The clinical effectiveness of nurse practitioners' management of minor injuries in an adult...

E V I D E N C E S Y N T H E S I S

The clinical effectiveness of nurse practitioners’ managementof minor injuries in an adult emergency department:a systematic review

Anne Wilson PhD, BN, MN, FRCNA, Elizabeth Zwart RN, Cert. Oncology, Cert. StomalTherapy, Grad Dip Onc Nsg, Iain Everett RN, BN, Cert A&E and Jodie Kernick RN, BN, GradDip ICU Grad. Cert. RetrievalDiscipline of Nursing, The University of Adelaide, Adelaide, South Australia, Australia

AbstractBackground The increasing cost of healthcare in Australia demands changes in the way healthcare is delivered.Nurse practitioners have been introduced into specialty areas including emergency departments. Specific interven-tions are known to include the treatment and management of minor injuries, but little has been reported on theirwork.

Objectives Examine the best available evidence to determine the clinical effectiveness of emergency departmentnurse practitioners in the assessment, treatment and management of minor injuries in adults.

Inclusion criteria For inclusion studies had to include adult patients treated for minor injuries by nursepractitioners in emergency departments. All study designs were included.

Search strategy English language articles from 1986 onwards were sought using MEDLINE, CINAHL, Embaseand Science Citation Index.

Methodological quality Two independent reviewers critically appraised the quality of the studies andextracted data using standardised tools.

Data collection Two independent reviewers assessed the eligibility of each study for inclusion into the reviewand the study design used. Where any disagreement occurred, consensus was reached by discussion with anindependent researcher.

Data synthesis Studies were assessed for homogeneity by considering populations, interventions and outcomes.Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis wasconducted. For each outcome measure, results were tabulated by intervention type and discussed in a narrativesummary. Results from randomised controlled trials were pooled in meta-analyses where appropriate.

Results Nine studies from a total of 55 participants met the inclusion criteria. Two were randomised controlledtrials. Metasynthesis of research findings generated five synthesised findings derived from 16 study findingsaggregated into seven categories. Evidence comparing the clinical effectiveness of nurse practitioners to mainstreammanagement of minor injuries was fair to poor methodological quality. When comparable data were pooled, therewere no significant differences (P < 0.05) between nurse practitioners and junior doctors.

Conclusions The results emphasise the need for more high-quality research using appropriate outcome measuresin the area of clinical effectiveness of nurse practitioners, particularly interventions that improve outcomes forpresentations to emergency departments and address issues of waiting and congestion.

Key words: adult, emergency department, minor injuries, nurse practitioners, systematic review.

Correspondence: Dr Anne Wilson, Discipline of Nursing, School ofPopulation Health & Clinical Practice, Level 3, Eleanor HaroldBuilding, The University of Adelaide, North Terrance, Adelaide,Australia, 5005. Email: [email protected]

doi:10.1111/j.1744-1609.2009.00121.x Int J Evid Based Healthc 2009; 7: 3–14

© 2009 The AuthorsJournal Compilation © Blackwell Publishing Asia Pty Ltd

mailto:[email protected]

Background

The increasing cost of healthcare in Australia demandschanges in the way healthcare is delivered. In other coun-tries, nurse practitioner (NP) roles have evolved from theneed to provide improved access and affordable qualityhealthcare to increasingly complex patients.1–3 In Australia,as in other countries, the title ‘nurse practitioner’ is assignedthrough an application and certification process managedby the state nurses boards. Worldwide, these credentialsmight go by different titles that describe the status of nursesworking in extended and expanded roles, for example,advance practice nurse and nurse specialist.4

Nurse practitioners, working in an expanded scope ofpractice using extended repertoire of skill, are able to coordi-nate patients’ care both within and beyond the hospitalsetting, complementing the current clinical care already pro-vided.5 They might expand the hospital’s ability to respondeffectively and efficiently to evolving demands on the health-care system and act as the driving force for collaborationbetween the patient’s general practitioner and other health-care professionals to best meet the needs of the patient.6

Nurse practitioners have recently been introduced intospecialty areas including emergency departments. Specificinterventions are known to include the treatment and man-agement of minor injuries, but little has been reported on thework of emergency department nurse practitioners (ENP).Introducing NP is an approach that aims to improve patientaccess to interventions and decrease the demand on hospitalmedical services.7 Consequently, it is anticipated that inter-vention by an NP will decrease the amount of time spent byemergency department medical practitioners on specifiedpresentations.8 A report from one major Australian metropoli-tan hospital has indicated that although initiatives within theemergency department have shown dramatic improvementin waiting times to be seen by a medical officer, triagethresholds are still not meeting the agreed national accessperformance indicators under the Australasian Triage Scale.9

