You are on page 1of 43

Accident

& Emergency Nursing


... A Contribution to the Future

VA L U I N G D I V E R S I T Y. . . A W AY F O R W A R D
- W O R K I N G PA P E R N o . 1 .

2000
Department of Health, Social Services & Public Safety
An Roinn Sláinte, Seirbhísí Sóisialta agus Sábháilteachta Poiblí
Contents

Page

Recommendations 2

1.0 Introduction 8

2.0 Background 10

3.0 New Models of Service 18

4.0 Education and Training 23

5.0 Quality 25

6.0 Services for Children 28

7.0 Technology in Support of Care 32

8.0 Aggression and Violence 34

9.0 Recruitment and Retention 37

10.0 Appendices 39

1
Recommendations

Models of Service
1. The group envisages a service with main A&E departments based at the
major acute hospitals, with multi professional specialist teams led by
Consultants in Accident & Emergency Medicine. As an integral part of this
team, nurse led departments, such as minor injuries units could be
established. These nurse led departments would be based either within the
core A&E department or at a remote distance from it.
2. Key to these Minor Injuries Units will be the development of a clinical
network and the rotation of staff between the core and peripheral units. As
part of the continuing professional development and maintaining
professional standards of practice, staff in minor injuries units should work a
minimum of one week and ideally one month a year in an A&E
environment. This period should be tailored and extended to meet
individual needs as required.

Nursing Competencies
1. This report recommends the following model which defines nursing roles in
the Accident and Emergency and related departments.
Level 1 - This is entry level to the A&E environment. This period could
normally be expected to last a minimum of one year.
Level 2 - This period begins the consolidation of experience and practical
skills with knowledge and academic support. This period could be normally
expected to last a minimum of two years.
Level 3 - Nurses at this level would be expected to plan, deliver nursing
care, play an active role in education, training and support to other members
of staff. At Level 3 it is suggested that the term used to describe the nurse is
Nurse Practitioner irrespective of what emergency care environment the
practitioner is working in.

2
2. While it is essential that this nurse will have moved through levels 1 and 2 it
is not essential that they have completed their specialist practice module
before taking on this role. It would be expected that academic programs
would be developed to support the nurse’s move into this role.
The knowledge, experience and skills acquired in levels 1and 2 are
strengthened by an understanding of assessment and physical examination
techniques, decision making, a recognition of the scope and limitations of
professional practice and an indepth appreciation and understanding of
professional regulation and medico legal issues.
3. These levels are not necessarily essentially defined by academic
qualifications but by the skills and competencies required to complete the
roles at each level.
4. The Group welcomes the development and implementation of the new Nurse
Consultant role. It is envisaged that these posts would create a level 4 nurse
who as an expert practitioner would lead nurses in the development of
practice, education, standard setting and audit and advance the development
of new roles in emergency nursing in Northern Ireland.

Education
1. The Group recommends that education programmes should:
• Be competency based;
• Have core elements to help ensure a consistent approach throughout
Northern Ireland, ensuring the best use of transferable skills;
• Be flexible providing a pathway to higher level qualifications if so desired
by the practitioner;
• Equip nurses with the skills to practice within all A&E environments;
• Be developed in partnership with clinical practitioners;
• Where appropriate must make the best use of opportunities for multi
professional learning;
• Be delivered in innovative ways, through for example work based and on
line learning.

3
• Provide a pathway to differing levels of qualification other than that of
specialist practice.

Quality
1. The ultimate aim of developing regional guidelines and protocols is to
reduce variations in nursing practice in A&E departments in Northern
Ireland to ensure the best possible care to all patients.
2. The development of clinical guidelines needs to take into account their
acceptability to patients, professionals, commissioners and the public and
reflect the needs of the new equality legislation.
3. Protocols for care and treatment cannot be developed by any one
professional group, but should be developed by the clinical team. It is vitally
important that all professionals involved in the care and treatment of patients
are involved in and agree with their content and application.

Research
1. The Group have not had sufficient time to develop a research plan for A&E
Nursing within the context of completing this report. It is recommended that
further work needs to be completed and that research activities in A&E
nursing should be co-ordinated and results disseminated to nurses working in
the service. It is suggested that Central Nursing Advisory Committee ask a
regional group such as the RCN A&E Association to take this forward.

Services for Children


1. Appropriate nursing staff (Parts 8(RSCN) &15 RN(Children), PALS, APLS)
should be available at all times, in all A&E departments. Skills must be
maintained with ongoing training and education combined with rotation into
and out of the tertiary centre.

4
2. Effective procedures for communicating with GP’s, community nursing staff
and social services staff between primary, secondary and tertiary care must
be in place. This is particularly important in the identification of children
who are subject to or at risk of abuse and/or neglect.
3. There should be adequate provision of appliances and equipment appropriate
for the treatment of children, e.g. resuscitation equipment. A&E units must
ensure appropriately trained staff are available to ensure a safe, caring
environment and effective onward transfer to a secondary or tertiary centre
if required.
4. Separate facilities for children must be provided including waiting space,
play facilities and examination, treatment and recovery rooms furnished and
equipped to meet children’s needs in safe conditions.
5. The development of guidelines for the care of children needs to be
co-ordinated through uni and multiprofessional groups at a regional level,
supported by a network of interested professionals with sufficient resources
available to ensure development and monitoring of implementation.
6. Joint protocols should be developed between primary, secondary and tertiary
care for the treatment of children. This could include how and in what
circumstances should children be transferred between units. Procedures
should be developed for the inter-departmental / inter-hospital transfer of
children to another unit within 2 hours of admission to A&E. These
procedures should include the use of standard A&E documentation.
7. Procedures and facilities for counselling and support in the event of a sudden
death of a child should be provided.

Technology in Support of Care


1. The development of technology in the A&E environment must be within the
context of:
• Clear technical and practice standards.
• Appropriate education and training.

5
• Clarity about clinical and social care governance, ethical, patient
confidentiality and data security issues.
• Evidence of clinical and cost effectiveness.
• A co-ordinated approach which crosses professional and organisational
boundaries.

Aggression and Violence


1. Nursing staff need to be trained adequately to anticipate and deal with
violent patients. This training should be regularly updated and involve all
staff who work in the A&E and minor injuries environments.
2. Risk assessments should form part of a regular review of services and should
involve alongside relevant members of the A&E team, including appropriate
security staff.
3. A system, which records violent incidents or acts of aggression, verbal or
physical, should be in place. These records should be reviewed regularly so
that lessons can be learnt, and action taken to reduce the risk.
4. A key and integral part of the management process is the support and care of
patients and staff following violent and aggressive incidents. A review of
violent or aggressive incidents should be incorporated into regular clinical
supervision sessions.

Recruitment and Retention


1. The Group recommends that employers consider embracing the concept of
the ‘magnet hospital’ when developing a recruitment and retention plan for
nursing the A&E.
2. Employers must ensure there are mechanisms for professional update
through the development of professional networks throughout Northern
Ireland.

