Pitters – Nurse Practitioners
Nurse practitioners in the Pediatric Emergency Department – their current roles
and physician attitudes towards their role
Principal Investigator: Carrol Pitters1, MD
Co-Investigators: Shane English2, BSc., Amy Plint1, MD, Tammy Clifford, PhD3
Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of
Eastern Ontario/University of Ottawa, Ottawa, Ontario
1
2
Faculty of Medicine, University of Ottawa, Ottawa, Ontario
Chalmers Research Group, Children’s Hospital of Eastern Ontario Research Institute
and Departments of Pediatrics and Epidemiology & Community Medicine, University of
Ottawa, Ottawa, Ontario
3
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Pitters – Nurse Practitioners
Objectives:
The objectives of this study are: (1) to determine the current utilization of Nurse
Practitioners (NPs) among academic paediatric emergency departments (ED) in Canada
and (2) to examine paediatric emergency department physicians’ attitudes and confidence
in NPs assuming traditional physician duties.
Background:
Over the past decade, the role of the Emergency Nurse Practitioner (ENP) has been well
established in Accident and Emergency (A&E) departments in the United Kingdom
(Read et al. 1992; Tye et al., 2000; Cooper et al. 2001). By 1991, 6% of A & E
departments in England and Wales had implemented the NP role (Read et al. 1992). It is
now estimated that as many as 30-70% of A & E departments in some areas have
implemented the role (Cole and Ramirez 2002). The initial role of the NP in emergency
care in the United States resulted from a need to provide care for a growing number of
non-urgent patients presenting for health care to rural emergency departments (Curry,
2000). NPs now provide services in various ED settings, and guidelines for the role of
NPs in emergency departments have been endorsed and published by the American
College of Emergency Physicians with the last update in June 2000 (ACEP, 2000).
In Canada, the initial role of the Nurse Practitioner was in primary care, and the first
training program was established in the 1960s for NPs working in northern nursing
stations (NPAO, 2001). Today, the most common setting for NPs is in community
clinics, but with the recent strains in emergency services delivery, interest has been
expressed in the possible role of the NP in emergency departments. In April 2001, the
Canadian Association of Emergency Physicians and the National Emergency Nurses
Affiliation published a joint position statement on emergency department overcrowding
(CAEP & NENA, 2000). They outlined multiple contributing factors and proposed
several strategies to address some of the problems associated with over-crowding. They
suggested the implementation of Nurse Practitioners (NPs) in Emergency Departments as
one of these strategies (CAEP & NENA, 2000).
Definition of NP
A Nurse Practitioner is a registered nurse (RN) who has advanced training in diagnosing
and treating illness (NPAO, 2001). Nurse Practitioners prescribe medications, treat
illness, and administer physical exams. NPs differ from physicians in that they focus on
prevention, wellness, and education. NPs specialize in providing all-encompassing
individualized care. Most NPs specialize in particular areas of health care (NPAO, 2001).
Why is this study necessary?
Studies have been undertaken in the US on the role of NPs in emergency departments and
on attitudes toward them (Alongi et al., 1979; Cairo, 1996). In Canada, however, there
are no data on the number of pediatric emergency departments that employ NPs nor do
we know the nature of NPs’ roles within these departments or physicians’ views
regarding which current physician duties they believe NPs could assume (including
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Pitters – Nurse Practitioners
patient care and administrative duties). Collecting such information is an essential first
step in understanding possible benefits and roles of NPs in the pediatric ED, possible
barriers to implementing NP programs, and assessing the efficacy of NPs in the pediatric
ED. Our study will be the first to ascertain the number of Canadian pediatric EDs that
now have ENPs as part of their ED staff, to characterize the roles of ENPs within these
environments and to assess the attitudes of pediatric Emergency physicians to the ENP in
the PED.
Methods:
Study Design: Descriptive, cross-sectional, national survey.
Justification/Rationale for Design: Given the absence of empirical data
regarding the utilization of NPs within Canadian pediatric emergency departments, their
current roles within these departments, and physician views regarding their duties, a
descriptive survey reflecting current practice and views is a logical starting point.
Findings of this initial survey will serve to direct future research, including permitting the
generation of hypotheses that can be subjected to formal evaluation.
Sampling Procedures: Because there are only 10 pediatric EDs in Canada, all of them
will be surveyed and so this study forms a census and no sampling, per se, will be
required. The typical disadvantages of a census in terms of costs and time required to
obtain information from an entire population are not of concern here as our population of
interest is so small.
Eligibility Criteria: All physicians whose primary clinical appointment is to one of the 10
pediatric emergency departments in Canada will be eligible for study participation.
Sample Size: There are 10 pediatric hospitals with EDs in Canada. A list of physicians
in these departments has previously been compiled and will be used.
Data Collection: Each pediatric emergency physician will be contacted directly via mail.