Increased waiting times can affect patients’ total length ofhospital stay, leading to issues of violence/aggression andemergency department overcrowding. Overcrowding has adetrimental effect on stress levels for all emergency depart-ment staff, affecting staff retention and ultimately the qualityof patient care that can be provided. The reason for extendedwaits is always due to the patient’s needing to wait for anavailable medical officer to assess them and commence theappropriate investigations and treatment. An appropriatelytrained and educated NP would be able to target a specificgroup of patients to address waiting times and assist theemergency department to decrease overcrowding andincrease patient flow through the department.10,11

With international trends, Australian Departments ofHealth have been actively involved in the development ofthe role of the NP through the implementation of state-based projects.12 Within the Final South Australian NursePractitioner Project Report, a number of key issues and rec-ommendations arose from the defining features of an NP.12

These defining features combine the subroles of educator,

mentor, provider, manager and researcher. It is envisagedthat, in order for these roles to evolve, the setting in whichthe NP wishes to be accredited must be specified. The NPshould accordingly develop in areas where gaps in servicesexist, continually consulting with other healthcare profes-sionals to ensure services are productive and healthcarefacilities and clients are benefiting. Implementing ENP aimsto facilitate best practice, cost-effective patient care in col-laboration with medical and allied healthcare professionals,and to contribute to the safe, efficient and best possible careof patients whom fall within the defined scope of practice.13

This systematic review has generated new knowledgerelating to the contemporary role of NP in emergencydepartment patient care. As such, there is a need to ascertainwhether or not services provided by NP are an effectiveadjunct to current practice, reducing waiting times, readmis-sion rates and total length of stay. With this in mind, theobjective of this systematic review is to present the bestavailable evidence related to the clinical effectiveness of NPin the management of adults referred for treatment by themin an emergency department.

Objectives

The objective of this review was to examine the best avail-able evidence to determine the clinical effectiveness of ENPin the assessment, treatment and management of minorinjuries in adults and their effect on waiting times. Thespecific review questions addressed were:

Are ENP effective in:1 Reducing waiting times to be assessed2 Reducing waiting times for treatment3 Reducing overall length of stay times4 Reducing the amount of medical officer time spent on

specified presentations5 Improving patient access to interventions6 Reducing issues of emergency department overcrowding

Criteria for considering studies forthis review

Types of studiesThis review considered randomised controlled trials (RCTs),non-randomised clinical trials, case-series, case–control andcohort studies where the effectiveness of NP was comparedfor the assessment, treatment and management of emer-gency department presentations for minor injuries in adults.In the absence of large numbers of RCTs, other researchmethods, such as descriptive exploratory designs, wereused.

Types of participantsParticipants included adult (16 years and over) presentationsto an emergency department for treatment by an NP of aminor injury.

Types of interventionsThe phenomena of interest were the scope of practice of theENP and included activities of:

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• Assessment• Diagnosis• Consultation• Treatment• Referral• Patient education

Types of outcome measuresThe primary outcome of interest was the management ofminor injuries by NP in an adult emergency department.Given the wide range of presentations to an emergencydepartment and the breadth of nurses’ work, the authorsincluded studies that reported on the effectiveness of NP’smanagement of any presentation, including, but notlimited to:• Effect on waiting times• Referral (internal or external) to other practitioners or

services within the emergency department and/or hospi-tal or to practitioners or services in the community

• Representations to the emergency department within48 h

• Perceived or identified cost reduction• Patient satisfaction

Search strategy for identificationof studies

A comprehensive search strategy was developed to find bothpublished and unpublished studies in English from 1986onwards. An initial search of the Cochrane Database ofSystematic Reviews, Joanna Briggs Institute (JBI) and theDatabase of Abstracts of Reviews of Effect (DARE) weresearched for any systematic review publication on this topic.No such reviews were found at the commencement of thereview.

A three-step search strategy was used in each componentof this review. Initial keywords used were: emergencydepartment, nurse practitioner, nurse specialist, advancedpractice, expanded practice and extended practice. MeSHterminology and keywords were adapted to suit the needs ofthe different databases.

Step oneAn initial limited search of MEDLINE and CINAHL was under-taken followed by analysis of the text words contained in thetitle and abstract, and of the index terms used to describearticle. The databases searched included MEDLINE, CINAHL,Embase and DARE.

Step twoA second extensive search using all identified keywords andindex terms was then undertaken across all included data-bases. A second extensive search was undertaken using theidentified keywords and index terms. Databases searched inthe second stage included:1 PubMed2 PsycInfo3 Academic Search Elite

4 Expanded Academic Index5 Web of Science6 AustHealth7 Health and Society8 CINAHL9 Cochrane Library (incorporating DARE and CENTRAL)

10 ISI Current ContentsThe search for unpublished studies was conducted using

Dissertation Abstracts International and included proceed-ings, dissertations, abstracts and reports.

