Journal of Advanced Nursing, 1999, 30(1), 260±268 Issues and innovations in nursing practice 

An evaluation of the nurse practitioner role in a major rural 

emergency department 
Esther Chang 
RN CM BAppSc (Adv. Nurs) DipNEd MEdAdmin PhD FCN (NSW) Associate Professor and Dean, Faculty of 
Health and Co-Director, Centre for Research in Healthy Futures, University of Western Sydney Hawkesbury, Richmond 
John Daly RN BA BHSc(Nurs) MEd(Hons) PhD MINE FCN(NSW) FRCNA Professor and Head, Division of Nursing and 
Director of Research, Faculty of Health, University of Western Sydney Macarthur, Campbelltown 
Anne Hawkins RN AENC BAppSc(Nurs) Clinical Nurse Consultant (Emergency), Greater Murray Health Service, Wagga Wagga 
Joe McGirr MB BS FACEM Director, Emergency Department, Wagga Wagga Base Hospital, Wagga Wagga 
Kerin Fielding MB BS FRACS Consultant Orthopaedic Surgeon, Wagga Wagga Base Hospital, Wagga Wagga 
Lynne Hemmings RN DipAppSc(Nurs) BA MEd PhD Senior Lecturer and Head, School of Health and Human Services, Charles 
Sturt University, Wagga Wagga 
Anne O'Donoghue RN BAdmin Director of Nursing and Professional Standards Greater Murray Health Service, Wagga Wagga 
and Margaret Dennis RN CM AENC Nursing Unit Manager, Emergency Department, Wagga Wagga Base Hospital, Wagga 
Wagga, NSW, Australia 
Accepted for publication 30 September 1998 
CHANG CHANG E.,E., DALYDALY J., J., HAWKINS HAWKINS A., A., McGIRR McGIRR J., J., FIELDING 
FIELDING K., K., HEMMINGS HEMMINGS L.,L., O'O'DONOGHUE DONOGHUE A.A. & DENNIS DENNIS 
M. M. (1999) (1999) Journal of Advanced Nursing 30(1), 260±268 An evaluation of the nurse practitioner role in a 
major rural emergency department The purpose of this pilot study was to investigate whether nurse practitioners are 
able to provide a level of primary health service applicable to remote/ isolated settings in wound management and 
treatment of blunt limb trauma. It was hypothesized that there would be no signi®cant difference in the quality of 
Correspondence: Esther Chang, Dean, Faculty of Health, University of Western Sydney Hawkesbury, Locked Bag 1, Richmond, 
NSW 2753, Australia. 
260 Ó 1999 Blackwell Science Ltd 
 
Issues and innovations in nursing practice Nurse practitioner role 
care, or the level of client satisfaction, provided by the medical of®cers and the nurse practitioners in the study. Two 
groups participated in the study, nurse practitioners and medical of®cers. The study used a randomized trial design. 
Data were collected using quantitative and qualitative methods. Two hundred and thirty-two clients participated in 
the study. Of this number 63 were supervized cases in the pilot trial. In the randomized trial participants were 
distributed between nurse practitioners and medical of®cers (n = 169), of which 91 were randomized to medical 
of®cers and 78 to nurse practitioners. Telephone interviews were conducted to evaluate client satisfaction. The 
majority of study participants were surveyed for client satisfaction (n = 132). This represents approximately 78% of 
the randomized sample and multivariate analysis was carried out on the data. Study results indicate that there were 
no signi®cant differences between the two groups in relation to client satisfaction. Very positive outcomes of 
treatment were consistent across groups in the study. The study also found that there was strong support for the role 
of the nurse practitioner in the rural emergency setting. Recommendations include further research to measure the 
ef®cacy of nurse practitioners utilizing the selected competencies in remote/isolated settings. 
Keywords: nursing, emergency, nurse practitioner, evaluation, role, research, rural health care 
INTRODUCTION 
The  international  literature  is  replete  with  information on the role of the nurse practitioner and its evaluation. How- ever, there is 
a  shortage  of information on the role and function of nurse practitioners in the emergency setting. The relative lack of attention to 
the  potential  contribution  of  the  nurse  practitioner  role  in  emergency  departments  is  surprising  for  a  number  of  reasons. 