6
3. While this report highlights some of the areas which impact on A&E it is
clear that further work on skill mix needs to be undertaken. To facilitate this
work there needs to be a clear understanding by all providers of data
definitions and their appropriate applications.

7
1.0 Introduction

1.1 All Health and Social Services have undergone significant change over the
past decade. Many of these developments have occurred because of advances in
medical technology and increasing public demands for high quality services.
Accident and Emergency (A&E) services have had to respond to these changes.
Key to these changes has been nursing, with nursing taking on increasingly
autonomous roles in the care and treatment of patients.

1.2 Hospital accident and emergency departments treat patients with major
illness, major trauma, minor illnesses and minor injuries. Up to 75% of patients
may attend A&E with less serious conditions, with children accounting for over
25% of all new attendances. Many of these patients have conditions that could be
managed by general practitioners and nurses. In contrast to widespread
perception, less than 1% of patients have life threatening injuries1, estimated in
the province at around one patient per day.2

1.3 While local Accident and Emergency (A&E) services are valued by local
communities, patients and their families must have confidence in the clinical
standards of care delivered. Many A&E units do not have specialist multi
professional teams providing care, nor do they provide the full range of services
required to support the management of patients with major trauma or major
illnesses.

1.4 In response to the potential changes in the delivery of acute hospital


services the Chief Nursing Officer commissioned a group to conduct a review and
make recommendations on the future of A&E nursing in Northern Ireland.
The group was chaired by Mr Robert Sowney and the remit agreed with the
Central Nursing Advisory Committee. (Membership of the Review Group is set
out in Appendix A)

8
1.5 The remit of the group was:

• To review current models of care delivery and assess whether there is a


particular model to be recommended.

• To review current education and training requirements for all A&E nurses
including those working in minor injuries units.

• To develop core guidelines and protocols for care and treatment.

• To review current developments in nursing research in Accident and


Emergency

• To review current and anticipated workforce issues.

9
2.0 Background

2.1 The organisation and management of A&E services have come under
scrutiny for some time. The Royal College of Surgeons identified shortcomings
in the delivery of care in 1988.3 This report suggested that services were neither
effective nor designed to meet the particular needs of seriously injured patients.
The Royal College of Surgeons Report demonstrated that up to 20% of the 1000
seriously injured patients studied, died from treatable causes following admission
to A&E departments.

2.2 There are currently 16 A&E departments in Northern Ireland providing a


wide range of services and several minor injuries units, some nurse led and some
led by medical staff (Appendix B). Currently the range of services provided in
each unit varies, as does the methods of data collection. Its is recommended that
a consistent approach to data collection is developed to enable meaningful
comparisons particularly with regards to workforce planning.

Current Trends
2.3 The current national trends in providing A&E services are towards;
• having a smaller number of larger units, with highly trained specialist teams.
• treating minor conditions in more appropriate local facilities, such as minor
injuries units, GP practice or walk in centres.
• providing advice by telephone, such as NHS direct and decision support
systems.
• the development of nurse practitioners 4 in A&E and minor injuries units
treating patients with a range of conditions.

2.4 These trends have been developed as a result of shortcomings


identified in the delivery of care, by the Royal College of Surgeons in 1988.
There has also been growing pressures on A&E departments with attendance’s

10
increasing by an average of 2% each year. And in response the role of nurses has
been developing particularly in the treatment of patients with minor injuries.1,5
The development of any service needs to strike the balance between meeting
clinical standards, which help ensure high quality care and treatment, and local
accessibility to services.

Workforce

2.5 The British Association for Accident and Emergency Medicine6, the Audit
Commission5 and the Clinical Standards Advisory Group7 each recommend that
accident and emergency departments should have a multi professional team of
specialists, led by a consultant trained in accident and emergency medicine. In
addition, there is evidence that a team trained in Advanced Trauma Life Support
will provide more effective care.8

2.6 It has been suggested, that to maintain the expertise of doctors and nurses,
35,000 new patients should be a minimum level of attendance for a main A&E
department.9 In addition it has been recommended that, in order to provide
adequate cover, departments seeing in excess of 30,000 patients per year require
three and at 55,000 a minimum of four, consultants in accident and emergency
medicine.5

In Northern Ireland half of all accident and emergency departments treat


less than 35,000 new patients per year.

2.7 The British Association of Emergency Medicine believes that hospitals,


which have less than 35,000 new patients each year, are unlikely to have adequate
support from other specialities. It suggests that these departments should be
developed into minor injuries units which may not accept ambulance borne
patients.

11
Major Trauma

2.8 It is estimated that major trauma is rare and accounts for less than 1% of
the attendances at accident and emergency departments in Northern Ireland. The
public perception is that patients who have suffered major trauma should be taken
to the nearest hospital to be resuscitated. The Royal College of Surgeons10
illustrated, in the late 1980’s, that in the cases they reviewed, at least one in every
five deaths from trauma was avoidable and that inadequate clinical care in
accident and emergency departments was a major factor. The report’s proposals
included:
• The majority of patients should be managed in large district general hospitals
with a wide range of facilities and experienced supporting staff under the
supervision of consultants in A&E medicine, and
• Patients with life threatening injury beyond the facilities or capabilities of a
district general hospital should be transferred by high quality transport to a
Trauma Centre established at a regional or multi district centre.

2.9 For a seriously injured person to be given the best chance for survival then,
they must be given effective pre hospital care and moved quickly to hospital for
specialist care. For resuscitation to be most effective it must be co-ordinated,
efficient and needs to be carried out by a specialist multiprofessional team who
have additional training in advanced trauma life support. A report published in
1993, Management of Major Trauma in Northern Ireland recommended that,
outside greater Belfast, patients with major trauma should be taken to the nearest
appropriate hospital. This was defined as a hospital with immediate availability
of consultant surgeons and consultant anaesthetists, availability of laboratory
services and 24 hour radiography cover. However, opinion varies about the mix
of specialities which should be on site or close to a major A&E department.
Suggestions have included the immediate availability of specialists in,
general medicine; general surgery, anaesthetics, intensive care obstetrics and
gynaecology, paediatrics, radiology (24 Hour CT Scanning), pathology,
orthopaedics and acute psychiatry.

12
2.10 There is evidence to suggest that delays in accessing specialist treatments
will result in adverse consequences for patients.11, 12 While time is of the essence
in treating all of these patients, bringing a severely injured patient to a hospital
which is not equipped with the appropriately trained staff or resources to manage
such patients can simply delay full investigation and treatment.

2.11 Treatment at a specialist centre may require a longer journey to hospital.


The advantage to the patient of a specialist centre is that:
• the patient will be seen by a specialist multiprofessional team;
• will have the benefit of the full range of diagnostic and support facilities, and
• there are fewer secondary transfers to a specialist centre required.

Medical Conditions

2.12 There are some conditions however, where the travelling time to a
specialist centre could have a harmful effect on the patient unless special
arrangements are in place to provide safe care. This is particularly true of some
medical conditions, such as coronary thrombosis.

