ORIGINAL CONTRIBUTION
Physician and Patient Acceptance of Emergency Nurse Practitioners Sharon Alongi, RN, ENP Denise Geolot, RN, MS, ENP Linda Richter, RN, ENP Sally Mapstone, RN, MSN Milton T. Edgerton, MD Richard F. Edlich, MD, PhD Charlottesville, Virginia
Patient and physician attitudes toward emergency nurse practitioners (ENP) were surveyed in our emergency medical service. The responses to the questionnaires indicated a high degree of satisfaction with the ENP similar to that reported in a survey of patient reaction to physican assistants (PA) in the emergency department. In our emergency medical service, physicians expressed a concern over the practitioner's care of the emergent patient. Their confidence in the practitioner's clinical judgment was greater in their care of nonurgent and urgent patients. Alongi S, Geolot D, Richter L, Mapstone S, Edgerton MT, Edlich RF: Physician and patient acceptance of emergency nurse practitioners. JACEP 8:357-359, September 1979.
emergency nurse practitioner, physician and patient acceptance of
INTRODUCTION The emergency nurse practitioner (ENP) is a recently created category 1 of registered nurses who have received special postgraduate t r a i n i n g to assume an expanded role in the emergency department. Only three programs have been established so far to t r a i n the ENP. 2 Our nine-month program at the University of Virginia trains the student to diagnose and treat patients under physician supervision in the emergency department. This program is one of four nurse practitioner programs offered by our Graduate Division of the School of Nursing. A core curriculum has been developed using educational content common to all nurse practitioner programs. The role and functions of the ENP will reflect the needs of the hospital and surrounding community. In some small community hospitals, the emergency department may be staffed by emergency nurses without full-time physician coverage. In this setting, the E N P may t r e a t and dispense medications according t o protocols and will administer advanced life support in keeping with state laws until the physician arrives at the hospital. In larger hospitals with full-time physician coverage, the roles and responsibilities of the ENPs are similar to those in the small community hospital except that their activities are under the direct supervision of physicians. From tt~e University of Virginia School of Nursing and Emergency Medical Service, University of Virginia Medical Center, Charlottesville, Virginia. Dr. Edlich is a Junior Clinical Faculty Fellow of the American Cancer Society. Address for reprints: Richard F, Fdlich, MD, PhD, University of Virginia Medical Center, CharIottesville, Virginia 22908.
26/357
JACEP
8:9 (September) 1979
For ENPs to be successfully integrated into the emergency medical system, they must be acceptable to both p h y s i c i a n s and patients. To date, the question of acceptability has not been answered. We report here the results of an a t t i t u d i n a l survey of patients who received care from E N P s and p h y s i c i a n s who supervised that care.
too r-
and Physician Assistant
and Physician Assistant
Understanding of Care by
Completeness and Thoroughness of Examination
ENP
PA loo
ENP
PA
8O ~
70
~
60
80 7O
~ so ~. 4o
'°lJ 30
METHOD
2O
10
The E N P s who participated in this s t u d y were g r a d u a t e s of the emergency nurse practitioner program of the University of Virginia Medical Center. Their performance was e v a l u a t e d in the e m e r g e n c y medical service of this medical center located in rural central Virginia. In this service, nearly 40,000-patients receive care by house staff u n d e r faculty supervision. During the last three years, the ENP has joined our emergency health care team providing care with physician supervision. At the time of this study, the pract i t i o n e r ' s major clinical responsibilities were directed at patients with urgent and nonurgent clinical problems. P a t i e n t s and the p h y s i c i a n s supervising care completed questionnaires similar to that used by Maxfield eiJ al 3 in their survey of patients' reaction to physician assistants (PA) providing emergency coverage in a small rural community hospital. By using this same questionnaire, the patients' reaction to the ENP could be compared to that reported by Maxfield et aP for PAs. The patient and physician quest i o n n a i r e s were r e t u r n e d in addressed envelopes with a response of 40% (50 patients) and 90% (22 physicians). The response rate to this questionnaire was higher than response rates (15% to 30%) to other surveys that examined patient attitudes in our hospital. The significance of the increased compliance to this questionnaire was not examined. Our response rate is r e m a r k a b l y similar to t h a t (35%) reported by Maxfield et al 3 using the same questionnaire.
Patient's Attitude Toward Emergency Nurse Practitioner
Patient's Attitude Toward Emergency Nurse Practitioner
Yet
No
Nat Initially
Yes
-
No
v
6O
~
so 4O 3O 20 10
Not InillafJy
Fig. 1. Do you understand the care you were given at the hospital was by an E N P under the supervision o f a doctor?