Contextual  issues  which  confront  emergency  departments  often  include  varying  levels  of  client  acuity  which  require treatment, 
and  com-  petition  for  access  to  medical  expertise.  Client  classi®cation  processes  usually  ensure  that  urgent  cases  are  treated 
ahead  of  non-urgent  cases  which  means  that  the  latter  are  often  subjected  to  lengthy  waiting  times  before  assessment  and 
treatment  by  a  medical  of®cer.  In  areas  of  medical  disad-  vantage  such  as  the  rural  or  remote  setting,  such  problems  may  be 
ampli®ed  considerably.  Superimposed  on  this  is  the  public's  expectation  that  service  will  be  readily  available  and  expeditious 
when  required  in  the  hospital  emergency  room.  It  appears  that  a  practice  gap  exists  where  appropri-  ately  prepared  nurse 
practitioners  could  undertake  roles  to  improve  the  level  of  service  and  ef®ciency  in  emergency  practice  areas.  The  bene®ts  of 
this  could  extend  to  the  community,  staff  working  in  the  emergency  area  and  overall  resource  management.  Until  such time as 
hard  data  are  available  to  support  the  development  and  introduction  of  such  a  role  its  potential  bene®ts  remain  theoretical  and 
speculative. 
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(1), 260±268 261 This pilot study of the emergency nurse 
practitioner role was undertaken in an emergency hospital that services a regional/rural/remote population of approximately 150 
000. The pilot study was one component of a major state-wide research project funded by the New South Wales (NSW) 
Department of Health. In total there were 11 pilot sites located in differing clinical settings throughout metropolitan and rural 
NSW. The purpose of the study was to investigate whether nurse practitioners are able to provide a level of primary health 
service applicable to rural/remote/isolated settings in wound management and treatment of blunt limb trauma. Importantly it was 
intended that the role the nurse practitioners undertook would transcend these speci®c conditions, as nurses drew on their clinical 
knowledge to provide an holistic health service. 
LITERATURE REVIEW 
There  is  a  surprising  shortage  of  information  in  the  literature  on  the  role  and  function  of  nurse  practitioners  in  the  emergency 
setting. In a comprehensive report of studies of nurse practitioner effectiveness, where 55 North American studies were reviewed, 
not  one  was  located  in  the  emergency  setting  (Feldman  et  al.  1987).  Consequently  there is a lack of research-based information 
on  the  potential  of  the  nurse  practitioner  in  emergency  areas.  However,  a  search  of  the  literature  uncovered  a  small  number  of 
studies which have relevance in the context of 
 
E. Chang et al. 
nurse practitioners in accident and emergency (Powers 
gency room nurses assume roles normally restricted to et al. 
1984, Read et al. 1992, Howie 1992, Ferguson & 
medical of®cers. A salient example here is suturing of 
Sapelli 1992, Burgess 1992, Strange 1994, Read & George 
wounds guided by hospital policy and after appropriate 
1994). 
inservice training (Cockerill & Sweet 1993). It is important to 
note that the label `nurse practitioner' 
The nurse practitioner role has emerged in the UK over 
in itself reveals little of what may comprise the practice 
the last decade. Read et al. (1992) found that only 6% of 
role and responsibilities which may be associated with it 
accident and emergency centres in the UK actually used 
from one setting to another. For example the role is 
designated nurse practitioners. However, a signi®cant 
described in the North American literature from the 
number of centres used de facto nurse practitioners. Most 
mid-1970s in relation to practice in emergency areas. 
commonly these nurse practitioners managed minor Nurse 
practitioners were introduced at a time of physician 
trauma such as cuts and abrasions (Harford 1993). As in 
shortage. However, the incumbents were involved in 
the USA, the role often involves triage activities and triage 
activities in the main and their purpose was to 
responsibilities. Other duties undertaken by nurse practi- 
assist in decreasing waiting time for ambulant non-urgent 
tioners in the UK can include `treatment of minor burns 
cases (Cardello 1992, Covington et al. 1992). Pardee 
and wounds, suturing small lacerations, suture removal, 
(1992), however, does describe the extended role of triage 
X-ray requests and patient referral' (Harford 1993 p. 40). 
