A 10 year old child with a history of blunt trauma of two hours enters the Emergency Department triage counter. He is encountered by a triage nurse who has 1 year of experience in the Emergency department with a general diploma in nursing and no special ED courses. The triage nurse categorizes the patient as priority three and puts him into waiting list due to non-availability of bed. A senior nurse with an experience of 9 years, however, reassesses the child immediately and upgrades his equity level to immediate and sends him for instant resuscitation. The child is then encountered with a nurse of 2 years of experience, but without any ED specific credentials – who again does not prioritize the child despite a prediction of internal abdominal bleed, and the treatment of the boy is delayed. The resuscitation nurse was not certified for PALS and thus ends up in a chaotic situation when the patient crashes.
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Emergency nursing is a multidimensional specialty of nursing; requiring integration of knowledge, skills, critical thinking and leadership for provision of quality patient care. An emergency nurse is a midpoint where all primary, secondary and tertiary care requirements of the clients intersect (Emergency Nurses Association). Nurses working in the emergency department of hospitals are required to possess the quality of assessing the condition of patients before the physical appearance of signs and symptoms. ED nurses are expected to acquire the skills of predicting the future condition of patients and intervening appropriately (Valdez, 2009). It is mandatory for ED nurses to identify, prioritize and assess life-threatening cases, give emergent and non-urgent care according to the equity levels, and provide competent quality care in an environment of commotion and chaos (Valdez, 2009). Emergency departments are surrounded with multiple problems of overcrowding, aging nurses, conflicting multidisciplinary teams, workplace dissatisfaction and salary disappointments (Fordyce et al, 2003); however, emergency nurses, despite all these issues, require specialized ED education apart from nursing degrees (Kirstin & Henrik, 2009). Errors in the emergency department occur due to multiple reasons of overcrowding, delayed patient stay, disrupted sleep cycles of the staff and extreme pressure of the work (Fordyce et al, 2003). However, one can also deduce incompetency of ED nurses as a reason for errors in ED of hospitals. Thus nurses recruited and working in the ED require core competencies to provide quality care to patients.
The search engines used in this literature review were CINAHL, MOSBY NURSING INDEX and GOOGLE SCHOLAR. A number of articles were derived from these databases, which were filtered using the advanced search options of either specifying the search to Pakistan or making it a time bound search starting from year 2000 to year 2012. Common keywords used for search were ‘competency of emergency nurses’, ’emergency nurses competency’, emergency nurse competencies’ and ‘concept of competency’. The articles found in GOOGLE SCHOLAR were accessed through CINAHL, MOSBY NURSING INDEX and SCIENCE DIRECT.
CINAHL revealed 13 results for the keywords ‘competency of Emergency nurses’ out of which 2 were used; 497 results for ’emergency nurses competency’ between the years of 2000 – 2012, out of 3 articles were utilized; and 15 results for ‘concept of competency’ out of which 1 result was referred. The database of MOSBY NURSING INDEX revealed 411 results for ’emergency nurses competencies’ of which 3 results were availed. Along with this, JOURNAL OF EMERGENCY NURSING, accessed through the database of SCIENCE DIRECT, revealed 283 results for ’emergency nurse competency’ from years 2000 to 2012, out of which 9 results were used. All the articles referred were selected on the basis of their abstracts and relevance to the research question.
Moreover, specific websites of EMERGENCY NURSES ASSOCIATION, AMERICAN NURSES ASSOCIATION and PAKISTAN NURSING COUNCIL were used to extract competency based practice specific to emergency nursing. These websites were accessed through the website WWW.GOOGLE.COM. To add on, the INTRANET/JCIA database of the tertiary care hospital internal system was also used to find the accreditation criteria of the hospital to judge the standards of practice required for ED nurses. Furthermore, the data base of PUBMED was also used to find relevant literature studies in Pakistan and other Asian countries using the same keywords; however, there was a dearth of literature support. According to the search engines, multiple researches have been conducted in Canada and United States of America which have been used as a base for this literature review and formulation of relevant research question. The searched articles consisted of variety of methodologies including Qualitative, Quantitative, Meta analysis of literature and Concept analysis.