Good
ENP
Fair
Good
Poor
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant Rating of Treatment
Promptness of Care
loo~ 9o~-
Poor
Fig. 4. How do you rate the examination you received from the E N P as to completeness and thoroughness?
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant
eoLL
Fair
ENP
PA
PA
90F
7o 6o
~ so ~. 4o
L
~°°F
30 2O 10 a
;r
Poar
Go d
Faft
P oar Goad
Fig. 2. H o w w o u l d you rate the promptness o f care you received by the ENP?
Poor
Good
Fair
Poor
Fig. 5. H o w w o u l d y o u rate the treatment you received from the E N P ?
Patient's Attitude-Toward Emergency Nurse Practitioner and Physician Assistant
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant
Courtesy ENP
Fair
PA
9O
Willingness to Be Reexamined by
gO 70 ~ ~
6O 50t-
~
401-
ENP
301-
PA
100 r-
201-
90 I
101-
Good
Fair
Poor
Good
Fair
Poor
80 t 701
Fig. 3. How would you rate the cour-
60l
tesy shown to you during your visit to the Emergency Medical Service?
40 I
501
301 201
RESULTS Patient Reaction
The responses to the p a t i e n t questionnaire indicated a high degree of satisfaction with the E N P similar to that reported by Maxfield et al 3 for PAs (Figure 1). Our patients knew that care was being delivered by practitioners under physi8:9 ( S e p t e m b e r ) 1 9 7 9
101
cian supervision. They believed that t h e i r care was delivered promptly (Figure 2) and courteously (Figure 3). They rated the ENP's physical examinatior~::as c o m p l e t e and thorough in 92% of cases (Figure 4). The patient understood the care provided by the ENP and rated their
JACEP
Yes
No
Yes
No
Fig. 6. I f you were to be seen again in the Emergency Medical Service o f the University o f Virginia Medical Center for a similar illness or injury, would you be willing to be reexamined a n d treated again by an ENP? 358/27
Physician's Attitude
Physician's Attitude Acceptance of ENP b y the Patient
Clinical Performance of ENP in Different Clinical Settings
100 r90 t80 I-
ioo
g 6o .~
5O 40 2O 10
I
Good
~
7(1
._o
50
~ 80 6O I
Saris.
Fair
Poor
F i g . ?. How do you rate the acceptance o f the E N P by the patient?
Physician's Attitude
100
r-
90 1-
J=
Q" 3O 20 !o Good Satis. Fair Poor
Good Satis. Fair Poor
Good Satis. Fair Poor
Emergent
Urgent
Non-urgent
Performance Of Physical Examination by ENP
F i g . 10. How do you rate the clinical performance o f the E N P in the care of emergent, urgent, and nonurgent patients?
90 180 I70 1u
60 F50 140 I-
2O 10
I
Good
Satls.
Fair
Poor
Fig. 8. H o w do you rate the performance o f a physical examination by the E N P ?
Physician's Attitude Clinical Judgment'of ENP lOO 90 80
~ 7o ~ 6o .~ 4o 5O
physicians. The g e n e r a l satisfaction w i t h the E N P is s i m i l a r to t h a t reported by Maxfield et al for the PA w o r k i n g in t h e e m e r g e n c y d e p a r t m e n t in r u r a l c o m m u n i t i e s 3 .or in another setting 4 under physician s u p e r v i s i o n . C o n s e q u e n t l y , t h e results of this s t u d y l e a d us to believe t h a t p a t i e n t a n d p h y s i c i a n acceptance is not a serious obstacle for the p r a c t i t i o n e r to overcome. However, this p a r a m e t e r is only a part of the d e f i n i t i v e e v a l u a t i o n of t h i s new h e a l t h professional. Well-controlled studies a r e still needed to m e a s u r e the i m p a c t of t h e p r a c t i t i o n e r on prod u c t i v i t y , a v a i l a b i l i t y , and cost of medical care.
DISCUSSION
1. Geolot D, Alongi S, Edlich RF: Emergency nurse practitioner: An answer to an emergency care crisis in rural hospitals. JACEP 8:355-357, 1977. 2. Hardy VG: The emergencynurse practitioner: The role and training of an emerging health professional. JACEP 7:372-376, 1978.