nurse practitioners who may undertake certain tasks 
Howie (1992) undertook a study of emergency nurse 
guided by strict protocols. Generally speaking the emer- 
practitioners in Lincoln in the UK. It is described as a 
gency nurse practitioner role in the United States of 
limited study of the theoretical management of patients. A 
America (USA) is ®lled by a nurse who holds a university 
sample of 400 ambulant patients was used in this study. 
master's degree in their area of specialization (Becker 
Of the 400 patients seen in the study, 322 were assessed by 
et al. 1989, Harford 1993). Some of these specialist emer- 
nurses. Their theoretical management of 298 of these cases 
gency nurses may hold a doctoral quali®cation (Harford 
was deemed satisfactory. The nurses proposed manage- 
1993). Nurse practitioners in the USA undertake 
ment of the patients was compared with actual manage- 
`advanced practice'. The Emergency Nurses Association 
ment by `middle-grade doctors'. In this study `The nurses 
(ENA) de®nes the advanced practice nurse as follows: `the 
mismanaged 12 of the patients according to local practice. 
Advanced Practice nurse is a registered nurse who 
They also requested X-rays in 22 more patients than did 
through advanced study at the Masters or Doctoral level, 
middle-grade doctors. None of the patients returned with 
has become an expert in Emergency Nursing' (Harford 
a fracture. Of the patients suitable to be seen by nurses, 
1993 pp. 34±35). 
94% said that they would use a nurse practitioner system 
Harford (1993) undertook a review of the literature on 
if introduced' (Howie 1992 p. 10). This study fell short the 
emergency nurse practitioner role in the USA. She 
of actually assessing the practice of the nurses. states 
(Harford 1993 pp. 35±36) that the duties of these 
A number of tasks for nurse practitioners are listed in the 
practitioners may include: 
article by Howie (1992). They include: assess all walking 
· taking patient histories; 
· performing physical examinations; 
· minor wound closure Ð simple suturing; 
· ordering basic laboratory studies, cultures and X-rays; and 
· generating treatment plans and discharge education. 
262 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(1), 260±268 patients; treat those who fall within the 
following criteria: assess, treat and dress minor wounds, burns, scalds, stings and insect bites, suture minor lacerations using local 
anaesthetic, prescribe and administer tetanus toxoid inoculations, remove foreign bodies from the eye using local anaesthetic. 
Other examples include instilling eye drops, advising patients and referring patients to appro- These duties are undertaken in 
addition to traditional 
priate specialty areas. In this study the nurse practitioners 
nursing duties. Harford (1993) notes that in the USA, 
did not treat the following groups (Howie 1992 p. 11): 
emergency nurse practitioners are accredited through state legislation. This speci®es level of experience, training and scope of 
practice (Harford 1993). 
The  accident  and emergency nurse practitioner role is also discussed in the British literature (Burgess 1992, Howie 1992, Read 
et al. 1992, Robinson 1993, Read & George 1994). Compared with the USA, the role is not as well delineated and is in a different 
stage of evolution. 
1⁄4children  under  the  age  of  eleven  years,  assault  cases, suicide cases, road traf®c accident victims, alcohol intoxicated patients, 
patients  with  lacerations  over  joints,  foreign  bodies  in  wounds,  police  cases,  head,  neck,  chest  and  abdominal  injuries  or  cases 
which  the  nurse  practitioner  identi®ed  as  needing  a  medical  opinion,  or patients who had already been sent for an X-ray, or any 
patient who requested to be treated by a doctor. 
In this context role de®nition is raised as an issue by 
A further British study of the nurse practitioner role in 
Robinson (1993). A further issue is educational standard- 
the emergency department was undertaken by Burgess 
ization and training (Read et al. 1992). Literature from the 
(1992). In this trial the nurse practitioner was assigned a 
United Kingdom (UK) shows that in some settings emer- 
triage and treatment role. The aims of the trial were to: 
 
Issues and innovations in nursing practice Nurse practitioner role 
reduce waiting time, make more ef®cient use of available 
numbers should be increased during busy times, and staff 
nursing time and skills, make more appropriate use of 
should improve their attitudes towards patients and medical 
staff time, improve quality of service to patients, 
provide information more readily. From `the ®ndings of 
and meet patient expectations (Burgess 1992). Five thou- 
this study it seems that patients mainly wanted the basics 
sand patients took part in the trial, but only half of this 
apart from the expected technical competence and triage 
number completed questionnaires. All of the patients who 
capabilities that were usually managed well. However, a 
completed the questionnaires in this study believed that 
positive attitude from staff was the most sought after the 
service exceeded their expectations. Opinions were 
commodity' (Lewis & Woodside 1992 p. 963). This was 
also sought from reception staff and nurses working in the 
not a study of nurse practitioners in emergency per se but 
accident and emergency unit regarding the service. The 
registered nurses working in the area. nurse practitioner 
service was unanimously supported. 
