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Alternate models of care and the role of the emergency nurse practitioner

The recent editorial ‘Emergency Nurse Practitioners: an underestimated addition to the emergency care team’ outlines some of the important workforce and system challenges for ED and argues that alternate models of care are necessary to overcome these. I agree that alternate models of care should be considered and evaluated, but the evidence so far for emergency nurse practitioners (ENP) is not compelling. The editorial makes a number of points that warrant closer examination. The statement that ENP are a potential solution to access block does not correlate with its known aetiology. The solution to ED overcrowding from access block is not more or different ED staff, but for boarded patients to be moved out of the ED. The efficiency argument is also tenuous. The editorial relies on a single retrospective case series to argue that ENP have ‘impacted positively on ED key performance indicators’, but another similar study found no difference in waiting times or ED length of stay. The other literature on ENP consists largely of descriptive reports and survey analyses. On cost–benefit, the authors claim that a ‘compelling business case’ supports further recruitment of ENP in Victoria. It is hard to credit this, given that the direct salary costs alone of ENP are double that of the junior medical officer, with no evidence that ENP are any safer or more efficient. One of the ‘three key themes’ of the ENP role is the emphasis on autonomous and independent practice. It is clear that ENP are not going to work under the direction, supervision and delegated authority of emergency physicians, in the way that junior medical officers do. At the same time, the editorial’s authors want emergency physicians to provide ‘collaborative input’ and to ‘ensure patient safety by contributing to the clinical diagnostic and management decisions’. This lack of a clear line of responsibility and accountability is a major impediment to the utility of the ENP role. There is great scope for new models of care in ED that match skills and capabilities with specific tasks and service needs. Roles, such as communication clerks, ED technical assistants and physician assistants, who work under the supervision of emergency specialists and leverage their abilities and expertise, offer great opportunities for efficiency. However, these roles have not been widely introduced in Australia, with a recent proposed trial of physician assistants in Queensland strongly opposed by nursing industrial associations. I agree with the editorial that ‘training healthcare professionals for the tasks required rather than for roles based on historical models’ is a worthy goal. However, the ENP role is less about filling a service gap than meeting a perceived career progression need for nursing. The editorial authors recognize this by noting that ‘nursing recruitment, retention and sustainability of nursing career structures (is) high on the agenda for hospital administrators’. I hope the editorial stimulates further discussion of ED workforce planning. With demand for ED services increasing, all potential models of care and health-care roles should be considered, trialled and evaluated against transparent criteria before their adoption.