An electronic search of Google and Google Scholar assearch engines for relevant conference proceedings, reportsand unpublished studies was also conducted in an attemptto identify further trials, although no additional studies werelocated by this approach.

Step threeThird, the reference list of all identified reports and articleswas searched for additional studies. Key journals which con-sistently appear in searches were hand-searched to capturerelevant research-based articles which fall outside theidentified search terms. In order to avoid publication bias,hand-searching was also undertaken in journals which arenot listed on databases but are known to contain works inour field of investigation. A search of the reference listsand bibliographies of all relevant articles was conducted tofind additional articles not found in the preceding searchstrategies.

The initial search of the above-mentioned electronic data-bases elicited 385 articles. These 385 articles were assessedby two reviewers for relevance to the review based on theinformation provided in the title and abstract using theinclusion/exclusion criteria. Articles identified as potentialinclusions were retrieved and then assessed for inclusionbased on the full text. The reference lists of all studiesdeemed to match the inclusion criteria were searched forany further possible inclusions.

Those studies that were of poor methodological quality ordid not meet the inclusion criteria were excluded from thereview. The identification of articles for inclusion and exclu-sion is outline in Figure 1. The included articles are presentedin Appendix I and the basis for the excluded articles isoutlined in Appendix II.

Methods of the review

Assessment of methodological qualityPapers selected for retrieval were assessed independently bytwo reviewers for methodological validity before inclusion inthe review using standardised critical appraisal instrumentsfrom the Joanna Briggs Institute Meta Analysis of StatisticsAssessment and Review Instrument (JBI-MAStARI).14 Descrip-tive papers of survey research and case-note audit selectedfor retrieval were assessed independently by two reviewersfor methodological validity before inclusion in the reviewusing the critical appraisal tool for observational studiesfrom JBI.14

Effective management of minor injuries 5


Where no comparative studies are identified, opinion andtext papers selected for retrieval were assessed by two inde-pendent reviewers for authenticity before inclusion in thereview. Any disagreements that arose between the reviewerswere resolved through discussion or with a third reviewer.

Data extractionData extraction of the eligible studies was undertaken inde-pendently by two reviewers using the data extraction toolsfrom JBI-MAStARI.14 Any disagreement was resolved by dis-cussion between the reviewers. The data extracted includedspecific details about the interventions, populations, studymethods and outcomes of significance to the review ques-tion and specific objectives.

Data synthesisTwo independent reviewers entered data. The findings/conclusions from descriptive studies were categorised andsynthesised. This involved the aggregation or synthesis offindings to generate a set of statements representing thataggregation, through assembling the findings (level 1 find-ings) with their quality, and categorising these findings onthe basis of similarity in meaning (level 2 findings).

These categories were then subjected to a metasynthesisin order to produce a single comprehensive set of synthe-

sised findings (level 3 findings) that can be used as a basis forevidence-based practice. Where textual pooling was notpossible the findings are presented in narrative form.14

Where possible, papers were pooled in statistical meta-analysis using the JBI-MAStARI.14 All data entered into JBI-MAStARI were subject to double data entry. Odds ratio (forcategorical data), weighted mean differences (for continu-ous data) and their 95% confidence intervals were calcu-lated for analysis. Heterogeneity was assessed using thestandard c2. Where statistical pooling was not possible, thefindings are presented in narrative form.

The included studies in this review were assessed for fea-sibility of meta-analyses of primary and secondary outcomes.As only one study was found on the primary outcome (thatof clinical effectiveness of emergency NP’s management ofadults with minor injuries), analysis was not possible.However, it was possible to extract data relating to thereduction of waiting time in the emergency department andpatients satisfaction with care received.

Two RCTs were identified that used care by junior doctorsas the measure of the comparison against ENP.15,16 Wherecount data were present, numbers needed to treat, relativerisk and 95% confidence intervals have been calculated inorder to provide a treatment effect.

A single study17 was identified that compared the clinicaland cost-effectiveness of ENP, but as this was the case meta-analysis was not possible. Therefore, the data from theincluded study have been combined in a narrative review.

Results

Description of studiesSelection of studiesOver 385 titles were identified from the search criteria. Ofthese, 55 were retrieved on the basis that the title and/orabstract appeared relevant to the review. Two independentreviewers individually assessed these articles against thereview criteria. Twenty retrieved articles were found to meetthe inclusion criteria. Of the 35 excluded, reasons for exclu-sion were as follows: 10 articles were not studies, 16 did notdescribe an intervention study, two articles did not meet theparticipant inclusion criteria, and seven were unclear in theirreporting. Of the studies retrieved only two were RCTs andthe remainder descriptive studies predominantly usingsurvey design.

InterventionsThe focus of reported interventions in the included studieswas the reduction in waiting times, referral to other practi-tioners or services, provision of medication, radiographs andother treatment, such as bandaging and suturing.

