Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
MAJOR TRAUMA TRAINING FOR EMERGENCY NURSES Rob Fenwick discusses a study of trauma education provision among nursing staff in three types of service in the Midlands Correspondence [email protected] Rob Fenwick is a charge nurse in the emergency department of the Princess Royal Hospital, Telford, Shropshire Date submitted December 17 2013 Date accepted February 11 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract The Midlands regional trauma network was established in March 2012 to improve and standardise the care offered to patients with major trauma. This article discusses the results of a survey of formal training in, and self-assessed knowledge of, trauma management among emergency department nurses working in the network. Less than one third of the nurses had received formal training against which standards can be benchmarked, and the article recommends that nurse education standards are reinstated as key performance indicators in the region. Keywords Trauma, training provision, key performance indicators IN MARCH 2012, the Midlands regional trauma network (RTN) was established to improve and standardise the care offered to major trauma patients in the region. Anticipated benefits included reductions in mortality and disability rates, more equal access, more effective educational programmes for clinicians, and better communication between different hospitals, disciplines and professionals (Intercollegiate Group on Trauma Standards (IGTS) 2009). Services in the region that previously received major trauma patients were designated as either: ■■ Major trauma centres (MTCs), in which consultant-led teams representing all specialties provide a tertiary service for the most ill polytrauma patients 24 hours a day. These
12 April 2014 | Volume 22 | Number 1
centres typically serve populations of more than two million (NHS England 2013). ■■ Trauma units (TUs), which provide life-saving assessment and interventions, and some surgical procedures, 24 hours a day. These units also receive patients who are more than 45 minutes primary transfer distance from an MTC (NHS England 2013). ■■ Local emergency hospitals (LEHs), in which patients who are too ill to go to MTCs or TUs, usually because they have time-critical airway, breathing or circulation problems, are received. These hospitals also receive patients who selfpresent or whose injuries have not been fully identified by pre-hospital care professionals. Medical staff in Midlands RTN are required in line with their key performance indicators (KPIs) to undertake an Advanced Trauma Life Support (ATLS) course or a European Trauma Course (ETC). However, there are no KPIs to ensure a single standard of emergency nurse education and, in the Midlands region, nurses may undertake the Advanced Trauma Nursing Course (ATNC), Trauma Nursing Core Course (TNCC), ATLS observer course or the ETC. The author therefore undertook a survey to establish what kind of formal training Midlands trauma nurses receive, how this training varies by nurses’ hospital designation and how nurses assess their knowledge of major trauma management.
Survey Development Between November 2012 and April 2013, the RTN emailed links to an online EMERGENCY NURSE
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Art & science | nurse training Figure 1 Midlands emergency department nursing staff who have and have not received trauma training n=77
25 (32%) 52 (68%)
Received training Received no training questionnaire to emergency nurses in all 19 hospitals in the Midlands region. To publicise the survey, the author distributed posters to emergency departments (EDs) in the network and asked senior staff, such as department managers and practice development staff, to encourage their teams to take part. In addition, a news article with the web link was published in the April 2013 issue of Emergency Nurse. Participants were asked to record: ■■ The designation of the hospital in which they worked: MTC, TU or LEH. ■■ Their band. ■■ The formal trauma courses they had completed: ATNC, TNCC, ATLS observer or ETC. ■■ Whether their qualifications were up to date. ■■ How many major trauma patients they had cared for in the past 12 months. ■■ Their self-assessed knowledge of major trauma care using a Likert scale numbered from 1 to 10, in which a score of 1 indicates poor knowledge and 10 indicates excellent knowledge. Results A total of 77 ED nurses from 11 of the 19 hospitals contacted returned completed questionnaires. Of these, 32 were from two MTCs, 23 from seven TUs and 22 from two LEHs. The number of respondents from each site ranged between 1 and 24. Twenty five (32%) respondents had up-to-date formal trauma training (Figure 1). Of these, two (8%) had completed only the ATNC, three (12%) only ETC, nine (36%) only TNCC, ten (40%) only the ATLS observer course, and one (4%) had completed TNCC 14 April 2014 | Volume 22 | Number 1