REFERENCES
20 10
Good
Satis,
Fair
Poor
Fig. 9. H o w do you rate the clinical j u d g m e n t o f the E N P ?
t r e a t m e n t as good in 92% of cases (Figure 5). Consequently, 94% of the p a t i e n t s e x p r e s s e d a w i l l i n g n e s s to be r e e x a m i n e d by E N P s ( F i g u r e 6). Physician Response
The m a j o r i t y (88%) of physicians r e s p o n d i n g to t h e q u e s t i o n n a i r e
28/359
realized t h e p a t i e n t ' s acceptance of the E N P (Figure 7). They expressed confidence in t h e i r p h y s i c a l e x a m i nation, r a t i n g it '~good" or '~satisfactory" in 90% of cases (Figure 8). The physicians were more reserved in t h e i r p r a i s e of t h e p r a c t i t i o n e r ' s clinical j u d g m e n t , r a t i n g it as good or satisfactory in 70% of cases (Figure 9). This r e s e r v a t i o n was r e l a t e d to conc e r n over the p r a c t i t i o n e r ' s care of the e m e r g e n c y patient, which E N P s r a r e l y e n c o u n t e r e d in t h i s s e t t i n g (Figure 10). T h e i r confidence in the p r a c t i t i o n e r ' s c l i n i c a l j u d g m e n t increased w h e n t h e y r a t e d performance in the care of t h e n o n u r g e n t and urg e n t p a t i e n t s , which d e m a n d e d most of t h e i r a t t e n t i o n .
The E N P s a r e t r a i n e d t o perform c e r t a i n t a s k s (ie, history a n d physical examination) that have been t r a d i t i o n a l l y done by physicians. It was, therefore, conceivable t h a t pat i e n t s m i g h t be skeptical of this new h e a l t h w o r k e r ' s t e c h n i c a l competence and professionalism. However, the m a j o r i t y of p a t i e n t s r e s p o n d i n g to t h i s q u e s t i o n n a i r e were v e r y satisfied w i t h t h e i r t r e a t m e n t , so much so t h a t t h e y w o u l d be w i l l i n g to be t r e a t e d a g a i n b y t h e s a m e person. This confidence in the practitioner's performance was shared by the
JACEP
3. Maxfield RG, Lemire DR, Wansleben TO: Utilization of supervised physician's assistants in emergency room coverage in a small rural community hospital. J Trauma 15:795-799, 1975. 4. Nelson EC, Jacobs AR, Johr/sorn KG: Patient's acceptance of physician"s assistants. JAMA 228:63-67, 1974.
" 8:9 (September) 1979
Physician and Patient Acceptance of Emergency Nurse Practitioners Sharon Alongi, RN, ENP Denise Geolot, RN, MS, ENP Linda Richter, RN, ENP Sally Mapstone, RN, MSN Milton T. Edgerton, MD Richard F. Edlich, MD, PhD Charlottesville, Virginia
Patient and physician attitudes toward emergency nurse practitioners (ENP) were surveyed in our emergency medical service. The responses to the questionnaires indicated a high degree of satisfaction with the ENP similar to that reported in a survey of patient reaction to physican assistants (PA) in the emergency department. In our emergency medical service, physicians expressed a concern over the practitioner's care of the emergent patient. Their confidence in the practitioner's clinical judgment was greater in their care of nonurgent and urgent patients. Alongi S, Geolot D, Richter L, Mapstone S, Edgerton MT, Edlich RF: Physician and patient acceptance of emergency nurse practitioners. JACEP 8:357-359, September 1979.
emergency nurse practitioner, physician and patient acceptance of
INTRODUCTION The emergency nurse practitioner (ENP) is a recently created category 1 of registered nurses who have received special postgraduate t r a i n i n g to assume an expanded role in the emergency department. Only three programs have been established so far to t r a i n the ENP. 2 Our nine-month program at the University of Virginia trains the student to diagnose and treat patients under physician supervision in the emergency department. This program is one of four nurse practitioner programs offered by our Graduate Division of the School of Nursing. A core curriculum has been developed using educational content common to all nurse practitioner programs. The role and functions of the ENP will reflect the needs of the hospital and surrounding community. In some small community hospitals, the emergency department may be staffed by emergency nurses without full-time physician coverage. In this setting, the E N P may t r e a t and dispense medications according t o protocols and will administer advanced life support in keeping with state laws until the physician arrives at the hospital. In larger hospitals with full-time physician coverage, the roles and responsibilities of the ENPs are similar to those in the small community hospital except that their activities are under the direct supervision of physicians. From tt~e University of Virginia School of Nursing and Emergency Medical Service, University of Virginia Medical Center, Charlottesville, Virginia. Dr. Edlich is a Junior Clinical Faculty Fellow of the American Cancer Society. Address for reprints: Richard F, Fdlich, MD, PhD, University of Virginia Medical Center, CharIottesville, Virginia 22908.