Competence is defined as the capability of an individual to perform certain skills and tasks (Henrik & Kerstin, 2009) using intellectual and interpersonal attributes. Patricia Benner in 1984 according to Smith (2012) explained nursing competence as the ability of the nurse to integrate knowledge and skills together to perform improved quality care of the patient. Proehl (2002) defined competence as “a cluster of related knowledge, attitudes, and skills that affect a major part of one’s job; that correlates with the performance on the job; and that can be measured against well accepted standards”. Emergency Nurses Association defines competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (Andrew, Allison, Gabriel, & Stephen, 2009) . Clinical competencies have been divided into two parts: the first level is acquired at orientation into the specialized nursing area and the second level is an ongoing learning and evaluation process (Bolin, Peck, Moore, & Smith, 2011); necessary for professional up gradation of nurses working in the emergency departments. The Institute of medicine (IOM) publication Future of Nursing: Leading Change, Advancing Health has provided 2 key messages for ED nurses by focusing them for optimal use of their nursing knowledge and concentrating on upgrading their knowledge and skills according to the specialty requirements of Emergency department (Howard & Papa, 2012).
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Emergency nurses association (ENA), an international forum, has defined core competencies of the ED nurses and made them a necessary prerequisite for nurses working in ED throughout the world. According to ENA, all ED nurses are required to clear core competency courses of Advanced Care Life Support (ACLS), Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), Basic Trauma Life Support (BTLS), Advanced Trauma Life Support (ATLS), Emergency Nursing Pediatric Course (ENPC), management of critical patients including intubations and shocks, Myocardial arrests, IV access ECG monitoring, interpretation and analysis; assessment of minor and major injuries, care of obstetrics emergencies and psychiatric emergencies (Proehl, 2002). According to ENA principles and practices, nurses in ED are required to utilize their basic skills of assessment, planning, intervention and evaluation for patients with either underdiagnosed disease processes or no diagnosis and for patients requiring immediate to emergent care during their short 2 to 3 hours stay in the emergency department (Emergency Nurses Association). These, however, can be achieved through appropriate competency development of new recruits and existing employees in the emergency department; essential for quality patient care in a dynamic and unstable sociopolitical condition of Pakistan. The Pakistan Nursing Council, however, does not provide any specific guidelines for the standards of practice for nurses in Emergency department, but the code of ethics by PNC prioritizes knowledge up gradation of nurses for quality care (Pakistan Nursing Council Code of ethics).
Examples of various studies
Detailed orientation courses and ongoing learning programs have played important roles in the development of competent ED nurses. Various studies and articles support the use of competency based programs as a benchmark in converting nurses to emergency nurses. According to the JCIA standards of nursing practice, nurses should be provided with complete knowledge of the specialty area, so that they are well aware of their roles and responsibilities; and are able to develop these competencies according to the requirement of the institute (intranet/jcia). The South Naussa Communities hospital developed a fellowship program for new recruits based on ENA scope of practices which ultimately helped in an increased competency of ED nurses (Lisa, 2005). The fellows completing this program were more comfortable working in the chaotic and demanding environment of ED as they had the necessary knowledge, skills and attributes (Lisa, 2005). Valdez (2008) has identified cultural shock, stress, frustration, and inadequate preparation as the major themes for nursing staff turnover in the ED of hospitals. ED nurses feel less confident, incompetent and incomplete without adequate knowledge and skills required for working in the ED (Valdez, 2008). Another program organized in Cape Cod Hospital in Masaccheuttus provided new recruits a detailed 16 week program for development of competencies necessary for working in the Emergency department (Gurrey, 2002). The program proved very successful as nurses were able to adjust and perform optimally in ED (Gurrey, 2002). Canadian hospitals organized a 4 month competency program for ED nurses involving classroom teaching, adult experiential learning and work in the practical field as their major strategies (Loiseau, Kitchen & Edgar, 2003). The competency of ED nurses was evaluated on an ongoing basis by the senior nursing staff and medical officers who were affirmative about the increased confidence and knowledge of nurses undergoing these programs (Loiseau, Kitchen & Edgar, 2003). These examples formulate a strong framework on the importance of competency development, and ascertain it as a major requirement for provision of quality care in Emergency Departments of hospitals. However, lack of appropriate ED nurses’ competencies could be accounted as one of the reasons for decreased patient satisfaction in the tertiary care hospital of Pakistan. Thus it is necessary to define the core competency requirement of ED nurses in this tertiary care hospital for the provision of incredible patient care.
Development of competencies of ED nurses is important for improved and safe patient care. It is also vital in reducing nurses’ burnout and turnover as ED nurses feel less pressurized and develop more confidence. Due to dearth of studies in Pakistan, and successful nature of various competency based programs in hospitals outside Asia, it is probable that a study on the core competencies of ED nurses could be conducted in order to improve nursing practice and patient satisfaction in Pakistan.
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