and ATLS observer (Figure 2). Staff who worked in TUs were most likely to have received such training, with ten (43%) of the 23 respondents stating that they had done so. Thirteen (41%) of the 32 nurses from MTCs, but only two (9%) of those from LEHs, were similarly trained (Figure 3). Nurses’ self-assessments of major trauma knowledge produced mean scores of 6.92, 7.39 and 5.45 for MTC, TU and LEH respectively (Table 1). Discussion There have been no studies examining whether trauma education reduces mortality or morbidity among people who have experienced major trauma, but such education has been shown to improve clinicians’ knowledge about immediate emergency response and treatments (Jayaraman and Sethi 2009). Lack of evidence of an effect is not evidence of no effect, however, and education provision remains essential for ED staff who work with patients with major traumatic injuries. This survey demonstrates that major trauma training provision for emergency nurses in the Midlands RTN is inconsistent. Less than one third of respondents had up-to-date training, which is provided by four different courses. Most respondents who have received training work in either MTCs or TUs, and less than one in ten who work in LEHs have received training. Nurses in MTCs and TUs see more patients with major trauma, and receive more formal training, Figure 2 Study participants who have received different types of trauma training 1 (4%)
n=25 2 (8%)
3 (12%)
10 (40%) 9 (36%)
Advanced Trauma Nursing Course European Trauma Course Trauma Nursing Core Course (TNCC) Advanced Trauma Life Support (ATLS) observer TNCC and ATLS observer
EMERGENCY NURSE
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Figure 3 Proportion of study participants with up-to-date training by service designation 100 90 80 -
Local emergency hospital Major trauma centre Trauma unit
Percentage
70 60 50 40 30 20 10 0 Service designation
than their LEH colleagues, and this difference is reflected in the self-assessments of knowledge of trauma management. The study results do not demonstrate whether patient outcomes or experiences depend on the extent of nurses’ knowledge, nor whether this knowledge depends most on nurses’ training, experience or both. However, they do indicate that there is a need to improve nurses’ knowledge of trauma management. With the implementation of RTNs, this need to improve emergency nurses’ knowledge creates an interesting question: should more training be provided to staff who see major trauma patients frequently or to those who see such patients infrequently? No definitive answer to this question can be gleaned from the literature because the optimal level of training for emergency nurses in major trauma has yet to be determined. However, it has been Table 1
found that nurses who attend ATLS observer courses rarely develop the skills they require (Baird et al 2004) and that those who attend formal courses, such as ATNC, tend to lose their skills rapidly, often within six months of course completion (Tippett 2004). Skill loss is not unique to nurses attending training courses, although the rate of decline may be influenced by the nurses’ professional backgrounds and how much they practise the skills they have acquired (Carley and Driscoll 2001). These findings suggest that emergency nurses who work in units where fewer major trauma patients are managed, such as LEHs, require different education provision from those who work in MTCs or TUs. One way to reverse skill loss is to second staff from low- to high-volume units and thereby ensure they have additional clinical exposure (Barleycorn 2013), although this idea may be unattractive to staff in the Midlands where there is a considerable distance between such units. Seven years ago, Patient (2007) recommended the implementation of a standardised, one-day trauma training course for emergency nurses in the UK. However, until the idea that all emergency nurses should be trained in the same way has been accepted across the region, provision of such a course is unlikely. According to Barleycorn (2013), barriers to the provision of courses include: ■■ Their high cost. ■■ A lack of resources. ■■ A tendency to pitch courses too high, at the expense of less experienced nurses. ■■ A lack of study leave. ■■ The unavailability of instructors. ■■ A perception that there is little need for specialist training.
