Chapter 1: Introduction to Emergency Nursing Practice

Introduction

This chapter provides a broad introduction to emergency nursing as a practice speciality in the United Kingdom (UK). It begins by comprehensively defining emergency nursing, identifying it as a specialty which requires nurses to work with a variety of patients, manage various clinical conditions, and practice in a range of different settings. The chapter goes on to consider the origins and development of the speciality, the diverse role of emergency nurses, the current context of emergency nursing practice in the UK, and options for undergraduate and postgraduate pathways into the speciality. Finally, it analyses some of the complex legal and ethical issues relevant to practice in an emergency care setting, and discusses the key challenges in the future of emergency care nursing in the UK. The aim of this chapter is to provide you with a general overview of emergency nursing as a practice speciality, and so to prepare you for your progression through the remainder of this module and, perhaps, for your practice as an emergency nurse.

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To define emergency nurses' diverse scope, roles and required skills / knowledge.

-To describe the emergency nursing context - including the diverse types of patients, presentations and settings in which emergency nurses in the UK practice.

-To discuss the origins of emergency care provision and emergency nursing in the UK.

-To be familiar with the pathways into emergency nursing practice in the UK.

-To be able to list the broad values shared by emergency nurses internationally.

-To understand the complex legal and ethical issues relevant to emergency nursing practice.

-To be aware of the challenges facing the future of emergency nursing in the UK. 

What is emergency nursing?

Emergency nursing involves the episodic care of people with physical and / or psychological health problems. These health problems: (1) may result from injury and / or illness, (2) are usually acute, and (3) require further, often immediate, investigation and / or intervention. Emergency nurses care for people of all ages, and work with conditions which may affect any - or, indeed, all - of the body's systems. Often (though not always), patients requiring emergency care are physiologically (or psychologically) unstable, have complex health and other needs, and require intensive nursing care. As with all nursing care, emergency nursing care is provided in a way that is patient centred - that is, focused on the individual patient and their unique needs, wants and preferences.

Emergency nursing care may be delivered in a variety of settings - including in accident and emergency (A&E) departments, minor injury units, ambulance or other acute transport services, out-of-hours walk-in centres and in the armed forces. These settings usually allow for the unplanned or unscheduled presentation of a patient, often without prior warning, either via self-referral or referral from another service (e.g. a road ambulance service, a helicopter emergency service, another hospital or health care service, etc.). In emergency settings, care is often provided on an 'as-needed' basis - usually outside regular working hours, and often continually 24 hours per day, 7 days per week.

As with general nursing, emergency nurses work within the assessment  planning  intervention  evaluation (APIE) framework. The emergency nurse's role includes a range of general nursing tasks, such as rapid patient assessment, making accurate diagnoses, allocating priorities for care, delivering treatment interventions, monitoring and evaluating care, and facilitating discharge and referral, etc. However, because they work with diverse populations and manage a variety of different disease processes, emergency nurses must also possess a range of specialist nursing skills. These specialist skills include the ability to comprehensively assess patients, to effectively resuscitate and provide life-sustaining care to patients, to apply sound clinical judgement to diagnose and manage a range of traumatic injuries and serious physical / psychological illnesses, to practice effectively in large interdisciplinary care teams, and to engage positively with the public in what is often a stressful and emotionally-charged environment.  You will study and develop each of these specialist skills as you progress through this module. 

Origins of emergency care provision in the UK

Emergency nursing - and, indeed, emergency medicine generally - is a relatively new specialisation, both in the United Kingdom and internationally. The speciality of emergency medicine emerged in the 1960s; prior to this, orthopaedic surgeons managed 'casualty departments' which focused on the care of acute injuries, rather than acute illness. The focus on orthopaedic injury in the delivery of emergency care may have had its origins in the Second World War; during this period, the vast majority of emergency cases seen in healthcare settings in the UK and Europe involved orthopaedic and associated injuries. However, because of their limited focus, and because they were often staffed only when they were required, these 'casualty departments' failed to meet the growing demand of the UK population for emergency care. This saw the development of broader emergency care services - including, initially, A&E Departments in hospital settings, and gradually other urgent and unscheduled care settings, including minor injury units and out-of-hours walk-in centres, etc. As will be described in greater detail in a later section of this chapter, as the provision of emergency care services in the UK grew and developed, so did the speciality of emergency nursing.