2.13 Most deaths, after a first attack occur within the first 2 hours. Lives can be
saved by the immediate availability of trained personnel such as paramedics, who
can provide defibrillation and resuscitation. The Northern Ireland Ambulance
Service now endeavours to have a trained paramedic on each emergency
ambulance. They also have equipment which allows an immediate diagnosis of
the patient’ condition.

13
2.14 The care of these patients can often be enhanced with the use of
thrombolytic therapy and aspirin. The important factor in this treatment is that
they are given as early as possible, within 6 hours. The European Society of
Cardiology states that a realistic aim is to start thrombolysis within 90 minutes of
the patient calling for medical treatment. These drugs have the potential to be
given by General Practitioners (GPs) or paramedics in primary care.

Minor Injuries and Illnesses

2.15 The treatment of minor injuries and illnesses has always been an integral
part of A&E nursing. There have been many studies which report large numbers
of patients presenting at A&E departments with minor injuries, illnesses or
primary health care problems. In a study by Myers (1982) 54% of a sample of
1000 patients presented with primary health care problems, with similar studies
suggesting that anything from 35% to 51% of patients attending some A&E
departments could be managed by their GP.13

2.16 The role of nurse practitioners in A&E was recommended by the


Tomlinson Report and Audit Commission Report. 14, 15 Research into the role
of nurse practitioners in A&E has identified;
• A marked decrease in both waiting times for minor injury attenders with a
subsequent reduction in complaints; 16
• A reduction in the levels of aggression towards staff, attributed to reduced
waiting times; 17
• Clinical effective practice in requesting and interpreting X- rays;18
• Effective performance when compared to A&E research registrars, with
evidence that fewer of the patients of the nurse practitioners had to seek
unplanned follow up advice about their injury;19
• Enhanced patient satisfaction and improved quality of care.20, 21, 22, 23, 24

14
2.17 A more recent initiative has been the development of stand alone minor
injuries units. They are to provide, ‘an open access minor injury service to
patients not requiring the specialist investigative and support services of an acute
general hospital’.25 Some concern has been expressed that patients may judge
their needs inaccurately and attend minor injuries units with inappropriate
conditions or create a new demand for care. Several studies have found no
evidence to support these concerns 26, 27 concluding that ‘given adequate
publicity, most members of the public use these services appropriately’.28
However to sustain this it has been recommended that a ‘sustained advertising
campaign is required’. 29 A study completed in North Staffordshire Hospital A&E
departments suggested that approximately 70% of patients attending had minor
injuries.30

2.18 Most minor injuries units are staffed by nurse practitioners working either
on their own or in partnership with local GPs. Many of these departments have
on site X ray facilities, but are not usually open 24 hours a day. More recently
technology has been used to support the development of remote care such as stand
alone minor injuries units. Tele-medicine and tele-radiology facilities provide
access to advice from specialist centres supporting the nurse in providing
accessible high quality care, an approach endorsed by the British Association for
Accident and Emergency Medicine.31, 32

2.19 Reviews of Minor Injuries Units suggest that for them to be effective
there must be a close professional/managerial relationship with the nearest A&E
department. This ‘network’ model assists in clinical supervision and rotation of
staff ensuring that expertise and clinical standards are maintained. This network
should be extended to primary care as approximately 25% of patients who attend
A&E with minor illnesses have conditions which are often more appropriately
treated by their GP or other primary care professionals.

15
2.20 There is considerable variation in the range of treatments provided by
nurse practitioners within A&E units or minor injuries units. This variation has
been attributed to:
• Location of the unit;
• Hours of availability of Nurse Practitioners;
• The development of the scope of nursing practice;
• Nursing culture and philosophy of unit;
• Management culture;
• Availability and access to facilities such as x rays, and
• The experience / skills of nurse practitioners. 33
One factor to success identified is a management culture which promotes and
encourages the increasing scope of the nurse, particularly in the area of
requesting and interpreting X rays.

2.21 The Council of International Hospitals (1998) suggests that while there are
no real cost savings using nurse practitioners, both the quality of care and
efficiency is improved. This is supported by the Audit Commission Report (1996)
which acknowledges that while Nurse Practitioners may appear more expensive
than Senior House Officers (SHO) the assessment of SHO costs did not include
the care carried out by the nurse on the direction of the doctor, the SHO cost is
therefore significantly under estimated.

Current Profile of Services

2.22 Accident and Emergency services in Northern Ireland are provided


through a number of Health and Social Services Trusts, in a variety of
environments and with a range of support services. (Appendix C)

2.23 The development of Minor Injury Units is in its infancy in Northern


Ireland. There are currently three units, Armagh Community Hospital, Ards
Community Hospital and Bangor Community Hospital, some of which are

16
undergoing a formal review of effectiveness. There is evidence that this model
has a potentially useful role in acute care, especially in terms of responsiveness
and accessibility to services. 34, 35, 36

Hospital 24 hr. on Labs ICU Emergency Tele- A&E


site CT in patient medicine Obs
services links beds
Antrim Yes 24hr Yes Yes No No
Mid Ulster No 9-5 Yes Yes No No
Coleraine No 24hr Yes Yes No No
Altnagelvin Yes 24hr Yes Yes No No
Tyrone County No 9-5 Yes Yes No No
Erne Yes 24hr Yes Yes Yes No
South Tyrone No 9-5 No No No No
Craigavon Yes 24hr Yes Yes No Yes
Armagh No No No No No No
Downe No No No Yes Teleradiology No
Lagan Valley 9-5 Off-site Yes Yes Yes No
Daisy Hill No 24hr No Yes No No
Ulster Yes 24hr Yes Yes Yes No
Ards No Off-site UHD UHD Yes No
Bangor No Off-site UHD UHD Yes No
Belfast City Yes 24hr Yes Yes Yes Yes
Hospital
Royal Victoria Yes 24hr Yes Yes Yes No
Hospital
Mater Hospital 9-5 24hr Yes Yes No No

Pressures to continually improve standards of service, education of professionals


and public demands for high quality services means that the current model of
service cannot be sustained into the medium to long term. Indeed in some areas
there have been difficulties in sustaining services in the short term. A new way
must be found which combines the need for clinical excellence with the need
for accessible services.

17
3.0 New Models of Service

3.1 Change is inevitable, and will happen whether or not organisations or


individuals are prepared for it. The map of A&E and acute hospital services in
Northern Ireland will change dramatically over the next few years.37 This report
is A&E nurses’ contribution to this debate.

3.2 The group envisages a service with main A&E departments based at
the major acute hospitals, with multi professional specialist teams led by
Consultants in Accident & Emergency Medicine. As an integral part of this
team, nurse led departments, such as minor injuries units could be
established. These nurse led departments would be based either within the
core A&E department or at a remote distance from it. This clinical network
forms the model on which accident and emergency nursing services can be
further developed. Key to these Minor Injuries Units will be the development
of a clinical network and the rotation of staff between the core and
peripheral units. As part of the continuing professional development and
maintaining professional standards of practice, staff in minor injuries units
should work a minimum of one week and ideally one month a year in an
A&E environment. This period should be tailored and extended to meet
individual needs as required.