Study participants’ assessments of their own experience, training and knowledge Hospital designation Major trauma centre
Number of respondents Median number of major trauma cases attended over the past 12 months Percentage of staff whose training is up to date Mean self-assessed knowledge score between 1 and 10*
Trauma unit
Local emergency hospital
32
23
22
9
9
4
41
43
9
6.92
7.39
5.45
* Where 1 = poor knowledge and 10 = excellent knowledge
EMERGENCY NURSE
April 2014 | Volume 22 | Number 1 15
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Art & science | nurse training Several of these barriers could be overcome if RTNs’ KPIs required a specific standard of education and training from nurses in those regions. Such a requirement would highlight the importance of trauma care, and would encourage trusts to release staff for the relevant education and training. When the commissioning of services was considered in 2009, the IGTS (2009) suggested a series of KPIs for RTNs, including one that required all nursing staff in EDs to complete a minimum of the ATNC or TNCC. It is unclear why this requirement was removed from more recent indicators for the Midlands RTN, when minimum requirements for medical education are unchanged from those in the IGTS (2009) document. In considering the training requirements of emergency nurses, a comparison can be drawn between the provision of adult life support training, which involves statutory annual updates, and major trauma training, which does not. In light of the finding that skills can be lost over six months (Tippett 2004), there is a clear need for regular, supplementary education, for example involving simulations or scenarios, particularly for staff in units where fewer major trauma patients are managed. The NHS Clinical Advisory Group on Major Trauma Workforce (2011) and Barleycorn (2013) state that national trauma education programmes for emergency nurses must be examined, and
the appropriate training frameworks should be developed, to ensure that patients receive standardised care wherever they present. Limitations The survey under discussion has several limitations. First, the data are applicable only for the collection dates. Since the survey was conducted, more staff in the Midlands RTN have received trauma training, although the training of others may now be out of date. Second, self-assessments of knowledge do not necessarily reflect ability and an accurate evaluation of competence would require an assessment of each nurse’s performance by independent researchers (Davies et al 2006). Third, the small sample size of the study may limit the applicability of its results.
Conclusion Trauma care is a high impact and high frequency intervention. Modern trauma networks have been established to provide optimal treatment for patients with multiple injuries, but this small self-reported survey in one region suggests that less than one third of ED nurses had up-to-date training against which standards can be benchmarked. Further examination of training requirements is urgently required, therefore, and RTNs should consider the introduction of nurse education standards as part of their KPIs.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Baird C, Kernohan G, Coates V (2004) Outcome of advanced trauma life support training: questioning the role of observer. Accident and Emergency Nursing. 12, 3, 131-135. Barleycorn D (2013) Trauma nursing development in England: insight from South Africa. International Emergency Nursing. 21, 3, 190-193. Carley S, Driscoll P (2001) Trauma education. Resuscitation. 48, 1, 47-56.
16 April 2014 | Volume 22 | Number 1
Davies D, Mazmanian P, Fordis M et al (2006) Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Journal of the American Medical Association. 296, 9, 1094-1102. Intercollegiate Group on Trauma Standards (2009) Regional Trauma Systems: Interim Guidance for Commissioners. Royal College of Surgeons of England, London.
Jayaraman S, Sethi D (2009) Advanced trauma life support training for hospital staff. Cochrane Database of Systematic Reviews. 2. doi: 10.1002/14651858.CD004173.pub3 NHS Clinical Advisory Group on Major Trauma Workforce (2011) Regional Trauma Networks. Centre for Workforce Development, London.
NHS England (2013) NHS Standard Contract for Major Trauma: All Ages. tinyurl.com/olzshpn (Last accessed: March 11 2014.) Patient L (2007) Trauma training: a literature review. Emergency Nurse. 15, 7, 28-37. Tippett J (2004) Nurses’ acquisition and retention of knowledge after trauma training. Accident and Emergency Nursing. 12, 1, 39-46.