Patient satisfaction with treatment by an NP was reportedin few studies and is reported as an outcome. In one study,some participants reported they would have preferred to beseen by a medical officer.18 In all other studies, satisfactionwith NP services was reportedly over 70%.

Articles excluded not retrieved n=330

Articles that met all inclusion criteria n=20

Experimental studies included in review n=8

Descriptive studies included in the review n=12

Experimental studies n=5

Articles excluded n=35 10 not a study 16 no intervention 2 did not meet participant

inclusion criteria 7 unclear reporting

Descriptive studies for synthesis n=4

Descriptive studies excluded n=8

Experimental studies excluded n=3

Articles from search strategy n=385

Articles retrieved n=55

Figure 1 Flow chart for identification of papers included in a sys-tematic review of the clinical effectiveness of nurse practitioners’management of adults in an emergency department.

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Methodological quality of included studiesOf the 12 survey research and case-note studies criticallyappraised, four studies were included and eight studiesexcluded because of meeting less than 60% of the assess-ment criteria. No studies were able to fulfil all requirementsof the critical appraisal form. The four included studies wereable to meet more than 60% of assessment criteria.10,18–20

Of eight other quantitative studies critically appraised, onestudy was able to fulfil all requirements of the criticalappraisal form.15 Four studies were able to meet more than60% of requirements.2,16,17,21 Of the three excluded, twostudies were excluded after finding one did not have com-parable groups22 and another23 included paediatrics beingtreated by NP’s and junior doctors did not fit the inclusioncriteria. Additionally, Considine examined NP and theirspecific scope of practice only.24

Results of metasynthesis of the research findingsOther than the four survey and case-note studies,10,18–20 twostudies were RCTs.15,16 The remaining studies were a retro-spective case-series study,21 a satisfaction survey2 and abefore- and after-cohort study.17 The RCTs reported on theeffectiveness of the ENP in comparison with the role of thejunior medical officer in relation to length of stay, waitingtimes, follow-up and significant error. Results of the synthesisof the descriptive studies are presented below as narrativefindings. Results of the meta-analysis of the two RCT arereported separately.

Narrative findingsWaiting times. In examining waiting times, the study byJennings et al. was a retrospective case-series study thatclearly showed a significant reduction in waiting time andlength of stay for patients managed by the NP in comparisonwith the traditional medical model (TM) of care.21 Theoverall median waiting time for emergency patients to beseen by the ENP was less than the traditional model(junior doctors): ENP 12 min (5.5–28 min), TM 31 min(11.5–76 min) (P < 0.001).

This is supported by Byrne et al., who report that patientsmanaged through the traditional care pathways waited sig-nificantly longer to be seen than patients seen by the ENP(t177 = 43.23, P < 0.001).2

Length of stay. Length of stay was also significantlyreduced in patients managed by the ENP. Jennings et al.found median times for length of stay for those seen by theENP were 94 min (53.5–163.5 min) and for those seen in theTM 170 min (100–274 min) (P < 0.001).21 This is also sup-ported by Byrne et al., who reported that patients managedthrough the traditional model of care (managed by doctors)spent an average of 33 min longer than those managed bythe ENP (t177 = 19.94, P < 0.001).2

Patient satisfaction. Cooper et al.15 found from outcomesmeasured over a period of 2 months using patient satisfac-tion scores that patients overall were more satisfied with thetreatment and information provided by the ENP. The samefindings are confirmed by Byrne et al.2 who report that ENPsignificantly provide more health promotion and advice cor-relating with patient satisfaction support.

Meta-analysisFollow up. A meta-analysis was conducted for the twoRCT15,16 comparing care provided by ENP and junior doctors(Table 1; Fig. 2). The studies were shown to be homogenous(c2 = 2.63, P = 0.10.).

It was found that there was no significance differencebetween the two groups overall (Z = 0.87, P = 0.38), there-fore showing that the follow up provided by the ENP com-pared with the junior doctor was equal or just the same. In

Table 1 Summary of two randomised controlled trials comparingfollow up of patients managed by emergency department nursepractitioners (ENP) or managed in a minor injuries unit (MIU) withjunior doctors or patients managed in a traditional accident andemergency department (A&E). The table includes the number ofpatients (n) followed up in each group and the total (N) in eachgroup

Study ENP or MIU(follow up)

Junior doctors orA&E (follow up)

n N n N

Cooper et al. (2002)15 63 128 65 128Sakr et al. (1999)16 618 1315 391 1447

Cooper et al. (2002)

DerSimonian and Laird Relative Risk (Risk Ratio) Weight (confidence interval 95% random)

62.51% 0.97 (0.76, 1.24)

37.49% 0.61 (0.35, 1.04)

100.00% 0.81 (0.51, 1.30)

Favours ControlFavours Treatment 000

Heterogeneity χ2 = 2.63, P = 0.1055245

88.0

Sakr et al. (1999)

Overall

Overall Z = 0.87, P = 0.3898

Study

Figure 2 Forest plot of two randomised controlled trials comparing follow up of patients managed by emergency department nursepractitioners or managed in a minor injuries unit with junior doctors or patients managed in a traditional accident and emergency departmentfollow up.