The Role of Accident and Emergency Nursing Services in a Clinical


Network.

3.3 Nursing practice is developing rapidly, influenced not only by the


reduction in junior doctors hours but by developments in nursing practice
through the Scope of Practice.

3.4 ‘Valuing Diversity… a way forward’ the strategy for nursing, outlines the
challenges and opportunities faced by nurses in the future and recognises the
dynamic approach developed by many nurses – A&E nurses are no exception.

18
3.5 The demands and pressures placed on A&E nurses are already immense.
In meeting the challenge of the future A&E nurses must build on the current
good practice demonstrating;
• flexible and innovative working practices and professional thinking;
• commitment to life long learning and ongoing training;
• an acknowledgement of capabilities and limitations;
• appropriate standards of education, clinical skills and competencies to
provide quality services to patients.

Developments in Accident and Emergency Nursing


3.6 Many of the developments in A&E nursing have been associated with the
development of A&E nurse practitioners. There have been many definitions of
the characteristics of the nurse practitioners.38 The RCN A&E Association
Policy and Practice Group defines an Emergency Nurse Practitioner as:
‘ an A&E nurse who has a sound nursing practice base in all aspects of A&E
nursing with formal post-basic education in holistic assessment, physical
diagnosis, prescription of treatment and promotion of health’.39
They identify the role as:
1. A key member of the emergency health care team.
2. Directly available to members of the public.
3. An autonomous practitioner, able to assess diagnoses, treat and discharge
patients without reference to a Doctor, but within pre-agreed protocols.
4. Able to make independent referral to other health care professionals.

3.7 This report recommends the following model which defines nursing
roles in the Accident and Emergency and related departments.

19
Level One
3.8 This is entry level to the A&E environment. This period could
normally be expected to last a minimum of one year. While gaining
experience in A&E nursing it would be expected that nurses would utilise
opportunities for continuing professional development which would support
their practice in the A&E environment. These could include access to education
and training opportunities in areas such as, communication skills, wound care,
managing aggression and violence and health promotion. Nurses at this level
would be expected to plan and deliver nursing care in a supported and
supervised environment. The period spent in A&E itself can be seen as a
development opportunity for some nurses.

Level Two
3.9 This period begins the consolidation of experience and practical
skills with knowledge and academic support. Nurses would be expected to
learn new additional practical skills within a theoretical framework. They
would be expected to work towards and attain qualifications which will
support their practice which could include Advanced Trauma Life Support
(ATLS), Advanced Life Support (ALS) Advanced Paediatric Life support
(APLS) or Paediatric Advanced Life Support (PALS) as component parts of
the need for continuing professional development. This period could be
normally expected to last a minimum of two years.

Level 3
3.10 The development of nurses to specialist practice level as defined by the
UKCC should be an integral part of the overall workforce plan of the unit,
linked in to the development of services to meet patient needs. Nurses would
be expected to plan, deliver nursing care, play an active role in education,
training and support to other members of staff.

20
In the same way the development of what is commonly referred to as Nurse
Practitioners in A&E must be within a workforce plan which is designed to
meet the needs of service. Key to this role is defined decision making required
to fulfil the role of an autonomous practitioner. The nurse practitioner would
be expected to assess, diagnose, prescribe and deliver care, in partnership
with medical colleagues and working to agreed protocols. These nurses
would have the authority to either discharge patients home or refer
patients on to appropriate health and social care professionals.

3.11 While it is essential that this nurse will have moved through levels 1
and 2 it is not essential that they have completed their specialist practice
module before taking on this role. It would be expected that academic
programs would be developed to support nurse’s move into this role.
The knowledge, experience and skills acquired in levels 1 and 2 are
strengthened by an understanding of assessment and physical examination
techniques, decision making, a recognition of the scope and limitations of
professional practice and an indepth appreciation and understanding of
professional regulation and medico legal issues.

3.12 These levels are not necessarily essentially defined by academic


qualifications but by the skills and competencies required to complete the
roles at each level.

Nurse Consultant
3.13 The development of the nurse consultant is in its infancy. The Group
welcomes the implementation of this initiative and looks forward to the
development of nursing services in a positive and energetic way to ensure that
nursing makes its full and appropriate contribution to effective emergency care
services for the community in Northern Ireland. It is envisaged that these posts
would create a level 4 nurse who as an expert practitioner would lead nurses in
the development of practice, education, standard setting and audit and advance
the development of new roles in emergency nursing in Northern Ireland.

21
3.14 The development of the nurse’s role has been paralleled by an explosion
of job titles, A&E nursing is no exception. A recommendation of this report is
to achieve a consistent approach to terminology. At Level 3 it is suggested
that the term used to describe the nurse is Nurse Practitioner irrespective of
what emergency care environment the practitioner is working in. In coming
to this recommendation it is recognised that all nurses are practitioners but it is
acknowledged that the term Nurse Practitioner in the Accident and Emergency
environment is one which is recognised by the public. Currently nurse
practitioners function in two distinct areas, minor injuries units and accident and
emergency units. However, while the working environment will be different,
the role of the nurse practitioner is, similar in both, with minor differences in the
roles occurring according to local operational protocols.

3.15 It is envisaged that nurse practitioners will continue to develop their roles
and responsibilities, enabling them to work in any emergency care environment.

22
4.0 Education and Training

4.1 A &E nurse education and training is not immune from the changes
effecting not only the service, but the profession itself. Several key concerns
have been highlighted:
• Throughout Northern Ireland there is no consistent approach in the
preparation of nurses for the role of nurse practitioner;
• The position of senior, experienced nursing staff who may not wish to
pursue an academic career;
• The special needs and requirements of nurses working in ‘Minor
Injuries Unit’ and the potential difficulty in maintaining resuscitation
skills; and
• The future clinical standards and competencies required by nurses.

Current Arrangements
4.2 Current educational packages which support the development of this role
through skills based training and professional development are run at both
universities, in-service education consortia and the Institute of Advanced
Nursing Education. While these courses are viewed as extremely valuable, in
the same way as practitioners need to respond to service needs, educational
programmes need to evolve to adequately prepare nurses for developments in
future practice and service delivery.

4.3 Education programmes should:


• Be competency based;
• Have core elements to help ensure a consistent approach throughout
Northern Ireland, ensuring the best use of transferable skills ;
• Be flexible providing a pathway to higher level qualifications if so
desired by the practitioner;
• Equip nurses with the skills to practice within all A&E environments;

23
• Be developed in partnership with clinical practitioners;
• Where appropriate must make the best use of opportunities for multi
professional learning;
• Be delivered in innovative ways, through for example work based
and on line learning;
• Should provide a pathway to differing levels of qualification other
than that of specialist practice.