EMERGENCY NURSE
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The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
MAJOR TRAUMA TRAINING FOR EMERGENCY NURSES Rob Fenwick discusses a study of trauma education provision among nursing staff in three types of service in the Midlands Correspondence [email protected] Rob Fenwick is a charge nurse in the emergency department of the Princess Royal Hospital, Telford, Shropshire Date submitted December 17 2013 Date accepted February 11 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract The Midlands regional trauma network was established in March 2012 to improve and standardise the care offered to patients with major trauma. This article discusses the results of a survey of formal training in, and self-assessed knowledge of, trauma management among emergency department nurses working in the network. Less than one third of the nurses had received formal training against which standards can be benchmarked, and the article recommends that nurse education standards are reinstated as key performance indicators in the region. Keywords Trauma, training provision, key performance indicators IN MARCH 2012, the Midlands regional trauma network (RTN) was established to improve and standardise the care offered to major trauma patients in the region. Anticipated benefits included reductions in mortality and disability rates, more equal access, more effective educational programmes for clinicians, and better communication between different hospitals, disciplines and professionals (Intercollegiate Group on Trauma Standards (IGTS) 2009). Services in the region that previously received major trauma patients were designated as either: ■■ Major trauma centres (MTCs), in which consultant-led teams representing all specialties provide a tertiary service for the most ill polytrauma patients 24 hours a day. These
12 April 2014 | Volume 22 | Number 1
centres typically serve populations of more than two million (NHS England 2013). ■■ Trauma units (TUs), which provide life-saving assessment and interventions, and some surgical procedures, 24 hours a day. These units also receive patients who are more than 45 minutes primary transfer distance from an MTC (NHS England 2013). ■■ Local emergency hospitals (LEHs), in which patients who are too ill to go to MTCs or TUs, usually because they have time-critical airway, breathing or circulation problems, are received. These hospitals also receive patients who selfpresent or whose injuries have not been fully identified by pre-hospital care professionals. Medical staff in Midlands RTN are required in line with their key performance indicators (KPIs) to undertake an Advanced Trauma Life Support (ATLS) course or a European Trauma Course (ETC). However, there are no KPIs to ensure a single standard of emergency nurse education and, in the Midlands region, nurses may undertake the Advanced Trauma Nursing Course (ATNC), Trauma Nursing Core Course (TNCC), ATLS observer course or the ETC. The author therefore undertook a survey to establish what kind of formal training Midlands trauma nurses receive, how this training varies by nurses’ hospital designation and how nurses assess their knowledge of major trauma management.
Survey Development Between November 2012 and April 2013, the RTN emailed links to an online EMERGENCY NURSE
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Art & science | nurse training Figure 1 Midlands emergency department nursing staff who have and have not received trauma training n=77
25 (32%) 52 (68%)
Received training Received no training questionnaire to emergency nurses in all 19 hospitals in the Midlands region. To publicise the survey, the author distributed posters to emergency departments (EDs) in the network and asked senior staff, such as department managers and practice development staff, to encourage their teams to take part. In addition, a news article with the web link was published in the April 2013 issue of Emergency Nurse. Participants were asked to record: ■■ The designation of the hospital in which they worked: MTC, TU or LEH. ■■ Their band. ■■ The formal trauma courses they had completed: ATNC, TNCC, ATLS observer or ETC. ■■ Whether their qualifications were up to date. ■■ How many major trauma patients they had cared for in the past 12 months. ■■ Their self-assessed knowledge of major trauma care using a Likert scale numbered from 1 to 10, in which a score of 1 indicates poor knowledge and 10 indicates excellent knowledge. Results A total of 77 ED nurses from 11 of the 19 hospitals contacted returned completed questionnaires. Of these, 32 were from two MTCs, 23 from seven TUs and 22 from two LEHs. The number of respondents from each site ranged between 1 and 24. Twenty five (32%) respondents had up-to-date formal trauma training (Figure 1). Of these, two (8%) had completed only the ATNC, three (12%) only ETC, nine (36%) only TNCC, ten (40%) only the ATLS observer course, and one (4%) had completed TNCC 14 April 2014 | Volume 22 | Number 1