A study of the nurse practitioner role in accident and 
Furthermore the nurse practitioners found the job reward- 
emergency was conducted in South Australia by Strange 
ing, stimulating and worthwhile (Burgess 1992). 
(1994). The role was trialed for a period of 6 months. Read 
and George (1994) undertook a pilot study of the 
Objectives were to: reduce waiting times for clients with 
assessment and treatment of patients with minor injuries 
minor injuries; increase job satisfaction among the by nurse 
practitioners or junior doctors in an accident and 
department's experienced registered nurses; and to 
emergency setting in the UK. The proposed aim of the 
increase their accountability. A patient satisfaction survey 
study was to compare the clinical outcomes of treatment 
was conducted in this setting. Three hundred question- of 
minor injury patients randomly assigned either to nurse 
naires were distributed and only 48% (n = 143) were 
practitioners or junior doctors. Random allocation was 
returned. An interesting ®nding in this study was that used 
in this study. Patients treated in the study were 
77% of those who returned their questionnaire believed 
invited to return for follow-up assessment after treatment. 
that a medical practitioner or a specialist medical doctor 
This assessment was undertaken by a senior medical 
was the most appropriate person to treat their problem. 
of®cer who was unaware of who had treated the patient. 
Twelve per cent felt that a specialist nurse with training The 
researchers estimated that a sample of 2000 would 
would be appropriate and only 10% said that a registered be 
required in order to detect a signi®cant difference in 
nurse with no additional training would be appropriate. 
treatment. The study found that nurse practitioners, when 
However, all the clients that were treated by the nurse on 
duty, were not always free to undertake the clinical 
practitioners were satis®ed with their care. management of 
patients because of heavy workload. 
A survey of the nurses working in the area (n = 9) was 
Dif®culties in randomization were encountered in this 
conducted and eight returned their questionnaire. The study, 
with small numbers of patients managed by nurse 
majority of the respondents felt comfortable in the role of 
practitioners compared to junior doctors, resulting in the 
nurse practitioner. Only half of the group maintained that 
termination of the clinical trial. 
the ̄ow of clients through the department was smooth. Read 
et al. (1992) recommend that in the UK the 
Moreover, only half reported increased job satisfaction. 
following areas should be investigated for the nurse 
One nurse said that the role created additional stress for 
practitioner role: 
other nursing staff in the area. However, all of the 
1 staf®ng arrangements so that nurse practitioners can actually practice and are not diverted to other tasks; 2 establishment of 
clear protocols; 3 establishment of standards and auditing arrangements; 
and 4 national training and accreditation. 
Ó  1999  Blackwell  Science  Ltd,  Journal  of  Advanced  Nursing,  30(1), 260±268 263 registered nurses in the setting wanted to see 
the nurse practitioner role continued beyond the trial. 
Ferguson & Sapelli (1992) undertook a study of nurse practitioner managed wounds in the USA. The role of the nurse 
practitioner was introduced in a beef processing plant to deal with occupational health and safety. The study was a retrospective 
analysis of patient records. It In a Canadian study of patient satisfaction in the emer- 
included 327 men and two women. The mean age in the 
gency department a three-point Likert scale was used to 
sample was 27á83 years (SDSD = 6á97). Findings were 
that measure patient satisfaction with nursing care (Lewis & 
the infection rate in occupationally related lacerations 
Woodside 1992). Dimensions of this included patient 
sutured by the nurse practitioner was low (3á1%) in a 
satisfaction ratings of components of nursing care and 
setting where a high infection rate might be anticipated. 