Each survey package will contain the appropriate survey instrument with an explanation
of the study and a pre-stamped, return-addressed envelope in which to return the
completed questionnaire. This method of data collection was selected because selfadministered questionnaires are cheaper to administer than other methods (e.g., in-person,
telephone) (Fink, 1995). Postal surveys also permit wide geographic coverage; this is an
important consideration in this survey as we intend to reach a national audience. Also,
respondents may be more likely to complete a mailed survey since they can do so at their
convenience.
In order to ensure our results are as robust as possible, concerted efforts will be
made to encourage responses from all individuals. This will use a modified version of
Dillman’s Total Design Survey Method (Dillman, 2000). In this approach, all doctors
will be mailed the appropriate questionnaire with a pre-stamped, return addressed
envelope in which to return the completed questionnaire. A reminder postcard will be
mailed to all participants one week after the initial mailing; another copy of the
questionnaire will be sent after a further 2 weeks, and again 2 weeks after that, to the
remaining nonrespondents. To ensure anonymity, the questionnaires will be coded so
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Pitters – Nurse Practitioners
that the investigators will be unaware of the names of the residents completing the
questionnaires. Tracking of responses, subsequent mailings to non-respondents and data
entry will be performed by a Research Assistant who has no contact with study
participants.
.
Survey Instruments: Two survey instruments have been developed and piloted. Their
content was based in part on work of previous authors (Cole and Ramirez, 2000a, 2000b).
The first instrument, for Medical Directors of Pediatric Emergency Departments, will
examine the demographics of the individual emergency department (such as ED census,
proportion of patients per triage category, presence of a “fast track” service and current
use of NPs). A second survey will be sent to all pediatric emergency physicians and will
collect demographic information, their opinions and comfort level regarding NP patient
management. The surveys comprise a series of single- and multiple-select closed ended
items; however, some items also allow for selection of a residual "other" category. In
cases where the respondent feels that their response did not correspond to those already
listed (i.e., they selected "other"), they are asked to elaborate upon their answer in fulltext. The surveys will be translated into French by the translation service at CHEO, to
facilitate the collection of information from sites in Quebec and elsewhere. It is
estimated that the surveys will take a maximum of 10 minutes to complete.
Data Analysis:
Descriptive statistics will be determined for all measures. Frequencies of responses to
questionnaire items that solicited information on NPs current roles and physicians’
attitudes towards NPs assuming duties will be tallied. Bivariable analyses will examine
the relationships between respondents’ demographics and practice settings (e.g., site,
patient census, length of time in practice, level of training) and the variables that relate to
NPs current roles and physicians’ attitudes towards NPs using the Mantel-Haenszel chisquared test or Fisher’s exact test, as appropriate. For example, one such comparison will
juxtapose years of experience versus physicians’ opinion as to what class(es) of patient
care they would be comfortable with an ENP managing without supervision. In all cases,
because this survey aims to generate, rather than test, hypotheses, adjustments will be
made for multiple testing by setting alpha at 0.01 rather than 0.05.
Dissemination Plans:
Findings will be disseminated at national and international paediatric conference as well
as by publication in a relevant peer-reviewed medical journal.
Ethical Considerations:
This proposal will be submitted to the Research Ethics Board of the Children’s Hospital
of Eastern Ontario for review. There are no anticipated risks associated with
participation in this study. Participation by the survey recipient is voluntary; consent to
participate in this research by the respondent will be assumed with receipt of a completed
survey. Participants can not be sanctioned by their program/institution for choosing not
to participate or not completing their survey in its entirety. All precautions will be taken
to assure participants’ confidentiality; only participant identification numbers (PINs) will
appear on survey instruments. A database that links PINs with participant names and
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sites will be kept geographically separate from the study forms. This database will be
prepared by the research assistant and will not be available to the investigators, so that
anonymity is maintained. The research assistant has no direct interest in the research
results. All information collected will be held in strictest confidence and will be kept in
locked cabinets in the research office. When the study is completed only aggregate data
will be reported; neither participants’ nor institutions’ identities will be revealed.
References
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department. www.acep.org./1,583,0.html (accessed 4-April-2002).
Alongi S, Geolot D, Richter L, Mapstone S, Edgerton MT, Edlich RF. (1979).
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Physicians 8: 357-359.
CAEP and NENA. (2001). Joint position statement on emergency department
overcrowding. Cam J Emerg Med 3; 82-84.
Cairo MJ. (1996). Emergency physicians’ attitudes toward the emergency nurse
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Cole FL, Ramirez E. (2000a). Nurse practitioner autonomy in a clinical setting.
Emerg Nurse 7; 26-30.
Cole FL, Ramirez E. (2000b). Activities and procedures performed by nurse
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Dillman D. Mail and internet surveys: the tailored design method. New York: John
Wiley & Sons, 2000
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