and ATLS observer (Figure 2). Staff who worked in TUs were most likely to have received such training, with ten (43%) of the 23 respondents stating that they had done so. Thirteen (41%) of the 32 nurses from MTCs, but only two (9%) of those from LEHs, were similarly trained (Figure 3). Nurses’ self-assessments of major trauma knowledge produced mean scores of 6.92, 7.39 and 5.45 for MTC, TU and LEH respectively (Table 1). Discussion There have been no studies examining whether trauma education reduces mortality or morbidity among people who have experienced major trauma, but such education has been shown to improve clinicians’ knowledge about immediate emergency response and treatments (Jayaraman and Sethi 2009). Lack of evidence of an effect is not evidence of no effect, however, and education provision remains essential for ED staff who work with patients with major traumatic injuries. This survey demonstrates that major trauma training provision for emergency nurses in the Midlands RTN is inconsistent. Less than one third of respondents had up-to-date training, which is provided by four different courses. Most respondents who have received training work in either MTCs or TUs, and less than one in ten who work in LEHs have received training. Nurses in MTCs and TUs see more patients with major trauma, and receive more formal training, Figure 2 Study participants who have received different types of trauma training 1 (4%)
n=25 2 (8%)
3 (12%)
10 (40%) 9 (36%)
Advanced Trauma Nursing Course European Trauma Course Trauma Nursing Core Course (TNCC) Advanced Trauma Life Support (ATLS) observer TNCC and ATLS observer
EMERGENCY NURSE
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Figure 3 Proportion of study participants with up-to-date training by service designation 100 90 80 -
Local emergency hospital Major trauma centre Trauma unit
Percentage
70 60 50 40 30 20 10 0 Service designation
than their LEH colleagues, and this difference is reflected in the self-assessments of knowledge of trauma management. The study results do not demonstrate whether patient outcomes or experiences depend on the extent of nurses’ knowledge, nor whether this knowledge depends most on nurses’ training, experience or both. However, they do indicate that there is a need to improve nurses’ knowledge of trauma management. With the implementation of RTNs, this need to improve emergency nurses’ knowledge creates an interesting question: should more training be provided to staff who see major trauma patients frequently or to those who see such patients infrequently? No definitive answer to this question can be gleaned from the literature because the optimal level of training for emergency nurses in major trauma has yet to be determined. However, it has been Table 1
found that nurses who attend ATLS observer courses rarely develop the skills they require (Baird et al 2004) and that those who attend formal courses, such as ATNC, tend to lose their skills rapidly, often within six months of course completion (Tippett 2004). Skill loss is not unique to nurses attending training courses, although the rate of decline may be influenced by the nurses’ professional backgrounds and how much they practise the skills they have acquired (Carley and Driscoll 2001). These findings suggest that emergency nurses who work in units where fewer major trauma patients are managed, such as LEHs, require different education provision from those who work in MTCs or TUs. One way to reverse skill loss is to second staff from low- to high-volume units and thereby ensure they have additional clinical exposure (Barleycorn 2013), although this idea may be unattractive to staff in the Midlands where there is a considerable distance between such units. Seven years ago, Patient (2007) recommended the implementation of a standardised, one-day trauma training course for emergency nurses in the UK. However, until the idea that all emergency nurses should be trained in the same way has been accepted across the region, provision of such a course is unlikely. According to Barleycorn (2013), barriers to the provision of courses include: ■■ Their high cost. ■■ A lack of resources. ■■ A tendency to pitch courses too high, at the expense of less experienced nurses. ■■ A lack of study leave. ■■ The unavailability of instructors. ■■ A perception that there is little need for specialist training.