26/357
JACEP
8:9 (September) 1979
For ENPs to be successfully integrated into the emergency medical system, they must be acceptable to both p h y s i c i a n s and patients. To date, the question of acceptability has not been answered. We report here the results of an a t t i t u d i n a l survey of patients who received care from E N P s and p h y s i c i a n s who supervised that care.
too r-
and Physician Assistant
and Physician Assistant
Understanding of Care by
Completeness and Thoroughness of Examination
ENP
PA loo
ENP
PA
8O ~
70
~
60
80 7O
~ so ~. 4o
'°lJ 30
METHOD
2O
10
The E N P s who participated in this s t u d y were g r a d u a t e s of the emergency nurse practitioner program of the University of Virginia Medical Center. Their performance was e v a l u a t e d in the e m e r g e n c y medical service of this medical center located in rural central Virginia. In this service, nearly 40,000-patients receive care by house staff u n d e r faculty supervision. During the last three years, the ENP has joined our emergency health care team providing care with physician supervision. At the time of this study, the pract i t i o n e r ' s major clinical responsibilities were directed at patients with urgent and nonurgent clinical problems. P a t i e n t s and the p h y s i c i a n s supervising care completed questionnaires similar to that used by Maxfield eiJ al 3 in their survey of patients' reaction to physician assistants (PA) providing emergency coverage in a small rural community hospital. By using this same questionnaire, the patients' reaction to the ENP could be compared to that reported by Maxfield et aP for PAs. The patient and physician quest i o n n a i r e s were r e t u r n e d in addressed envelopes with a response of 40% (50 patients) and 90% (22 physicians). The response rate to this questionnaire was higher than response rates (15% to 30%) to other surveys that examined patient attitudes in our hospital. The significance of the increased compliance to this questionnaire was not examined. Our response rate is r e m a r k a b l y similar to t h a t (35%) reported by Maxfield et al 3 using the same questionnaire.
Patient's Attitude Toward Emergency Nurse Practitioner
Patient's Attitude Toward Emergency Nurse Practitioner
Yet
No
Nat Initially
Yes
-
No
v
6O
~
so 4O 3O 20 10
Not InillafJy
Fig. 1. Do you understand the care you were given at the hospital was by an E N P under the supervision o f a doctor?
Good
ENP
Fair
Good
Poor
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant Rating of Treatment
Promptness of Care
loo~ 9o~-
Poor
Fig. 4. How do you rate the examination you received from the E N P as to completeness and thoroughness?
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant
eoLL
Fair
ENP
PA
PA
90F
7o 6o
~ so ~. 4o
L
~°°F
30 2O 10 a
;r
Poar
Go d
Faft
P oar Goad
Fig. 2. H o w w o u l d you rate the promptness o f care you received by the ENP?
Poor
Good
Fair
Poor
Fig. 5. H o w w o u l d y o u rate the treatment you received from the E N P ?
Patient's Attitude-Toward Emergency Nurse Practitioner and Physician Assistant
Patient's Attitude Toward Emergency Nurse Practitioner and Physician Assistant
Courtesy ENP
Fair
PA
9O
Willingness to Be Reexamined by
gO 70 ~ ~
6O 50t-
~
401-
ENP
301-
PA
100 r-
201-
90 I
101-
Good
Fair
Poor
Good
Fair
Poor
80 t 701
Fig. 3. How would you rate the cour-
60l
tesy shown to you during your visit to the Emergency Medical Service?
40 I
501
301 201
RESULTS Patient Reaction
The responses to the p a t i e n t questionnaire indicated a high degree of satisfaction with the E N P similar to that reported by Maxfield et al 3 for PAs (Figure 1). Our patients knew that care was being delivered by practitioners under physi8:9 ( S e p t e m b e r ) 1 9 7 9
101
cian supervision. They believed that t h e i r care was delivered promptly (Figure 2) and courteously (Figure 3). They rated the ENP's physical examinatior~::as c o m p l e t e and thorough in 92% of cases (Figure 4). The patient understood the care provided by the ENP and rated their
JACEP
Yes
No
Yes
No
Fig. 6. I f you were to be seen again in the Emergency Medical Service o f the University o f Virginia Medical Center for a similar illness or injury, would you be willing to be reexamined a n d treated again by an ENP? 358/27
Physician's Attitude
Physician's Attitude Acceptance of ENP b y the Patient
Clinical Performance of ENP in Different Clinical Settings
100 r90 t80 I-
ioo
g 6o .~
5O 40 2O 10
I
Good
~
7(1
._o
50
~ 80 6O I
Saris.