The emergency nursing specialisation

As explained earlier in this chapter, emergency nursing is a diverse specialisation. Emergency nurses work with a variety of patients, manage various clinical conditions, and practice in a range of different settings. Read the following from a Registered Nurse in the UK, who explains the diversity of the emergency nursing speciality and the range of options available to those who chose to work in this field:

Quote

"After five years in theatre and a year on a cancer ward, I felt increasingly drawn to the intensity of accident and emergency. When I made the move, it was amazing. I was shown how to cope with absolutely anything and did things I never dreamed of: I went out with the flying squad, attended major accidents, plastered, sutured, prescribed, learned how to recognise fractures and request X-rays, and became an independent practitioner.

Soon I wanted even earlier contact with emergency patients, so I applied to East Midlands Ambulance Service. My current role is completely different - I'm a triage nurse based in the control room. Now I never actually see my patients, as I handle the 999 calls with less urgent coding: anything from abdominal pains to minor injuries. Specialist software helps us to make diagnoses by phone and determine the best course of action: GP or nurse referral, self-care advice, even an ambulance callout."

NHS Nursing Careers, ND

Currently, emergency nursing is not one of the specialist fields which UK nursing students can study as part of their undergraduate nursing degree. However, the specialist fields of adult nursing, children's nursing or mental health nursing may all provide opportunities for nurses, once graduated and registered, to work in an emergency care context. Nurses may also undertake a postgraduate qualification - for example, a diploma, which usually includes a dissertation component - to build their knowledge, skills and qualifications for employment in an emergency care setting. Depending on the type of postgraduate qualification undertaken, nurses may also specialise in a particular area of emergency care - for example, emergency paediatric care, emergency burns care or emergency trauma care, etc. 

The Royal College of Nursing's (RCN) Emergency Care Association represents nurses working, or wishing to work, in emergency, urgent and unscheduled care settings in the UK. The Association provides useful professional development opportunities for nurses interested in or currently working in the emergency nursing specialisation (e.g. study days, conferences, self-directed learning, professional forums, etc.). You are encouraged to visit the Association's website, which can be accessed online by searching for its title.

The emergency nursing context

As noted earlier, emergency nurses must be able to effectively care for diverse populations. In the UK, the four most likely groups to present to A&E Departments are people aged >90 years, people aged 80-89 years, people aged 20-29 years, and people aged 0-9 years. In younger age-groups (<29 years), women are more likely than men to present to an A&E Department; however, in older age-groups (>35 years), men are slightly more likely than women to present. The ability to communicate with, assess and provide treatment to paediatric, adolescent, adult and elderly populations, and people of all genders, is clearly a fundamental skill for emergency nurses!

Also highlighted earlier, emergency care services in the UK are often provided outside regular working hours, and sometimes continually on a 24/7 basis. Statistics compiled by the National Health Service (NHS) suggest that the two busiest days in terms of A&E attendance are, interestingly, Mondays and Sundays. Most people attend A&E Departments during business hours, between 9am and 6pm; generally, the busiest attendance time is 11am, though ambulance arrivals at A&E Departments tend to peak at 3pm, and the quietest time is 5am. People tend to present to A&E Departments for different reasons at different times across the week; for example, presentations for injuries due to road traffic accidents are highest at 6pm on weekdays, and presentations for assault are highest during the early hours of Sundays. Regardless of the shift onto which an emergency nurse is rostered, they will encounter a diverse and challenging practice environment.

People may present to A&E for a wide variety of reasons - consider the following common examples:

Orthopaedic injuries (e.g. fractures, sprains, strains, dislocations, etc.).

Traumatic injuries (e.g. from road traffic accidents, falls, strikes, etc.).