satisfaction with information received on a visit to the 
Furthermore the review suggested that work site avail- 
emergency department. One hundred and ®fty-two patients 
ability of a nurse practitioner with expertise in suturing 
participated in this study. Of this number, 87á4±97á1% were 
and aseptic technique was correlated to a low infection 
satis®ed or very satis®ed with the care given. Some negative 
rate. The study suggests that the nurse practitioners were 
comments were made regarding the lack of follow-up care 
able to decrease wound-related morbidity. by the registered 
nurses. Patients suggested that in order to 
Studies have been undertaken to evaluate patient improve 
nursing care in the emergency department staff 
satisfaction with emergency care provided by nurse 
 
E. Chang et al. 
practitioners. In one notable study a comparison was 
of the role across a range of competencies acceptable in 
made between medical practitioners and nurse 
a given context, and development of standardized, 
practitioners (Powers et al. 1984). This study compared 
acceptable protocols. knowledge, satisfaction and 
compliance in a cohort of non-urgent emergency room patients (n = 62) who were treated by either a physician or nurse 
practitioner. The 
Aims of the study 
study had an experimental ®eld design with the nurse 
It was hypothesized that there would be no signi®cant 
practitioners constituting the experimental group and the 
difference in the quality of care, or the level of client 
physicians functioning as the control group. The most 
satisfaction, provided by the medical of®cers and the 
common presenting problem for subjects allocated to the 
nurse practitioners in the study. nurse practitioners was cold 
or sore throat. However, the 
In substantiating this hypothesis, it was expected that 
nurse practitioners were required to manage a range of 
the study would: clinical problems. The data in the study 
were collected via structured interviews, telephone survey at 2 weeks and 3 months, mailed questionnaires and chart review. 
Satisfac- tion with care was measured by use of a ®ve-point scale and reasons for ratings were sought. 
Overall  the  study  found that there was no signi®cant difference between groups in overall compliance, appoint- ment keeping, 
number  of  health  recommendations  recalled, resolution of health problem and satisfaction ratings. Experimental subjects showed 
greater  compre-  hension  of  diagnostic  recommendations  and  therapeutic  applications,  while  controls  had  better  knowledge  of 
medications.  Interestingly,  `77%  of  experimentals  were  completely  satis®ed  with  NP  [nurse  practitioner]  care  as  compared  to 
only 48% of the controls with MD [medical 
264 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(1), 260±268 1 Demonstrate that nurse practitioners were 
able to provide a level of primary health service that is applicable to remote/isolated settings and is consistent with acceptable 
standards of service. 2 Compare wound management and treatment of blunt limb trauma by nurse practitioners with the care 
provided by resident medical of®cers. 3 Develop methodologies that may be used in the evaluation of care provision in the 
speci®ed compe- tencies and more widely in the evaluation of health care service provision in remote/isolated communi- ties. 4 
Develop a comprehensive nurse practitioner training 
programme for the identi®ed competencies. 
doctor]  care;  and  reasons  for  satisfaction  centred  on  the  quality  of  care,  while  reasons  for dissatisfaction focused on unresolved 
problems and slow care' (Powers et al. 
METHODOLOGY 
1984: 39). 
In the study the role the nurse practitioners undertook was 
Other claims made in the literature are that nurse 
consistent with an autonomous role that could have been 
practitioners can improve access to services, facilitate cost 
undertaken in a remote/isolated health care setting. The 
savings, and provide high quality care (Lewis 1980, 
study comprised a 4-month supervized competency trial 
Harford 1993). Harford (1993 p. 39) states: 
of four nurse practitioners and a 3​-month unsupervized 
`An  additional  advantage  of  the  NP  is  that  these  practitioners  bring with them to the primary care setting an added dimension of 
holistic  and  humanistic  care  incorporating  principles  of  health  maintenance,  health  promotion,  patient  education,  counselling, 
advocacy, collaboration and comprehensive, patient-centred care.' 
comparative  study  with  randomized  allocation  of  clients  to  nurse  practitioners  and  resident  medical  of®cers.  The  results  were 
used  to  evaluate  the  treatment  decisions  of  nurse  practitioners  providing  a  primary  clinical  service  in  a  rural  emergency 
department. 