24
5.0 Quality

5.1 People are entitled to expect the highest quality health and personal
social services. One of the key elements, which will support the delivery of
quality services, is the system of clinical and social care governance.

5.2 Clinical and social care governance is a framework within which


organisations providing or commissioning services will be:
• Accountable for continuously improving the quality of services;
• Responsible for safeguarding high standards of care and treatment, and
• Creating an environment in which continuous improvement flourishes.40

5.3 A key element of a clinical and social care governance framework is the
development and application of clinical standards, guidelines and protocols.

Clinical standards, guidelines and protocols


5.4 The prime motive for the development of protocols or clinical guidelines
is to improve the quality of patient care. The application of clinical guidelines
and protocols used in health and social care are coming under closer scrutiny as
efforts to improve and to measure clinical effectiveness continue. It is not as
some would argue a recipe for ‘ cookbook medicine’. 41

5.5 The ultimate aim of developing regional guidelines and protocols is to


reduce variations in nursing practice in A&E departments in Northern Ireland to
ensure the best possible care to all patients. For the purposes of this report the
following are the agreed definitions.

Clinical Guidelines: A systematically developed statement which assists


clinicians and patients in making decisions about appropriate and effective
treatment for specific conditions. 42

25
Protocols: A protocol consists of written recommendation, rules or standards to
be followed for any medical situation where rational procedures can be
identified.43

Current Development of Guidelines and Protocols


5.6 The development of clinical guidelines needs to take into account their
acceptability to; patients, professionals, commissioners and the public. While it
is essential to remember that protocols, guidelines and other written descriptions
of care should share a common goal of improving the quality of clinical
practice, their development will inevitably continue to have an influence on the
outcome of actions for clinical negligence.

5.7 Key issues were highlighted when protocols already developed were
examined.
• Protocols were used by all nurse practitioners.
• The key members of staff involved in their development were consultant
medical staff, nurse practitioners and nurse managers. Others were
involved according to the specific issue, e.g. pharmacists,
physiotherapists and radiologists.
• Protocols developed reflected the variation in local operational policies.

While broad clinical guidelines can be produced on a regional basis, protocols


for care and treatment need to involve local clinicians and need to embrace the
detail and spirit of the new equality legislation.

5.8 Protocols for care and treatment cannot be developed by any one
professional group, but should be developed by the clinical team. It is
vitally important that all professionals involved in the care and treatment
of patients are involved in and agree with their content and application. 44
The literature demonstrates the need for interdisciplinary teamwork and
active involvement in the creation and review of protocols in order to bring
about consensus and consistency in clinical practice between health care
professionals. 45

26
5.9 A key and integral part of delivering a quality A&E service is the
development of a culture which supports and encourages research. Research in
A&E nursing has been developed in an ad hoc fashion. A&E nurses report a
lack of time and resources, lack of perceived benefit to practice and lack of
access as some of the reasons why research has not been fully developed.
Research activities in A&E nursing should be co-ordinated and results
disseminated by a regional group such as the RCN A&E Association.

27
6.0 Services for Children

6.1 Approximately 25% -33% of all attendances at A&E departments are for
children under the age of 16 years.46 Locally only one A&E department is
specifically dedicated to children.

6.2 There are a range of special provisions which have become widely
accepted as necessary for the successful treatment of children in A&E
departments, such as those outlined in the Audit Commission Reports in 1996
and 1993.47 These reports include reference to:
• Effective Treatment.
• Child and Family centred care.
• Specialist Skilled Staff.
• Separate Facilities.
• Appropriate Hospitalisation.
• Non accidental Injuries.
Many of these, particularly with regards to staff and resources, are not fully met
within A&E departments in the province.

6.3 While there is a wide range of skills and experience in A&E nursing
further development of children’s A&E nursing has not been as well established.
Only 41% of A&E departments have 2 or more Registered Children’s Nurses.
Appropriate nursing staff (Parts 8(RSCN) &15 RN(Children), PALS,
APLS) should be available at all times, in all A&E departments.
Skills must be maintained with ongoing training and education combined
with rotation into and out of the tertiary centre.

6.4 However well organised and staffed an A&E department is, there will
always be circumstances in which some patients have to wait. Initial
assessment, or triage, is an established part of A&E work. All Trusts now use
the national Triage Scale developed in Manchester and endorsed by the British

28
Association of A&E Medicine and Royal College of Nursing A&E policy and
practice group. Completing an initial assessment on an adult is significantly
different to that of a child. Specialist skills are required to ensure that children
are assessed using different observational techniques with the appropriate use of
analgesia. Staff are also required to be familiar with childhood diseases and
have an ability to involve the parents in the care of the child as required.

6.5 Nurses and other professionals need to be aware of the possibility of


abuse or neglect presenting as an acute illness. Effective procedures for
communicating with GPs, community nursing staff and social services staff
between primary, secondary and tertiary care must be in place. This is
particularly important in the identification of children who are subject to
or at risk of abuse and/or neglect.58

6.6 Progress has been made in the provision of Advanced Paediatric Life
Support (APLS) and Paediatric Advanced Life Support (PALS) training for
nursing staff. While this is not a substitution for children’s nurses it does
provide nurses with essential competencies and skills in the initial management
of paediatric trauma and other emergencies. The proportion of acutely ill
children arriving at A&E is small. This inevitably means that skills learnt
during training are infrequently used, particularly in smaller units. While
on-going in-service training and updates will help support staff, there is a need
to strengthen practical skills and expertise. This may be facilitated through
rotation into and out of the tertiary centre and will not only improve clinical
standards but allow a greater understanding of roles and responsibilities,
particularly the difficulties faced by staff working in smaller units. In addition
it may go some way to improving morale and the retention of staff.

6.7 Ensuring skills are kept up to date can be difficult, particularly in smaller
units. One practical way of supporting staff is the availability of a system

29
which ensures that equipment, such as cannulae and endotracheal tubes
appropriate to the size of the child, are readily available. Many A&E
departments utilise the Browslow system of storage for this purpose. There
should be adequate provision of appliances and equipment appropriate for
the treatment of children, e.g. resuscitation equipment.

6.8 It is essential that A&E units within acute hospitals, which have
paediatric beds, are appropriately staffed. Children and their families will
however continue to present at hospitals which do not have on site paediatric
support. For these A&E units it is vital that sufficient, appropriately
trained staff are available to ensure a safe, caring environment and
effective onward transfer to a secondary or tertiary centre if required.

6.9 While staff endeavour to make the best use of their working
environment, many A&E departments do not have separate waiting or treatment
areas. Only one third of A&E departments in the province meet this standard at
present. The special needs of children in A&E have not been seen as a priority
area and this pattern must be reversed. Every effort must be made to create an
environment in which the child and family can feel safe and secure. In those
A&E departments where children and adults are cared for together, children
should be physically separated from the sights and sounds of ill and injured
adults. Separate facilities for children must be provided including waiting
space, play facilities and examination, treatment and recovery rooms
furnished and equipped to meet children’s needs in safe conditions.