Cardiovascular disorders (e.g. acute coronary syndromes, heart failure, etc.).

Respiratory disorders (e.g. acute respiratory failure, asthma exacerbation, etc.).

Gastrointestinal and hepatic disorders (e.g. bowel obstruction, cholecystitis, etc.).

Renal disorders (e.g. renal failure, renal calculi, urinary tract infection, etc.).

Shock (e.g. due to hypovolaemia, sepsis, burns, spinal cord injury, anaphylaxis, etc.).

Poisoning (e.g. due to envenomation, severe drug / alcohol intoxication, etc.).

Neonatal / paediatric problems; ostetric and / or gynaecologic problems.

Psychiatric - or mental health - emergencies.

The most common reasons for presentation to A&E Departments in the UK (2013/14 statistics) are listed following:

Diagnosis 'not classifiable' (14.2%). Dislocation, fracture, joint injury and / or amputation (4.6%). Gastrointestinal condition (3.8%). Laceration (3.8%). Sprain / ligament injury (3.7%). Soft tissue inflammation (3.6%). Respiratory condition (3.0%). Contusion / abrasion (2.6%). Head injury (2.4%). Cardiac condition (2.4%).

'Nothing abnormal detected' (2.0%). Ophthalmological condition (1.9%). Urological condition (1.8%). Ear / nose / throat condition (1.5%). Local infection (1.5%). Central nervous condition, excluding stroke (1.4%). Muscle / tendon injury (1.3%). Poisoning (0.9%). Infectious disease (0.8%). Gynaecological condition (0.8%).

Nurses in the emergency department may provide a range of treatments to the patients who present to these settings. The most common first treatments provided in A&E Departments in the UK (2013/14 statistics) are listed following:

Guidance / advice only. No treatment provided. Recording vital signs. Medication administered. Observation (e.g. electrocardiogram, pulse oximetry, etc.). Intravenous cannula insertion. Prescription / medications to take. Parenteral medications. Dressing. 'Other' treatment (not listed here).

Splint. Cast (e.g. using plaster of Paris). Wound closure (excluding suturing). Infusion of fluids. Bandage or other support. Wound cleaning. Sling / collar cuff / broad arm sling. Sutures. Nebuliser / spacer for a respiratory condition. Anaesthesia.

Statistics compiled by the NHS suggests that around 13% of people who attend an A&E Department are discharged without requiring any treatment, and another 35% receive advice and / or guidance only. However, this does not mean that these patients are attending A&E Departments unnecessarily, nor that they could be cared for in other settings. Indeed, there are a number of important reasons why people in the UK may present to A&E Departments for relatively minor complaints.

One key reason is the lack of general practitioner (GP) appointments available in the UK; indeed, the most recent UK GP Patient Survey suggests that 15% of patients requiring a GP appointment were unable to book one, and around 4% of these patients presented to an A&E Department instead. Confusion about the UK's complex healthcare system, particularly in relation to the services providing out-of-hours care, may be another reason that people present to A&E Departments for relatively minor complaints. As well, it is important that nurses practicing in an emergency care setting consider an individual patient's perceptions of what constitutes an 'emergency'; consider the following case study:

Example

Katherine is a graduate nurse working in an A&E Department of a large metropolitan hospital. On this shift, she has already helped to resuscitate an elderly man in cardiac arrest, and stabilised a critically injured woman involved in a road traffic accident.

Katherine's next patient is Alice, a young woman with a persistent urinary tract infection.

In comparison to Katherine's other patients during the shift, Alice is well. Her only symptoms are moderate abdominal pain (rated at 7/10), occasional nausea and a fever of 38.2 Celsius. However, to Alice these symptoms are significant; she feels more poorly than she ever previously has, and she believes her condition justifies her presentation to the A&E Department - particularly as she was unable to book a GP appointment for that day. In order to provide effective and high-quality care to Alice, it is important that Katherine respects Alice's perceptions of what constitutes an 'emergency'.