In conclusion, the extant literature shows that the concept of the nurse practitioner in emergency areas has 
Sample selection 
some appeal internationally. However, generally speak- 
The study population consisted of all clients, identi®ed ing, 
the role remains ill de®ned. Data exist to demon- 
as potential study participants by the triage nurse, who 
strate that appropriately prepared emergency nurse 
presented to the emergency department with blunt limb 
practitioners can assist in the management of non-urgent 
trauma or open wounds to the scalp, lower leg or forearm 
cases. A major bene®t here is decreased waiting time for 
between the hours of 07á00 and 24á00 when there was a 
nurse treatment. Where patient satisfaction with treatment has 
practitioner on duty. These categories included a range of 
been evaluated, it seems that in most cases nurse 
problems and interventions including: blunt trauma; 
practitioners were able to meet consumers' needs as well 
insect/animal bites; crush injuries; contaminated wounds; as 
medical of®cers. Australian issues remain, however; 
burns; simple fractures; lacerations and simple suturing; 
these include the role and responsibilities appropriate to 
wound management; administration of local anaesthetic; 
the nurse practitioner in emergency departments, 
administration of tetanus toxoid; and prescription of lim- 
standardized training and accreditation, evaluation 
ited antibiotics and pain relief greater than paracetamol. 
 
Issues and innovations in nursing practice Nurse practitioner role 
The following were excluded from the study: 
informed by a range of insights from the literature and 
· children under the age of 10 years; 
· clients with signi®cant presenting and continuing vital signs alterations; 
· clients presenting with multiple trauma; 
· clients presenting with high risk mechanisms of injury; 
· clients presenting with concurrent health problems in need of urgent treatment; and 
· clients requiring resuscitation. 
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(1), 260±268 265 professional experience. Speci®c reasons for 
the selection of wound management and treatment of blunt limb trauma as the focus in this pilot study include the following: the 
model of treatment was deemed to be accessible; it represented a signi®cant change to existing nursing roles in the emergency 
department; technical competence was readily assessable; health practitioners could be readily identi®ed; and the competencies 
could illustrate the nurse practitioners' capacity for role autonomy. Once potential study participants were identi®ed they were 
invited to participate in the study. Following proce- dures of informed consent (National Health & Medical 
Instruments 
Research Council, NH & MRC 1992) individuals were 
The following data collection instruments were used in 
randomly allocated to a nurse practitioner or medical 
the study: of®cer on duty. 
Demographic details 
Study design 
These included: date of birth; postcode of residential address; gender; language; ethnicity; and presenting The primary design 
was a randomized trial. Using this 
problem. approach, the project evaluated the care provided 
to clients randomly assigned to either treatment provided by 
Health service use a registered nurse working in a role 
considered to be 
This included: information on health services used by the a 
nurse practitioner role or resident medical of®cer. The 
person in the last 12 months, on a scale of not at all, once 
evaluation of the project was based on two phases, 
or twice, once or twice over the months, every couple a 
training phase and an evaluation phase. 
of months, once a month, or more regularly; and details of general practitioner, local hospital, community health Training phase 
services, and specialist medical of®cer. A training phase 
was developed in which four experi- enced emergency nurse clinicians who had consented to 
Clinical assessment participate in the trial (NH & MRC 
1992) were provided 
This included: the problem requiring management; other 
with competencies in the management of wounds and 
 problems identi®ed; relevant health history; current treat- 
blunt limb trauma essential to the role of the nurse 
ment; clinical ®ndings; and physical examination. 
practitioner in the remote/isolated setting. This training was provided by experienced medical staff and clinical 
Clinical management plan nurses servicing the hospital 
emergency department, and 
This included: provisional assessment ®ndings; details of 
academic staff from a university. The training programme 
any consultation with a medical of®cer and whether that 
incorporated an intensive series of lectures coupled with 
consultation was deemed necessary by the medical of®cer; 
supervized practice for 4 months in the selected compe- 
and comments by the nurse practitioners and medical 
tencies. 
of®cers. 
Evaluation phase 
Clinical care plan The evaluation phase consisted of: a 
comparative 
This included: the management of the problem; any 
evaluation of client satisfaction/outcomes; a comparative 
pathology or radiology investigations recommended by 
evaluation of the clinical outcome of the wounds; practi- 
the nurse practitioner; and referrals made by the nurse 
tioner self-evaluation, which included their perceived 
practitioner and to whom these were made and at what level 
of competence and decision making, and level of 
time. satisfaction with the role of nurse practitioner; and a 
documentation review of the treatment of the nurse 
Clinical reviews practitioner clients based on the treatment 
record. 