6.10 Currently the clinical management of the acutely ill child varies from
hospital to hospital, with some variations occurring as a direct result of a lack of
clearly defined protocols and guidelines, within and between hospitals.
Substantial work is required to develop policies, guidelines and standards which
could be shared throughout the province. This work needs to be co-ordinated
through uni and multiprofessional groups at a regional level, supported by
a network of interested professionals with sufficient resources available to
ensure development and monitoring of implementation.

30
6.11 When children and their parents attend A&E departments they are
understandably anxious and often distressed. The skills of staff and the
environment of the A&E department can do much to allay these fears and
anxieties. Good communication is key, while the child is in the department and
following discharge or onward referral. Problems can often occur when
transferring a child from one unit to another. Clear channels of communication,
between smaller hospitals and specialist units, should ensure that transfers to an
area hospital or tertiary centre are subject to the minimum of delay, that clear
and relevant clinical information is exchanged and continuity of care is
maintained. Joint protocols should be developed between primary,
secondary and tertiary care for the treatment of children. This could
include how and in what circumstances should children be transferred
between units. Procedures should be developed for the inter-departmental /
inter-hospital transfer of children to another unit within 2 hours of
admission to A&E. These procedures should include the use of standard
A&E documentation.

6.12 While there are many examples of good practice in A&E departments
throughout the province, there are few mechanisms to share good practice.
Networks already established should be further developed to facilitate the
sharing of best practice in the development of innovative nursing roles, such as
nurse practitioners in minor injuries units.

6.13 The sudden death of a child in an A&E department forces parents to deal
with an enormous range of complex emotions. It is an event which cannot be
equalled in its ability to impose emotional pain and distress.48 Adding to this
distress is the inappropriate setting of the A&E department itself. No family
chooses to make their final farewells in this environment.49 The busy
unpredictable workload and often lack of appropriate facilities does not lend
itself to the creation of an environment which enables nurses to provide
effective and meaningful comfort and support. Procedures and facilities for
counselling and support in the event of a sudden death of a child should be
provided.40

31
7.0 Technology in Support of Care

7.1 Emerging technologies will have a major impact upon healthcare and
information practice in a very short time period.50 There is a need to improve
equity and access to health and social care, with an emphasis on breaking down
inefficient organisational boundaries. Telemedicine and Telecare can contribute
to this.

7.2 Telemedicine and Telecare can be defined as any application which


electronically removes the effect of distance in the provision of health and
social care. There are two broad types;
• Interactive- with participants and resources present at the same time.
(For example: telephone- NHS Direct, video links – advice on patient
management, direct patient consultation, interactive computer links,
access to electronic libraries)
• Store and forward – where participants do not have to be present
simultaneously. (For example: access to remote expert opinion, CT
scans, histological images)

The development of Telemedicine is seen as being integral to the Health and


Social Services of the future.

Current Situation
7.3 Currently there is no regional approach to the design, development or
application of Telemedicine and Telecare systems. Technological links support
two minor injuries units through tele-medicine, which gives real time visual
links from one unit to another and tele-radiology which allows the smaller unit
to transmit X rays, through a telephone line, to the larger hospital for opinion
and advice.

32
7.4 The further development and technology in the A&E environment
must be within the context of:
• Clear Technical and practice standards.
• Appropriate education and training.
• Clarity about clinical and social care governance, ethical, patient
confidentiality and data security issues.
• Evidence of clinical and cost effectiveness.
• A co-ordinated approach which crosses professional and organisational
boundaries.

33
8.0 Aggression and Violence

8.1 Incidents of aggression and violence against patients, staff and property
have become increasingly common particularly amongst health and social care
professionals.51 Nurses are identified as amongst the highest risk categories,
with 7.9 % experiencing assaults or threats during the year, and 5.4% suffering
physical assault, the second highest risk of any occupational group except for
police officers and four times the national average risk.52

8.2 Aggression has been associated with a range of factors including, dealing
with the public, providing care and advice; working with the confused or those
with mental health illnesses and alcohol and drug misuse. Incidents of violence
and aggression have also been associated with practitioners who work alone or
work under stress.53

8.3 The A&E environment can often have a particularly emotionally charged
atmosphere. 54 Nurses working in A&E or minor injuries units are therefore
often particularly vulnerable to incidents of aggression and violence although
much can be done to minimise the risk to patients, staff and property.

8.4 Nursing staff need to be trained adequately to anticipate and deal


with violent patients. This training should be regularly updated and involve all
staff who work in the A&E and minor injuries environments. Risk assessments
should form part of a regular review of services and should involve
relevant members of the A&E team, including appropriate
security staff.

8.5 When incidents occur it is important that staff and managers learn from
them. A system which records violent incidents or acts of aggression, verbal
or physical, should be in place. These records should be reviewed regularly so
that lessons can be learnt, and action taken to reduce the risk.

34
Environment of Care
8.6 The physical surroundings can be key to providing a safe environment
for patients, relatives and staff. The department layouts should suit the
movement of patients and visitors through the unit, to avoid stress, discomfort,
anxiety and other factors contributing to potential aggressive or violent
incidents. Provision of an integrated signage system improves patient flow
through the department and will help reduce frustrations patients feel in trying
to find their way around. Where possible A&E departments should not be
situated where they would become a main thoroughfare for the public or other
members of staff.

8.7 There should be as few entrances into the unit as is consistent with
operational requirements. Locking mechanisms where required on doors should
be strong enough to prevent forced entry. The use of CCTV can assist in
identifying areas of the unit, although recent research suggests that there should
not be over reliance on CCTV as a key factor in reducing violence.55 Placing
signs indicating their use can deter potential threats. In smaller units it may be
possible to set automatic doors to exit only to enable nursing staff to identify
people wishing to gain access.

8.8 Reception areas should be adequately staffed and easily identifiable. It is


very distressing for a patient or relative, if they require information or assistance
and no one is on hand to help them. The use of screens, raised reception areas
and panic buttons should be considered only as part of an overall line risk
assessment.

Follow Up Care
8.9 The consequences of violent and aggressive incidents relate to
individuals and the organisation they work for. Staff are often traumatised
physically and emotionally by events. Employers can be faced with high
sickness rates and staff turnover due to fear of violence.

35
8.10 A key and integral part of the management process is the support
and care of patients and staff following violent and aggressive incidents.
Distressed staff, patients or relatives should be afforded an opportunity to
discuss their fears and anxieties arising from the incident. This can be
formalised into critical incident stress debriefing.56 In some cases formal
counselling is required, more often staff in particular require the support of
colleagues in the A&E department. A review of violent or aggressive incidents
should be incorporated into regular clinical supervision sessions.

36
9.0 Recruitment and Retention

9.1 Recruiting and retaining nurses in A&E can be often be difficult because
of perception of violence and the often unpredictable nature of the work.