Byrne et al.’s2 study, it found that patients seen by ENP hadreceived more printed information at discharge related tofollow up if required, as well as health advice than those seenin traditional models of care.

Significant error. A meta-analysis was conducted for thetwo RCTs15,16 comparing ENP and junior doctors (Table 2;Fig. 3). The studies were shown to be homogenous(c2 = 0.01, P = 0.92.).

It was found that there was no significant differencebetween the two groups overall (Z = 0.91, P = 0.36).

Metasynthesis of survey research and case-note auditstudies included in the review generated five synthesisedfindings. These synthesised findings were derived from 16study findings that were subsequently aggregated intoseven categories. The five synthesised findings are presentedbelow.

Effect on waiting times. Two studies reported that careprovided by ENP was effective in reducing waiting times fortreatment and overall length of stay in the emergencydepartment.10,20 In Wilson et al.’s study, 96.3% of presenta-tions triaged level 4, and 94.4% of those triaged level 5 wereseen within the time frame recommended by the Australa-sian Triage Scale.10 Patients’ acceptance of being treated byNP was high, and they considered ENP to be a good servicefor minor injuries and were happy to be offered appoint-

ments with them rather than waiting for long periods, espe-cially if it meant waiting all night.20

Scope of practice. In examining diagnostic interventionsprovided, one study found that 51% (n = 51) of patients didnot require any diagnostic treatment.10

Specific treatment provided by emergency NP included:• Pain relief20

• Radiographs: Meek et al. reported that of 49 majordepartments with official NP, 29 (59%) allowed them torequest certain radiographs. All were restricted to limbs,and in all situations there was a minimum age limit.19 Inanother study, 47% (n = 41) of patients required X-raysonly, and 2% (n = 2) required blood investigations inaddition to X-rays.10

• Prescribing: Of 49 major departments in a study by Meeket al., 40 (82%) allowed limited prescribing (dispens-ing).19 Of the 40, all could prescribe tetanus toxoid, 30allowed ‘over the counter’ medication, such as paraceta-mol, and nine allowed ‘prescription only’ items, such asoral antibiotics.19

• Referrals: Incidental data were recorded by Megahy andLloyd as they became apparent during their study.18 Theyincluded the number of X-rays taken, the number ofpositive fractures, the amount of orthopaedic referrals afterX-ray and the number of referrals to the accident andemergency clinic. Referral was found to be appropriateafter accurate diagnosis by the ENP. Their report concludedthat ENP with appropriate training managed minor injuriesappropriately and effectively. Wilson et al. found thatpatients were referred to consultants within the hospital,outpatient clinics and general practitioner for follow up.10

However, 20% of patients did not require referral.Additional procedures reportedly carried out by ENP

included suturing and suture removal, plaster cast applica-tion, dressings, ice-compress and incision and drainage.10

Restrictions to practice. Several papers reported that theENP positions were ‘unofficial’ and that other professionalgroups restricted NP activities.19 Investigating prevalence ofthe role, Meek et al. found that in 202 replies from majordepartments, 60 (30%) used NP. Of the 60, 49 (82%)were ‘official’ NP, and11 were ‘unofficial.’19 Of 140 minor

Cooper et al. (2002)

DerSimonian and Laird Relative Risk (Risk Ratio) Weight (confidence interval 95% random)

1.25% 1.01 (0.06, 15.93)

98.75% 0.86 (0.63, 1.18)

100.00% 0.87 (0.64, 1.18)

Favours ControlFavours Treatment 000

Heterogeneity χ2 = 0.01, P = 0.9203443

88.0

Sakr et al. (1999)

Overall

Overall Z = 0.91, P = 0.3628

Study

Figure 3 Forest plot of significant error in care for patients managed by emergency department nurse practitioners or managed in a minorinjuries unit with junior doctors or patients managed in a traditional accident and emergency department.

Table 2 Summary of two randomised controlled trials comparingsignificant error in care for patients managed by emergency depart-ment nurse practitioners (ENP) or managed in a minor injuries unit(MIU) with junior doctors or patients managed in a traditionalaccident and emergency department (A&E). The table includes thenumber of patients (n) with significant error in each group and thetotal (N) in each group

Study ENP or MIU(significant error)

Junior doctors orA&E (significant error)

n N n N

Cooper et al. (2002)15 1 99 1.00 100Sakr et al. (1999)16 126 1315 191 1447

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departments which responded, 89 (64%) used NP of which15 (17%) were officially recognised as NP. Major depart-ments were those with 24-h medical cover and receivingambulance trauma cases. All other departments were con-sidered minor.