Follow-up of nurse practitioner assessment and clinical management was undertaken using the randomized Protocol 
sample allocated to the nurse practitioners in the study. The 
protocol for the study was developed by several 
This procedure involved review and retrospective members 
of the project team, including medical and 
analysis of client records by the Director of Emergency 
nursing personnel. Development of the protocol was 
Services and Clinical Nurse Consultant (Emergency) using 
 
E. Chang et al. 
predetermined protocols. This was undertaken with 
only six Aboriginals (2á5%) entered the study. The regard 
to the following: the clinical review consisted of 
primary language for the majority of participants was seven 
areas: agree or disagree with regard to the following: 
English (99á2%). One participant's primary language was 
protocol followed; deviation justi®ed; appropriate 
Korean (0á4%), and another spoke Cantonese (0á4%). 
investigations recommended; appropriate treatment and 
Participants were drawn from 51 suburbs/towns. therapy 
recommended; alternatives appropriately 
Two hundred and thirty-two clients participated in the 
documented; appropriate referral recommended; and 
study. Of this number 63 were supervized cases in the 
change in clinical management recommended in future. 
pilot trial. In the randomized trial participants were distributed between nurse practitioners and medical Measure of client 
satisfaction 
of®cers using a randomization table (n = 169). Males Five 
items were used to measure client satisfaction on 
and females were almost evenly distributed in the a 
four-point Likert scale (very dissatis®ed, dissatis®ed, 
randomization between the two groups. There were 105 
satis®ed, very satis®ed). Questions incorporated satisfac- 
males and 64 females in the randomized trial. Ninety-one 
tion with overall treatment in the emergency department, 
participants were randomized to medical of®cers and 78 
with the explanation given before treatment, satisfaction 
to nurse practitioners. The trial included patients with with 
the advice given after the treatment, degree of 
open and closed wounds and/or blunt limb trauma. 
satisfaction with treatment, and satisfaction with waiting 
Furthermore, the open and closed wounds were approx- 
time before treatment. Participants were also asked 
imately equally distributed between the nurse practitio- 
whether they would be willing to see the same health 
ners and the medical of®cers. professional again and to 
give a reason for this. In addition 
The majority of study participants were surveyed for 
participants were asked for one suggestion for 
client satisfaction (n = 132), this represents approximate- 
improvement in emergency department services which 
ly 78% of the randomized sample. Almost 7% could not 
they would like to see on subsequent visits. Efforts were 
be followed-up because of change of address. A further 
made to contact all clients who participated in the study 
6% had no telephone and were therefore not included in by 
telephone to ascertain satisfaction with treatment and 
the survey. Almost 8% were telephoned but were service. 
Telephone interviews were conducted by a non- 
uncontactable. For 2% of the sample the telephone health 
professional who was unaware of who had treated 
number recorded initially was found to be incorrect. Of 
individual clients. This was to control for bias. 
the 132 participants in the study who were surveyed for satisfaction, 71 were treated by a medical of®cer and 61 Measure of 
clinical outcomes 
were treated by a nurse practitioner. Multivariate analysis 
Clients who were treated for open wounds in the study 
was carried out on the ®ve interval scales of measurement, 
were invited to return to a clinic 2 to 3 months after their 
and differences in these scores between the clients of 
treatment. This invitation was issued immediately follow- 
these two groups (nurse practitioners and medical of®cers) 
ing treatment and by a follow-up telephone call. Those 
were tested. Overall there were no signi®cant differences 
clients who returned were subjected to blind review by a 
between the two groups in all areas of care. When asked if 
consultant orthopaedic surgeon who evaluated individual 
they would see the same professional again, 60 out of 
wounds for cosmesis and function using a 10-point linear 
61 clients treated by the nurse practitioner, and 66 out scale. 
of the 71 treated by the medical of®cers, responded in the af®rmative. Clinical reviews were also conducted on all 
Data analysis techniques 
participants; the results of the review showed that the protocol was followed in all cases by nurse practitioners. Appropriate 
descriptive statistics were used for demo- 
Furthermore there was no signi®cant difference in waiting 
graphic and epidemiological data. Multivariate and chi- 
time between the two groups. square were used to examine 
differences with clients by 
Finally, in the area of follow-up wound assessment by 
two groups of practitioners. The computer software 
an orthopaedic surgeon, only 16 participants took up 
package SPSS-PC was used for the quantitative analysis. 
the invitation for evaluation of their wounds for cosmesis 
Content analysis was applied to the qualitative data from 
 and function. Of this number nine participants had been 
in-depth interviews and written responses of nurse 
treated by a medical of®cer and seven were treated by the 
practitioners and clients. 
nurse practitioners. The majority of outcomes were rated between seven and ten on both dimensions. 