9.2 Much can be learnt from the work of others. Research carried out by the
American Academy of Nursing as to why particular hospitals in the USA attract
and retain their staff. This work showed that directors of nursing and staff
nurses illustrated a high degree of common thinking and shared
understanding.57 The key areas identified were:
• Participative Management – Staff felt involved at all levels with good
communication and accessible managers including formal and informal
meetings with hospital administrators and board members attending ward
rounds on occasions.
• Leadership – Both staff and directors identified key elements of an effective
nurse leader as, knowledgeable and strong individuals with a philosophy of
high standards providing support both in terms of adequate resources and
professional support.
• Role of Senior Nurses – Head nurses in the ‘magnet hospitals’ were
reported almost without exception as clinically expert, and good managers
who treat subordinates with respect and consideration.
• Organisational Structure – The majority of ‘magnet hospitals’ had
decentralised departmental structures which give a sense of control over the
immediate work environment at nursing unit level. These included,
opportunities to formulate budgets, flexible working hours established by the
nurses themselves without approval from hierarchies, and titles reflecting
level of responsibilities.
Staffing – The proportions of registered and non-registered nurses was
considered critical to job satisfaction. Very few of the ‘magnet hospitals’
used agency staff.
Working Environment – Shift rotation is minimised, if not eliminated.
Efforts were being made to reduce the number of weekends worked by
nurses. These efforts convey a sense of appreciation of staff’s personal lives
by nursing administration.

37
• Professional Practice - Directors identified the quality of staff as key to
leading in excellent practice. Staff nurses identified, autonomy,
preceptorship, professional recognition and the ability to practice nursing as
it should be practised as essential.
• Education and Teaching – High value is placed on education and teaching
by nurses particularly, opportunities to teach patients and their families,
participation in education programmes, preceptorship and developing
learning modules with in service education staff attending ward rounds.

9.3 In addition to this, with the development of new roles in nursing and the
extended role of nurses in minor injuries units, employers would ensure there
are mechanism for professional update through the development of professional
networks throughout Northern Ireland.

9.4 While this report highlights some of the areas which impact on A&E it is
clear that further work on skill mix in the A&E which will incorporate the
balance between all grades of staff working within the A&E environment.

38
Appendix A

Robert Sowney Chairman Southern Health and Social Services Board.


(Formerly, Clinical Nurse Specialist Accident and Emergency, South Tyrone Hospital.)

Mary McGuigan Royal Victoria Hospital


Bernadette Glover Mater Hospital
Catherine McAleer South Tyrone Hospital
Joy Doherty Altnagelvin Hospital HSS Trust
Valerie Wilson Ards Community Hospital
Alison Rooney Downe Hospital
Sharon Watt Lagan Valley Hospital
Gillian Murray Belfast City Hospital
Martina Dunlop Royal Victoria Hospital
Bridie Campbell Royal Victoria Hospital
Linda Saunderson Erne Hospital
Frances O’Hara Altnagelvin Hospital
Brigiene McNeilly Coleraine Hospital
Kate McDowell Downe Hospital
Rosemary Gilchrist Belfast City Hospital
Noeen O’Donnell Craigavon Area Hospital
Sean McCorry Mid-Ulster Hospital
Avril Shaw Antrim Hospital
Garrett Martin Craigavon Area Hospital
Sheila McGrain Craigavon Area Hospital
Nora Sheridan Daisy Hill Hospital
Fiona Beattie Ulster Community & Hospitals Trust Ards Community Hospital
Mary Hinds Department of Health, Social Services and Public Safety

With additional contributions and comment from:


Mr Paul Curran, Consultant in Accident and Emergency Medicine, Mater Hospital, Belfast.
Mr Brian Fisher, Consultant in Accident and Emergency Medicine, Belfast city Hospital.
Mr James Steele, Consultant in Accident and Emergency Medicine, Altnagelvin Hospital.
Dr Olivia Dornan, Consultant in Accident and Emergency Medicine, Antrim Hospital.
Mr Sean McGovern, Consultant in Accident and Emergency Medicine, Ulster Hospital.

39
Appendix B
Accident & Emergency Services – Current Staffing

Hospital Consultant Nurses Nurse Children’s ATLS/ APLS/ Total No. of


Led WTE Practitioners Nurses TNCC PALS new
Service WTE WTE WTE WTE attendancesA
Antrim Yes 22.81 1.6 2.96 13.4 10.7 40,428
Mid Ulster No 12.0 1 1 6 3 18,250
Coleraine # No 22.61 None 1.8 13 7 23,599
Altnagelvin Yes 23.0 None 2 8 1 44,895
Tyrone County No 10.5 None 1 6 3 13,009
Erne No 8.5 None 1 TNCC3 None 11,396
Obs
(ATLS) 4
South Tyrone No 17 1 1 2.98 None 11,089
Craigavon Yes 39.00 None 6.53 40 5 44,076
Whiteabbey No 10.57 None 1 2 10 26,679
Downe No 10.00 2 0 0.86 0.86 19,110
Lagan Valley Yes 14.86 2 1 2 0 31,201
Daisy Hill # No 15.40 None 3.69 11.14 4.72 27,356
Ulster Yes 45.45 5.60 9.16 10.0 2.0 60,229
Ards Minor 5.77 5.77 ALS 2 - 6,879
Injuries TNCC 4
Bangor Minor 5.28 5.28 - ALS 2 - 8,005
Injuries TNCC 3
Belfast City Yes 37.80 3.67 2 18.45 3 45,290
Hospital #
Royal Belfast Yes 22.16 2 22.16 - 15 26,579
Hospital for
Sick Children
Royal Victoria Yes 36.00 2.5 2 18 1 61,307
Hospital 9
Mater Hospital Yes 23 None 2 ATLS8 2 42,453
#* TNCC6
ALS6

A Figures for First attendances in A&E for 1999/2000 provided by Regional


Information Branch, DHSSPS.
# These hospitals have indicated that A&E staff support fracture clinics
* A&E staff support an Orthopaedic Clinic.