Meek et al. reported that the NP could prescribe a limitedrange of drugs in 82% of major departments with ‘official’NP, but radiograph requesting was permitted in only 57% ofsuch departments: of those not able to request radiographs,95% blamed radiographers for preventing this.19

One study examining 60 major departments to determinethe professional groups and activities reported to restrict NPactivities the most found that radiographers (n = 31, 52%),legal considerations (n = 14, 23%), doctors in accident andemergency department (A&E) (n = 6, 10%), hospital or trustmanagement practices (n = 4, 6.7%), nurses in A&E (n = 1,1.7%) and other unspecified factors (n = 6, 10%) contrib-uted to restrictions.19 Interestingly, patients were not foundto restrict ENP practice at all.

Satisfaction with care received. Patient satisfaction withthe care received and acceptance of being treated by NPwas generally high in all the studies reporting on thisoutcome.10,18–20 Wilson et al. found patients were pleasedwith the ENP caring attitude, the intent of their listening,kindness, support shown and friendliness. Two studies foundENP to be friendly, understanding, attentive and providehelpful advice.10,20 One study found that over 80% attendingwith minor injuries were happy to be seen by an NP only.19

Another reported patients would use the service again.20

All respondents (n = 151, 83%) to 181 questionnaires inone of the studies agreed that NP introduced themselvesclearly and that they were happy with their treatment andhappy to be seen by an NP again, were given helpful advice,were satisfied with the care received from the NP, and woulduse the service again.18,20 The perception was that staff werehappy, helpful and friendly. In Megahy and Lloyd’s study, sixpeople (4%) commented they would prefer to see a doctor.18

Patients’ confidence in the ENP ability to treat them was highin one of the studies.10 Results showed 84.2% had no doubts,5.3% had some doubts, and 10.5% were uncertain.

Representation within 48 h. One of the studies includedrepresentation within 48 h after the visit with the NP as anoutcome.10 Out of 100 patients, it was noted that six (6%)had revisited within 48 h of their initial treatment.10

Cost-effectiveness. In a prospective study comparing theclinical effectiveness and costs of minor injury services pro-vided by NP, Sakr et al.17 used routine data collected pro-spectively and configured to assess the costs and costconsequences of both models of care. They found therevenue costs were slightly greater in the minor injuries unit(MIU) (£41.10) compared with the A&E (£40.01). With ahigher rate of referral by the ENP, the authors concluded thatthe costs and consequences were greater for MIU cases(£12.7 per minor injury case) compared with A&E depart-ment (£9.66 per minor injury case).

In contrast, Wilson et al. compared patient pathways afterthe implementation of ENP.10 Although the study did notseek to show cost-effectiveness, mapping of patient path-ways showed a greater number of steps and personnelinvolved in the traditional medical assessment.

Discussion

Quality of included studiesThe overall quality of the included studies appears to begenerally low based on the JBI critical appraisal forms. This isbecause the review included study designs other than RCT,which reduced the number of studies that were randomisedand blinded. However, the aim of the review was to identifyhow effective within emergency departments in the hospitalNP could be and if only RCT were included the review wouldonly include comparisons with medical officers. The justifi-cation of including non-RCT was based on developing amore comprehensive understanding of the effectiveness ofNP treating minor injuries.

The overall quality of the included studies was alsoaffected by very few of the included studies comparing likegroups in both characteristics and interventions. This couldbe because in reality only very large and funded studiescould accomplish this. In a field that is hungry for knowledgeand investigation, it is not uncommon for descriptive studiesto dominate. In addition, the differences in role betweencountries of NP do not lend easily to reviews includinginternational works.

Effectiveness of emergency NP managingminor injuriesBased on evidence from nine studies included in this system-atic review, there is no significant difference between theeffectiveness of ENP and junior doctors. There were no com-parative studies between ENP and other health professionalsin the management of minor injuries that could be included.A study comparing ENP with physiotherapists and doctorsdid not meet the inclusion criteria.22 Therefore, this conclu-sion must be interpreted with caution because of the poor tofair methodological study designs used and variable types ofoutcome measures used.

Anecdotally, there does appear to be a significance in thereduction of waiting times for patients to be assessed,waiting times for treatment and overall length of stay times,consequently improving the flow of patients through emer-gency departments.

Reducing the amount of medical officer time spent onspecified presentations logically has an effect in improvingpatient access to interventions, reducing issues of emer-gency department overcrowding and improving patientsatisfaction with health services.