Study participants’ assessments of their own experience, training and knowledge Hospital designation Major trauma centre
Number of respondents Median number of major trauma cases attended over the past 12 months Percentage of staff whose training is up to date Mean self-assessed knowledge score between 1 and 10*
Trauma unit
Local emergency hospital
32
23
22
9
9
4
41
43
9
6.92
7.39
5.45
* Where 1 = poor knowledge and 10 = excellent knowledge
EMERGENCY NURSE
April 2014 | Volume 22 | Number 1 15
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Art & science | nurse training Several of these barriers could be overcome if RTNs’ KPIs required a specific standard of education and training from nurses in those regions. Such a requirement would highlight the importance of trauma care, and would encourage trusts to release staff for the relevant education and training. When the commissioning of services was considered in 2009, the IGTS (2009) suggested a series of KPIs for RTNs, including one that required all nursing staff in EDs to complete a minimum of the ATNC or TNCC. It is unclear why this requirement was removed from more recent indicators for the Midlands RTN, when minimum requirements for medical education are unchanged from those in the IGTS (2009) document. In considering the training requirements of emergency nurses, a comparison can be drawn between the provision of adult life support training, which involves statutory annual updates, and major trauma training, which does not. In light of the finding that skills can be lost over six months (Tippett 2004), there is a clear need for regular, supplementary education, for example involving simulations or scenarios, particularly for staff in units where fewer major trauma patients are managed. The NHS Clinical Advisory Group on Major Trauma Workforce (2011) and Barleycorn (2013) state that national trauma education programmes for emergency nurses must be examined, and
the appropriate training frameworks should be developed, to ensure that patients receive standardised care wherever they present. Limitations The survey under discussion has several limitations. First, the data are applicable only for the collection dates. Since the survey was conducted, more staff in the Midlands RTN have received trauma training, although the training of others may now be out of date. Second, self-assessments of knowledge do not necessarily reflect ability and an accurate evaluation of competence would require an assessment of each nurse’s performance by independent researchers (Davies et al 2006). Third, the small sample size of the study may limit the applicability of its results.
Conclusion Trauma care is a high impact and high frequency intervention. Modern trauma networks have been established to provide optimal treatment for patients with multiple injuries, but this small self-reported survey in one region suggests that less than one third of ED nurses had up-to-date training against which standards can be benchmarked. Further examination of training requirements is urgently required, therefore, and RTNs should consider the introduction of nurse education standards as part of their KPIs.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Baird C, Kernohan G, Coates V (2004) Outcome of advanced trauma life support training: questioning the role of observer. Accident and Emergency Nursing. 12, 3, 131-135. Barleycorn D (2013) Trauma nursing development in England: insight from South Africa. International Emergency Nursing. 21, 3, 190-193. Carley S, Driscoll P (2001) Trauma education. Resuscitation. 48, 1, 47-56.
16 April 2014 | Volume 22 | Number 1
Davies D, Mazmanian P, Fordis M et al (2006) Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Journal of the American Medical Association. 296, 9, 1094-1102. Intercollegiate Group on Trauma Standards (2009) Regional Trauma Systems: Interim Guidance for Commissioners. Royal College of Surgeons of England, London.
Jayaraman S, Sethi D (2009) Advanced trauma life support training for hospital staff. Cochrane Database of Systematic Reviews. 2. doi: 10.1002/14651858.CD004173.pub3 NHS Clinical Advisory Group on Major Trauma Workforce (2011) Regional Trauma Networks. Centre for Workforce Development, London.
NHS England (2013) NHS Standard Contract for Major Trauma: All Ages. tinyurl.com/olzshpn (Last accessed: March 11 2014.) Patient L (2007) Trauma training: a literature review. Emergency Nurse. 15, 7, 28-37. Tippett J (2004) Nurses’ acquisition and retention of knowledge after trauma training. Accident and Emergency Nursing. 12, 1, 39-46.
EMERGENCY NURSE
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