RESULTS 
Age of the participants ranged from 10 to 77 years. The 
DISCUSSION 
mean age for study participants was 28 years (SDSD = 14á2). 
This study found that there was strong support for the role 
The majority of participants were non-Aboriginal (97á5%); 
of the nurse practitioner in the rural emergency setting. 
266 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(1), 260±268 
 
Issues and innovations in nursing practice Nurse practitioner role 
The nurse practitioners were accepted by medical staff 
needs to be considered in evaluating the study is that the 
and the participants in the study. Consumers were 
nurse practitioners had ready access to medical practitio- 
satis®ed with the treatment provided by the nurse 
ners at all times during the project. This means that their 
practitioners in the emergency department. The telephone 
ability to perform at the level achieved in the study has not 
interviews in the follow-up phase of the study indicate 
been tested in remote/isolated areas. However, they only 
strong acceptance and support for the service. Similar 
consulted medical of®cers to read X-rays in the study. 
results were found in the studies conducted by Strange (1994) and Lewis & Woodside (1992). Analysis of data generated by the 
client satisfaction survey shows very 
CONCLUSION 
positive results, although there were no signi®cant differ- 
Several directions for the nurse practitioner role are ences 
between the two groups of practitioners. It also 
possible given the ®ndings of this study. This pilot study 
suggests that the nurse practitioners' performance in the 
met its aims in that it demonstrated that registered nurses 
selected competencies was not signi®cantly different to 
working in a nurse practitioner role can be trained in the 
that of the medical of®cers in the study. 
selected competencies to a point where they can provide 
Interviews and documentations were also sought from 
a level of service consistent with acceptable standards. It 
the nurse practitioners who participated in the study. The 
also developed methodologies for evaluation of nurse 
nurse practitioners found their job satisfying and reward- 
practitioner care provision in the speci®ed competencies 
ing and their self-perceptions of competence increased 
and implemented and evaluated a speci®c training 
overtime. The experience overall was regarded as positive 
programme. 
and worthwhile. It increased the self-esteem, con®dence, 
Further issues regarding the role of the nurse practitio- 
competence, knowledge and skill of the nurse practitioners. 
ner remain. This study examined training for, and perfor- 
Service convenience was also a feature of this study. 
mance in, wound management and treatment of blunt 
There was no difference in the waiting times between the 
limb trauma only. Consistent with ®ndings from the 
two groups in the study. The ®ndings of the study suggest 
literature, this study demonstrated that appropriately 
that provision of this service may have potential bene®ts 
prepared emergency nurse practitioners can assist in the for 
isolated areas. Service choice is enhanced by avail- 
management of non-urgent cases. A bene®t here is ability 
of nurse practitioners in the emergency depart- 
decreased waiting time for treatment. This study supports 
ment. This is because consumers are allowed to access 
a training programme for nurses in the speci®ed 
one service or the other offered in the department. It is 
competencies to enable them to practice in the rural 
important to note that no one left the study. Some 
setting. The issues which remain include the need to 
participants were re-assigned in the study, this was 
examine the role and responsibilities appropriate to the 
justi®ed on the basis of, and to comply with, national 
nurse practitioner in emergency standardized training and 
triage scale times. The service provided by the nurse 
accreditation, evaluation of the role across a range of 
practitioners was accessible. Nurse practitioners were 
competencies acceptable in a given context, and 
available on the majority of shifts for the 3​-month 
development of standardized, acceptable protocols. 
unsupervized comparative study. During this time 78 clients were treated by the nurse practitioners. This was 
References achieved without additional staf®ng in the 
emergency department and the safety and risk management issues were not compromized in the study. Similar positive ®ndings 
were found by Burgess (1992), where the nurse 
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signi®cant proportion of the population. Medical of®cers practising in rural areas are required to cope with an inordinate 
workload. Training rural nurse practitioners to pick up some of this workload meets a community need. However, the ®ndings of 
this study need to be interpreted cautiously within the 
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