Restrictions to ENP practice were not reported in morecurrent studies, the reason for this being unclear. It is pos-sible that as the roles have become more established andfamiliar organisations and other health professionals aremore comfortable with the nurses’ extended role.



Limitations of the reviewThe results of this systematic review have been restricted bymultiple factors.

Terminology pertaining to NP and their incumbent roles isambiguous. NP have been active in the USA for over20 years and similarly in the UK, whereas their introductionin Australia is only recent. Commonly, the major character-istic of the role is for the provision of advanced emergencypractice. However, there is a lack of clarity in the works as towhat this entails, the terminology used and the formalappointment and qualifications required to fulfil the role.Whereas every endeavour was made to optimise inclusivity,the heterogeneity made selection of works and comparativeanalysis and synthesis of the data challenging. This issue hasbeen reiterated in a systematic review of the NP role inprimary care.6

Terminology pertaining to the roles within the emergencydepartment and the category of patients reviewed is alsoproblematic. The aim of this review was to investigate therole of the NP in the management of ‘minor injuries’ withinthe emergency department setting. Because of differingtriage scoring systems and diagnostic categories used inemergency departments internationally, collating compa-rable data were again difficult. Even with interventionsgrouped into subcategories, there were still dissimilaritiesamong interventions including how interventions areadministered, recorded and examined. A broad search strat-egy and terms based on a review of known works endeav-oured to address this issue.

The stipulation for inclusion in the review that practicemust only pertain to the treatment of adults in the emer-gency department might be perceived as another limitationof the review. A large case–control study23 found that therewas no difference in median waiting times, treatment timesand length of stay in the emergency department betweenemergency NP care and patients managed by traditionalprocesses. This study might have influenced the overall find-ings of the review; however, the study included children andwas therefore excluded. Similarly, a study by Ball et al. wasexcluded for including children in one of the comparisongroups.22

Horrocks, Anderson and Salisbury identified that the lackof recent RCTs and high-quality observational studiesrestricted their review.6 Our review was also significantlylimited by the lack of large rigorous, carefully designedstudies which evaluated the effectiveness of the NP role.Whereas focus was given to the included RCTs, the data fromobservational and interpretive studies were also included asthese particularly focussed on patient satisfaction, a keyoutcome for investigation. Rigorous and comprehensiveevaluation is pivotal for the development of the NP role inthe emergency department and a body of knowledge whichinforms policy and practice.

Economic analysis of the cost of implementing an NPservice in comparison with standard emergency departmenttreatment was unable to be formally conducted because ofthere being only one study available for inclusion. This is anarea for future research focus as the impetus for implemen-

tation of many NP run minor injuries clinics in the emer-gency department is a reduction of cost. Justification of thisis important if endorsement of the role within the healthsector is to continue.

Conclusion

This systematic review showed that there is no statisticallysignificant difference between the effectiveness of care byENP and junior doctors. Furthermore, no significant differ-ence was evident when various interventions used in theincluded studies were separately compared between TM andemergency NP. It would appear that ENP are effective inreducing patients’ waiting time and length of stay in emer-gency departments and that patients are satisfied with thecare they received. Although some of the studies includedin this review have methodological weaknesses, we haveincluded them as they do provide useful and interestinginformation for clinicians and managers looking at optionsfor improving service delivery.

Implications for practiceThe number of limited quality studies comparing the effec-tiveness of ENP managing minor injury presentations makesit difficult to draw conclusions regarding the most effectivemanagement strategies. The findings of the present reviewsupport the use of NP for the management and treatment ofminor injuries in adults. The results also confirm that imple-menting care by NP can reduce waiting times in the emer-gency department and therefore alleviate complications thatarise from people becoming agitated from waiting for treat-ment. Of importance is that those of greater need are morelikely to be seen by a medical practitioner earlier. The prioritytherefore remains for healthcare to find effective ways ofimproving patient outcomes. Finally, the review emphasisesthe need to ensure in both practice and research that effec-tive nursing practice is implemented.

Implications for researchThe results of the systematic review emphasise the need formore research to assess the effectiveness of interventionsaimed at effective healthcare in emergency departments andin particular that by nurses. Management of minor injuries ispotentially an area where effectiveness both in costs andhealth delivery remains unclear. Research should be of thehighest-quality practicable and explore useful outcomes,such as time saving, minimisation of health personnel andreduction in stress for staff. This will allow for more detailedunderstanding of the feasibility, cost and efficacy of particu-lar interventions.

Acknowledgements

We would like to thank Dr Tim Schultz and Dr Rick Wiechulafor assistance with conducting the systematic reviewprocess.

10 A Wilson et al.


Conflict of interest

The impetus for this review arose from a grant received bythe first author to conduct an evaluation of the RoyalAdelaide Hospital Emergency Department Nurse PractitionerInitiative.