Fair
Poor
F i g . ?. How do you rate the acceptance o f the E N P by the patient?
Physician's Attitude
100
r-
90 1-
J=
Q" 3O 20 !o Good Satis. Fair Poor
Good Satis. Fair Poor
Good Satis. Fair Poor
Emergent
Urgent
Non-urgent
Performance Of Physical Examination by ENP
F i g . 10. How do you rate the clinical performance o f the E N P in the care of emergent, urgent, and nonurgent patients?
90 180 I70 1u
60 F50 140 I-
2O 10
I
Good
Satls.
Fair
Poor
Fig. 8. H o w do you rate the performance o f a physical examination by the E N P ?
Physician's Attitude Clinical Judgment'of ENP lOO 90 80
~ 7o ~ 6o .~ 4o 5O
physicians. The g e n e r a l satisfaction w i t h the E N P is s i m i l a r to t h a t reported by Maxfield et al for the PA w o r k i n g in t h e e m e r g e n c y d e p a r t m e n t in r u r a l c o m m u n i t i e s 3 .or in another setting 4 under physician s u p e r v i s i o n . C o n s e q u e n t l y , t h e results of this s t u d y l e a d us to believe t h a t p a t i e n t a n d p h y s i c i a n acceptance is not a serious obstacle for the p r a c t i t i o n e r to overcome. However, this p a r a m e t e r is only a part of the d e f i n i t i v e e v a l u a t i o n of t h i s new h e a l t h professional. Well-controlled studies a r e still needed to m e a s u r e the i m p a c t of t h e p r a c t i t i o n e r on prod u c t i v i t y , a v a i l a b i l i t y , and cost of medical care.
DISCUSSION
1. Geolot D, Alongi S, Edlich RF: Emergency nurse practitioner: An answer to an emergency care crisis in rural hospitals. JACEP 8:355-357, 1977. 2. Hardy VG: The emergencynurse practitioner: The role and training of an emerging health professional. JACEP 7:372-376, 1978.
REFERENCES
20 10
Good
Satis,
Fair
Poor
Fig. 9. H o w do you rate the clinical j u d g m e n t o f the E N P ?
t r e a t m e n t as good in 92% of cases (Figure 5). Consequently, 94% of the p a t i e n t s e x p r e s s e d a w i l l i n g n e s s to be r e e x a m i n e d by E N P s ( F i g u r e 6). Physician Response
The m a j o r i t y (88%) of physicians r e s p o n d i n g to t h e q u e s t i o n n a i r e
28/359
realized t h e p a t i e n t ' s acceptance of the E N P (Figure 7). They expressed confidence in t h e i r p h y s i c a l e x a m i nation, r a t i n g it '~good" or '~satisfactory" in 90% of cases (Figure 8). The physicians were more reserved in t h e i r p r a i s e of t h e p r a c t i t i o n e r ' s clinical j u d g m e n t , r a t i n g it as good or satisfactory in 70% of cases (Figure 9). This r e s e r v a t i o n was r e l a t e d to conc e r n over the p r a c t i t i o n e r ' s care of the e m e r g e n c y patient, which E N P s r a r e l y e n c o u n t e r e d in t h i s s e t t i n g (Figure 10). T h e i r confidence in the p r a c t i t i o n e r ' s c l i n i c a l j u d g m e n t increased w h e n t h e y r a t e d performance in the care of t h e n o n u r g e n t and urg e n t p a t i e n t s , which d e m a n d e d most of t h e i r a t t e n t i o n .
The E N P s a r e t r a i n e d t o perform c e r t a i n t a s k s (ie, history a n d physical examination) that have been t r a d i t i o n a l l y done by physicians. It was, therefore, conceivable t h a t pat i e n t s m i g h t be skeptical of this new h e a l t h w o r k e r ' s t e c h n i c a l competence and professionalism. However, the m a j o r i t y of p a t i e n t s r e s p o n d i n g to t h i s q u e s t i o n n a i r e were v e r y satisfied w i t h t h e i r t r e a t m e n t , so much so t h a t t h e y w o u l d be w i l l i n g to be t r e a t e d a g a i n b y t h e s a m e person. This confidence in the practitioner's performance was shared by the
JACEP
3. Maxfield RG, Lemire DR, Wansleben TO: Utilization of supervised physician's assistants in emergency room coverage in a small rural community hospital. J Trauma 15:795-799, 1975. 4. Nelson EC, Jacobs AR, Johr/sorn KG: Patient's acceptance of physician"s assistants. JAMA 228:63-67, 1974.
" 8:9 (September) 1979
