included the ED physicians.

So from humble beginnings, the district EDNP was born and shaped. The role is still in its infancy but over the past two years we have made wonderful and surprising allies – many of them emergency physicians.

We will continue to strive for ongoing support and understanding of the vital role that nurse practitioners can provide to emergency patients.

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