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urban emergency department. J Emerg Nurs 1998; 24: 234–9.2. Byrne G, Richardson M, Brunsdon J, Patel A. An evaluation of

the care of patients with minor injuries in emergency settings.Accid Emerg Nurs 2000; 8: 101–9.

3. Cole FL, Ramirez E, Mickanin J. ED nurse practitioners’ employ-ment by a physician group versus hospital: pros and cons. JEmerg Nurs 1999; 25: 183–6.

4. Driscoll A, Worrall-Carter L, O’Reilly J, Stewart S. A historicalreview of the nurse practitioner role in Australia. Clin Excell NursePract 2005; 9: 141–52.

5. American Academy of Nurse Practitioners. Position Statementon the Quality of Nurse Practitioner Practice. 2007. Available at:http://www.aanp.org

6. Horrocks S, Anderson E, Salisbury C. Systematic review ofwhether nurse practitioners working in primary care canprovide equivalent care to doctors. BMJ 2002; 324: 819–23.

7. Cole FL, Kleinpell R. Expanding acute care nurse practitionerpractice: focus on emergency department practice. J Am AcadNurse Pract 2006; 18: 187–9.

8. Department of Human Services. Nurse practitioner projectreport (South Australia – Nu Prac Project). Project Report. Ade-laide, SA: Department of Human Services, 1999.

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11. Nash K, Zachariah B, Nitschmann J, Psencik B. Evaluation of thefast track unit of a university emergency department. J EmergNurs 2007; 33: 14–20.

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13. American Academy of Nurse Practitioners. Position StatementNurse Practitioner Cost-Effectiveness. 2007. Available at: http://www.aanp.org

14. Pearson A, Porritt KA, Doran D et al. A comprehensive system-atic review of evidence on the structure, process, characteristicsand composition of a nursing team that fosters a healthy workenvironment. Int J Evid Based Healthc 2006; 4: 118–59.

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http://www.aanp.org

http://www.aanp.org

http://www.aanp.org

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Appendix II – Excluded Studies

Descriptive StudiesMarr S, Steele K, Swallow V, Craggs S, Procter S, Newton J, Sen B,

McNabb A. Mapping the range and scope of emergency nursepractitioner services in the Northern and Yorkshire Region: atelephone survey.

Reason for Exclusion: Doesn’t address the effect on patientoutcomes of nurse practitioner services.

Meite S, Moser MS, Riyad BA, van Beek CA. Attitude of EmergencyDepartment Patients with Minor Problems to being Treated bya Nurse Practitioner.

Reason for Exclusion: Survey of opinion- they had a hypotheti-cal willingness to be treated. But none were actually treated bynurse practitioners.

Mills AC, McSweeney M. Primary Reasons for Emergency Depart-ment Visits and Procedures Performed for Patients who sawNurse practitioners.

Reason for Exclusion: identifies presenting complaints – ascoping study of types of injuries seen by nurse practitioners.

Norris T, Melby V. The Acute Care Nurse practitioner: challengingexisting boundaries of emergency nurses in the UnitedKingdom.

Reason for Exclusion: Opinion study only.Read S, Jones NMB, Williams BT. Nurse practitioners in Accident and

Emergency Departments: what do they do?Reason for Exclusion: Comparative study of nurse practitioners

and MDs over 2 days in an emergency department-noeffectiveness.

Rhee KJ, Dermyer AL. Patient satisfaction with a nurse practitioner ina university emergency service.

Reason for Exclusion: Minimal reporting on the data and howconclusions were reached; low level analysis.

Sheahan SL. Documentation of Health Risks and Health PromotionCounseling by Emergency Department Nurse practitioners andPhysicians.

Reason for Exclusion: Does not meet our review question/objectives – focuses on identification of health risks and healthpromotion counselling by emergency department nurse prac-titioner.

Wright, Erwin, Blanton & Covington, Fast Track in the EmergencyDepartment: A one-year experience with nurse practitioners.

Reason for Exclusion: Poor research design. Conclusions inad-equately supported.

Experimental StudiesBall, STE, Walton, K and Hawes, S. Do emergency department

physiotherapy practitioners, emergency nurse practitioners,and doctors investigate, treat and refer patients with closedmusculoskeletal injuries differently?

Reason for Exclusion: Focused on the role of the physiotherapypractitioner in comparison with the emergency nurse practitio-ner and the medical officer.

Considine, J., R. Martin, et al. Emergency nurse practitioner care andemergency department patient flow: case-control study.

Reason for Exclusion: Paediatric inclusion and the study was areview of the new role of nurse practitioners rather than aeffectiveness study.

Considine, J., R. Martin, et al. Defining the scope of practice of theemergency nurse practitioner role in a metropolitan emergencydepartment.

Reason for Exclusion: Did not fit inclusion criteria.

14 A Wilson et al.


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