It is also important for nurses to be aware of the ever-changing context in which they practice. In the UK, there have been a number of recent, and relatively major, policy shifts in relation to the delivery of emergency services. In particular, there has been a rapid expansion of nurse-led emergency services, such as minor injury units, which require emergency nurses to practice in a largely autonomous capacity. The emergency nurse's role has expanded, and nurse practitioners are now often responsible for leading the triage of patients in tertiary emergency care settings. The development of protocols relevant to the emergency care context - most notably, for the management of traumatic injury - have been implemented in an attempt to improve the efficiency and cost-effectiveness of the delivery of emergency care. If you practice as an emergency nurse, it is important that you remain abreast of the changes in the specialty, and that you are aware of how these changes affect you, your patients and your practice.

Values of emergency nursing

Interestingly, there is no professional body dedicated solely to the emergency nursing practice speciality in the UK. However, there are nations with healthcare systems broadly comparable to that of the UK which do have professional bodies for emergency nursing - for example, the Emergency Nurses Association (United States of America [USA]), the College of Emergency Nursing Australasia (Australia), the National Emergency Nurses' Affiliation (Canada), etc. These organisations describe a range of values which provide a framework for the provision of emergency care by nurses, including those broadly applicable to the UK nursing context:

The emergency nurse…

• Provides care which is comprehensive, accurate and ongoing.
• Utilises clinical judgement to analyse assessment data and make nursing diagnoses.
• Identifies expected outcomes, and evaluates the care provided against these.
• Proactively modifies plans of care to ensure it continually meets a patient's needs.
• Recognises their learning needs, and engages in professional development.
• Ensures open and timely communication with patients, families and other staff.
• Provides care which is patient-centred and collaborative, wherever possible. 
• Adheres to accepted, established and relevant practice standards and legislation.
• Engages, at all times, in professional activities and behaviours.
• Values life, dignity, worth, autonomy and individuality, etc.

Activity

You are encouraged to browse the Emergency Nurses Association's position statements, which can be obtained online. Although these position statements have been written specifically for nurses practicing in the USA, they communicate many important values which are broadly relevant to nurses practicing in a variety of different emergency settings.

Legal and ethical considerations

There are a variety of legal and ethical issues relevant to practice as an emergency nurse in the UK. Some of these legal and ethical issues can be complex; however, it is important to note that your organisation's policies and procedures will assist you to understand how they should be applied in the course of your day-to-day work. This section of the chapter will consider key legal and ethical principles related to consent, duty of care, scope of practice, negligence, restraint, and privacy and confidentiality in the context of emergency nursing care.

Consent: Consent is the agreement of a patient to submit to proposed investigation or treatment. Although it is a fundamental requirement in all nursing settings, consent is a particularly important consideration in the emergency nursing context where the care provided is often fast-paced, and may progress with little direct patient involvement. It is important to remember that a nurse may face professional disciplinary action, and / or be charged with trespass, assault and / or battery, if they fail to obtain adequate consent from a patient prior to commencing an investigation or treatment.

Consent may be provided in written, verbal or non-verbal form. Once given, consent applies indefinitely; however, it may also be refused or withdrawn at any time, if a patient considers this in their best interest - even if this places their wellbeing at risk. In the emergency nursing context, seeking consent can be thought of as a 'process'; nurses should continually seek the consent of patients to provide investigation and / or treatment, rather than during a single event. Consider the following case study:

Example

Mark is a senior nurse practitioner who manages a minor injury unit. During the course of a shift, he:

-Obtains written consent; he requests that a patient signs a consent form for a minor surgical procedure to remove a small piece of metal embedded in their thumb.

-Obtains verbal consent; he provides information to a patient about the importance of an intravenous cannula for antibiotic administration in the management of their minor burn, and then asks a patient if it is okay for him to proceed. The patient replies, "Yes, go ahead."

-Obtains non-verbal consent; he asks a patient who has presented with a migraine if it is okay for him to measure her blood pressure. The patient rolls up her sleeve and holds out her arm.

-Has consent refused; a patient presents with a small wound on the underside of his foot after stepping on a rusty nail. After explaining the risks of tetanus, he offers the patient a tetanus booster, however the patient replies, "No thanks, I'm terrified of needles!"

