Emergency nursing – Home and away

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Developing emergency and urgent care services that are high quality, effective, efficient and timely has never been so challenging. There are constant demands on staff, space and resources and it can often feel that all the workable solutions have been exhausted. Looking at your own service with a fresh, critical eye can be hard. Knowing what doesn’t work is often the easy part, finding the answer can be impossible. Visits to other centres with successful initiatives can be inspiring but this is often only for a short time and can leave you with more questions than answers.

I have recently had the opportunity to try something radically different in an attempt to learn new ways of delivering emergency care to children. Following a successful application to the Florence Nightingale Foundation I was awarded a travel scholarship sponsored by Nestle and have spent time working clinically in two internationally renowned Paediatric ED’s in Toronto and Melbourne. The overall aim of this trip was to identify areas of “best practice” in Paediatric Emergency Care but not just to understand it, but to experience the detail. The Florence Nightingale Foundation supported my proposal for an extended trip to enable me to truly experience clinical and operational differences and analyse their transferability in the NHS. The Paediatric ED’s at The Sick Children’s Hospital (Sick Kids) Toronto and Royal Children’s Hospital (RCH) Melbourne were chosen as they both have international reputations for research into Paediatric Emergency Care and both have public funded health care systems, similar to the NHS. I developed a number of specific clinical objectives regarding paediatric triage, pain management and advanced nursing roles. However, there were several other areas where the differences were striking and made a significant impression on me, these areas were non-clinical support roles and clinical educational roles and they are described below.

Both ED’s, on opposite sides of the world had identical non-clinical support roles which even had the same titles. The patient services assistants (PSA’s) worked 24h a day and maintained the environment. This team of staff were truly brilliant! They hovered in the background actively looking for clinical and non-clinical areas to clean, re-stock and tidy ready for the next patient. I can honestly say that I never went anywhere to get anything and it was not there. Everything was always stocked, available and ready for use, which saved untold time. I am sure most of us would loose count of the number of times we needed a patella hammer, tape/gauze for example and had to leave the patient to get what we needed. The success of these roles appeared to be that the PSA’s had no direct care element to their role. If the ED’s were busy they were not asked to deliver any clinical care as untrained staff do in the UK, they maintained the environment, the very time when this is crucial. The PSA’s were also very proud of their role and their place within the ED team.

The second role was that of the “ED Clerk” this person manned the phones, dealt with enquiries and liaised with all the medical specialities. Again this was a 24/7 role which maintained the flow of communication in geographically large departments and they always knew who was where, waiting for what. The ED clerk undertook all the clerical and administrative duties and was completely separate from the role of ED reception. Ask yourself, who does these roles where you work and in neighbouring departments, is it Registered Nurses?

The clinical educational roles in Melbourne ensured that the nursing staff were fully supported in their development. A team of educationalists worked jointly in ED and at the University of Melbourne, delivered formal and informal education to all grades of staff and worked alongside them facilitating the transfer of theory into practice. The level of knowledge and skill that junior staff had when dealing with critically ill and injured children was extremely impressive. As there is no separate children’s training in Australia there is a need for intensive support for new staff. Paediatric Emergency Care is a unique specialism and most other specialities can do little to prepare you for the depth and breadth of knowledge required, this too was recognised. Another striking difference was the lack of a 4h performance target. Children had to be seen and discharged within 6h or admitted within 8h, meaning there was time to teach. Nursing and medical staff were always discussing the care and treatment of children, checking evidenced based guidelines and spending more time explaining to parents in detail how to care for their ill/injured child on discharge.

You would be quite right challenging me by stating that both departments visited are world renowned tertiary referral centres with a significant amount of resources at their fingertips. But aren’t these roles the basics? An ED that is cleaned and stocked 24/7 has to make sense, be cost effective and save nursing and medical time. These are the very principles that “Lean Initiatives”, now endemic in the NHS, would support (Jones and Filochowski, 2006). A nursing workforce that is highly trained, well supported and developed throughout their careers is what we would all aspire to have. Nurses are the permanent workforce in ED, they will maintain standards, manage risk and enforce departmental quality on those less experienced. These were just two areas of practice that I observed after an amazing experience. By focussing here on these unexpected “finds” is not to detract from all the other areas of clinical excellence I observed (far too many to describe in a short editorial). As we all move into a Darzi era of health care we have to get the foundations right (DH, 2008). Quality initiatives will realise their true potential if ED nurses are freed of administrative, clerical and housekeeping duties and are trained and developed throughout their careers. This is not revolutionary or pioneering but it does have the potential to make a huge impact on quality, this is the important detail at a clinical level. Afterall, as ED nurses know “the devil is in the detail”.

My thanks go to the staff at Sick Kids and RCH for taking the time to share with me all their knowledge and skills. Thanks also to the Florence Nightingale Foundation and Nestle for my travel award.

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References 

1. DH (2008). High quality care for all. NHS Next Stage Review and Final Report DH: London.
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2. Jones, D., & Filochowski, J. (2006). Think yourself thin. Health Service Journal April 06 (supp 5).
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