40
Appendix C
Accident & Emergency Services – Current Support

Hospital 24 hr. on Labs on ICU Emergency Tele- A&E


site CT site in patient medicine Obs
services links beds
Antrim Yes 24hr Yes Yes No No
Mid Ulster No 9-5 Yes Yes No No
Coleraine No 24hr Yes Yes No No
Altnagelvin Yes 24hr Yes Yes No No
Tyrone County No 24hr No Yes No No
Erne No 24hr Yes Yes Yes No
South Tyrone No 9-5 No No No No
Craigavon Yes 24hr Yes Yes No Yes
Downe No Off-site No Yes Yes No
Lagan Valley No Off-site Yes Yes Yes No
Daisy Hill No 24hr No Yes No No
Ulster Yes 24hr Yes Yes Yes No
Ards UHD Off-site UHD UHD Yes No
Bangor UHD Off-site UHD UHD Yes No
Belfast City Yes 24hr Yes Yes Yes Yes
Hospital
Royal Victoria Yes 24hr Yes Yes Yes No
Hospital
Mater Hospital No 24hr Yes Yes No No
Royal Belfast Yes Yes Yes Yes No No
Hospital for
Sick Children
Whiteabbey No No No Yes No No

41
1 Williams B, Nicholl J, Brazier J. (1996) Accident & Emergency departments in ‘ Health Needs Assessment’.
2 McNichol B. Northern Ireland Major Trauma Outcome Study. 1990
3 Royal College of Surgeons England (1988) Commission on the Provision of Surgical Services. Report of the working party on the Management of
patients with Major Trauma.
4 Nurse Practitioners defined as those nurses who with extended training assess, diagnose, treat, discharge or refer onward patients within a defined
group .
5 Audit Commission Report (1996) ‘By Accident or Design, Improving A&E Services in England and Wales. HMSO
6 The British Association for Accident & Emergency Medicine. (1998) The Way Ahead - Accident & Emergency Services 2001.
7 Clinical Standards Advisory Group, (1995) ‘Urgent and Emergency Admissions to Hospital’ HMSO
8 Collicot PE., (1992) Advanced Trauma Life Support: Past, Present, Future. Trauma 33(5) 749 - 53
9 London Implementation Group (1993) A&E Reference Group: Accident and Emergency Services: the Desired Standard.
10 Royal College of Surgeons England (1988) Commission on the Provision of Surgical services. Report of the Working Party on the Management of
Patients with Major Injuries.
11 Mek RN., Vivoda E., Pirani S., (1986) Comparison of mortality of patients with multiple injuries according to type of fracture treatment: a retrospec-
tive age and injury matched service. Injury 17: 2-4
12 Sharples PM., Storey A. et al. (1990) Avoidable factors contributing to deaths in children with head injury. BMJ 300:87 - 91
13 Walsh M (1995) The health belief model and use of A&E services by the general public. Journal of Advanced Nursing. 22, 694-699
14 Tomlinson Report
15 Audit Commission Report (1996) By accident or design: Improving A&E Services in England and Wales. HMSO. London.
16 Beales J. 91997) Innovation in A&E Management: establishing a nurse practitioner - run minor injuries/primary care unit. Accident & Emergency
Nursing 5, 71-75
17 Dolanb., DaleJ., MorleyV. (1997) Nurse Practitioner: the role in A&E and primary care. Nursing standard. (11)17, 33-38
18 Freij R. Duffy T, Hackett D, Cunningham D and Fothergil J. (1996) Radiographic interpretation by nurse practitioners in a minor injuries unit. Journal
of Accident and Emergency Medicine. 13, 41-43
19 Sakr M, Angus J, Perrin J, Nixon C, Nicholl, Wardrope J. (1999) Care of minor injuries by emergency nurse practitioners or junior doctors: a
randomised controlled trial. The Lancet. Vol. 354. Oct. 16.
20 Burgess (1992)
21 Murphie and Marsden (1992)
22 Baker B (1993) Model Methods. Nursing times. Vol. 89, No. 47, 33-35
23 Beales J, Baker B. (1995) Minor Injuries Unit: expanding scope of Accident and Emergency provision. Accident and Emergency Nursing. 3, 65-67
24 Paxton F, Heaney D. (1997) Minor Injuries units: evaluating patients’ perceptions. Nursing Standard. 12, 5, 45-47
25 Dale J and Dolan B. (1996) Do patients use minor injuries units appropriately ? Journal of Public Health Medicine. Vol. 18, No.2, pp 152-156
26 Garrett S. M, Elton P.J. (1991) A treatment service for minor injuries: maintaining equity of access. Journal of Public Health Medicine. Vol. 13, No.4,
pp 260-266
27 Dale J and Dolan B (1996) Do patients use minor injury units appropriately? Journal of Public Health. Vol. 18,No 2,pp 152-156
28 NHS Management Executive (1994) A study of Minor Injury services. London.
29 Paxton F and Heaney D (1997) Minor injuries units: evaluating patients’ perceptions. Nursing standard. 12,5, 45-47
30 Wood I (1995) Use of Video recorders in auditing initial assessment times. Accident and Emergency Nursing. (3) 62-63
31 Benger J, Wooton R (1999) Minor Injuries Telemedicine. A Supplement to Journal of Telemedicine and Telecare.
32 British association of Accident and Emergency Medicine (1998) The way ahead.
33 Dolan B, Dale J, Morley V (1997) Nurse Practitioner: the role in A&E and primary care. Nursing Standard. 11, 17, 33-38
34 Nicholson D. (1995) the Emergency care Delphi Process
35 Hertfordshire Health Agency (1994) Towards a Healthier Hertfordshire, A&E service Review. Welwyn Garden City.
36 Rich G., (1994) A study of Minor Injuries Services. Leeds NHS Executive
37 DHSS ‘Putting it Right’ (1998) DHSS, Stationary Office, Belfast
38 Council of International Hospitals (1998) Lessons from the UK: the Role of Nurse Practitioners within the A&E departments, USA.
39 Royal College of Nursing (1998) Recommendations of Special Interest Group - Accident and Emergency Nurse Practitioners.
40 DHSS (1999) Extract from Nursing Services for Acutely ill Children
41 Merrett (1995) Clinical Protocols in Health Care. A Legal Perspective. Health Care
Risk Report June 11.
42 NHS Executive (1996) Promoting Clinical Effectiveness. A framework for action in and through the NHS, London: HMSO
43 Dukes & Stewart (1993) Be prepared, Health Service Journal
44 RCN (1993) Protocols and Nursing Guidance for good Practice, Issues in Nursing and Health, No. 27. London: RCN
45 Mariano C (1989) The case for interdisciplinary collaboration, Nursing Outlook, 3:6, 285-288
46 Audit Commission Report (1996) Improving A&E Services in England and Wales.
47 Audit Commission Report. (1993) Children First : A study of Hospital services. HMSO
48 Saines Janet. Phenomenon of Sudden Death. Accident & emergency nursing (1997) 5. 164 -171
49 Walters DT, Turpin JP. Family Grief in the Emergency Department. Emergency Medicine : (9) 189-206
50 NHS Executive (1999) Learning to Manger Health Information.. A Theme or Clinical Education
51 British Crime Survey (1999)
52 Carter (2000) High Risk of Violence against nurses. Nursing management Vol. 6 No. 8 December/January pp 5
53 Standing H and Nicolini D (1997) Review of Work related violence. London: HSE Books
54 Farrell GA and Gray C (1992) Aggression : A nurses’ guide to therapeutic Management. London: Scutaria.
55 Dobson R (1999) Closed circuit television does not reduce violence. BMJ 318:1717 (26 June)
56 Whitfield A (1994) Critical incident debriefing in A&E. Emergency Nurse..., 2(3) 6-9
57 American Academy of Nursing (1983) Take Force on Nursing
58 Co-operating to Protect Children- ‘Volume 6 of The Children (NI) Order 1995 Regulations and Guidance

42

You might also like