-Has consent withdrawn; a patient presents after a cycling accident, with gravel embedded in a flesh wound on their shin. After initially agreeing to allow Mark to wash the wound to remove the gravel, the patient then says, "Stop! It's just too painful!"

For consent to be valid, or legally sound, "it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question" (Department of Health, 2009: p. 9). This statement includes a number of key ideas. Firstly, consent must be given voluntarily by a patient: under their own free will, without undue pressure, influence or duress. Consent must be informed: the patient must have received sufficient information to allow them to make a decision about whether to provide, refuse or withdraw their consent to submit to an investigation or treatment. Patients must be provided with information about the nature and purpose of the proposed investigation or treatment, the foreseeable risks associated with this investigation / treatment, the risks associated with not proceeding with the investigation / treatment, and alternatives if these exist. Finally, a person must have the capacity to provide consent: under the Mental Capacity Act 2005, the person should be considered to have no impairment or disturbance which may affect their capacity to make a decision.

As an emergency nurse, you may frequently deal with patients who are unconscious. It is important, therefore, to make a note about consent in unconscious patients. If a patient is unconscious, it is assumed that - in most situations - as a mentally competent person they would wish for all appropriate measures to sustain life and promote wellbeing to be taken by the professionals involved in their care. However, in some cases (particularly in patients who are palliated), advance decisions may be made to refuse life-sustaining measures, such as resuscitation; in these situations, the decision to refuse consent will be formally documented.

Duty of care: Duty of care is owed by a nurse to any person - and particularly patients - who may be affected by their actions, advice or admissions. A breach of duty of care occurs when a nurse fails to do what a 'reasonable' person would do in a similar situation, or does what a 'reasonable' person would not do. The standard of care expected is that of a nurse with an average level of skills, knowledge and experience. To maintain your duty of care, you must practice within your scope. Essentially, this means you must provide care consistent with your own skills, knowledge and experience, and not beyond what you have learned in your training and become qualified to administer. It is important to highlight that nurses working in emergency care settings come from a variety of professional backgrounds and, therefore, have diverse skills, knowledge and experience. Furthermore, an emergency nurse's scope of practice may be impacted by factors such as the type of emergency care setting in which they practice (including the degree of autonomy they are afforded), and the region in which they are located. A nurse may be found legally negligent if they work outside their scope of practice, breach their duty of care, and cause damage to the patient (e.g. injury or loss). To avoid breaching your duty of care and practicing negligently, you must be familiar with, and work within, your own scope of practice at all times.

Restraint: As you will see in a later chapter of this module, violence and aggression are considerable problems in emergency care settings in the UK. Restraint - that is, restricting a patient's movement, with the intention of protecting their own and / or others' safety - can be used in managing patients who are violent or aggressive, and particularly those who are mentally ill, intoxicated or otherwise incapacitated. There are two types of restraint: (1) physical restraint, or the restriction of movement by physical or mechanical means, and (2) chemical restraint, usually via the administration of sedative medication. Although there is a movement away from restraint in healthcare settings in the UK, it is essential that you are familiar with your organisation's policies and procedures for the appropriate use of restraint.

Privacy and confidentiality: Maintaining the right of patients to privacy and confidentiality is a requirement in all general practice settings, but is particularly important for nurses working in busy and fast-paced emergency settings. It is crucial that nurses working in emergency care settings understand with whom, and under what circumstances, they are permitted to share a patient's confidential information; for example, it may not be appropriate, in some instances, to discuss a patient's condition in a multi-bed bay in an A&E Department, or with a large group of the patient's relatives, etc. Nurses must also ensure they are familiar with their organisation's systems for the collection, recording and storage of a patient's confidential information in the busy, fast-paced emergency care settings.

Challenges for emergency nursing into the future

The context in which emergency nurses practice is increasing in complexity, and so becoming more demanding. The number of people attending A&E Departments - and particularly Type 1 or 'majors' departments - in the UK is continually increasing; indeed, 22.3 million people attended A&E Departments in 2014/15, an increase of 35% from the previous year. In some months in the summer of 2015, nearly 56 500 patients attended A&E Departments in the UK each day. As the prevalence of chronic disease in the UK population increases, and the population ages, the demand for critical care services will continue to grow. Monitoring from 2015/16 suggests that A&E Departments in the UK are struggling to meet this demand for service, and continually fail to meet service delivery benchmarks (in particular, those related to wait times). It is essential that nurses practicing in emergency care settings in the UK are well-equipped with the skills and knowledge necessary to meet these challenges, and to contribute to the delivery of effective, high-quality emergency services.

Conclusion

This chapter has provided a broad introduction to emergency nursing as a practice speciality in the UK. It has introduced emergency nursing as a diverse and complex practice specialty; one which requires nurses to work with a variety of patients, manage various clinical conditions, and practice in a range of different settings. It has considered the origins and development of the speciality, the diverse role of emergency nurses, the current context of emergency nursing in the UK, and options for undergraduate and postgraduate pathways into the speciality. Finally, it has analysed some of the complex legal and ethical issues relevant to practice in an emergency care setting, and discussed the key challenges in the future of emergency care nursing in the UK. At the conclusion of this chapter, you should have a general understanding of emergency nursing as a practice speciality. You should also be prepared for your progression through the remainder of this module.

Reflection

Now we have reached the end of this chapter, you should be able:

-To define emergency nurses' diverse scope, roles and required skills / knowledge.

-To describe the emergency nursing context - including the diverse types of patients, presentations and settings in which emergency nurses in the UK practice.

-To discuss the origins of emergency care provision and emergency nursing in the UK.

-To be familiar with the pathways into emergency nursing practice in the UK.

-To be able to list the broad values shared by emergency nurses internationally.

-To understand the complex legal and ethical issues relevant to emergency nursing practice.

-To be aware of the challenges facing the future of emergency nursing in the UK. 

Reference list

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Department of Health. (2009). Reference Guide to Consent for Examination or Treatment: Second Edition. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf

Evans, N. (2016). Relieving pressure on struggling emergency departments. Emergency Nurse, 24(1), 26-29.

Fawdon, H. & Adams, J. (2013). Advanced clinical practitioner role in the emergency department. Nursing Standard, 21(16-18), 48-51.

General Medical Council. (2008). Consent: Patients and Doctors Making Decisions Together. Retrieved from: http://www.gmc-uk.org/static/documents/content/Consent_-_English_1015.pdf

House of Commons Library. (2015). Accident and Emergency Statistics. Retrieved from: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06964

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy's Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

International Council of Nurses. (2010). History of the Accident and Emergency Nursing Association in the UK. Retrieved from: http://www.icn.ch/networks/history-of-the-royal-college-of-nursing-accident-and-emergency-nursing-association/

Jones, G., Endacott, R. & Crouch, R. (2007). Emergency Nursing Care: Principles and Practice. Cambridge: Cambridge University Press.

Kings Fund. (2016). What's Going on in A&E? The Key Questions Answered. Retrieved from: http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters

Marr, S., Steele, K., Swallow, V., Craggs, S., Procter, S., Neton, J., Sen, B. & McNabb, A. (2003). Mapping the range and scope of emergency nurse practitioner services in the Northern and Yorkshire region: A telephone survey. Emergency Medicine Journal, 20(1), 414-417.

NHS Nursing Careers. (ND). Paul Malone: Triage Nurse. Retrieved from: http://nursing.nhscareers.nhs.uk/stories/paul_malone

Royal College of Nursing. (2016). RCN Emergency Care Association. Retrieved from: https://www2.rcn.org.uk/development/nursing_communities/rcn_forums/emergency_care

Wales NHS. (ND). Day in the Life of an Emergency Nurse Practitioner. Retrieved from: http://www.wales.nhs.uk/sitesplus/documents/863/Day%20in%20the%20life%20of%20an%20emergency%20nurse%20practitioner.pdf