Emergency care – More than just a collection of tasks

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There is little doubt that emergency nursing is a skilful and technical specialty. An efficient patient journey through the emergency department is dependent on a wide range of interventions, investigations and treatments. As such, emergency nurses must learn, and become competent in, a variety of skills; from cannulation to application of Plaster of Paris, and from preparation for thoracotomy to ankle splinting. However, excellence in emergency care is not just about technical expertise. It is essential that the staff are competent in undertaking observations, but if they do not know what to do with the information, or are not confident enough to discuss their findings with a colleague, then the patient is still at significant clinical risk. I am really enthusiastic about expanding the nursing role but if we cannot communicate effectively, then the patient may be left feeling scared, and vulnerable.

Two very different papers in this issue highlight the importance of technical proficiency, but also how skill in itself is only a small element in the overall picture of care – Unhasuta et al. (P. 3–7) describe the process of generating a national competency framework for trauma in Thailand, and Sheppard et al. (To be published in next issue) report their study on patient experience in the emergency department.

Unhasuta et al. (P. 3–7) identified that there were inconsistencies in trauma care due to a deficit in medical staff with the requisite skills, with significant implications for patient outcomes. They recognise how fundamental nurses are to effective service delivery as they are seen as the stable workforce, gaining extensive knowledge about their patient groups and departments and how the local healthcare services work. Doubtless, Thailand is not the only country where medical staff with the appropriate skills are in short supply. This leaves the specialist emergency nurses to initiate and ‘guide’ patient management. This happens globally and is often the basis for expansion of the nursing role – they already advise and manage the care episode, so why not deliver it themselves? We simply have to look at the development of the advanced nurse practitioner across the globe, to see this in action.

Unhasuta et al.’s paper provides a very brief overview of the generation and validation of a national framework for nursing competence in trauma care. Using Benner’s Novice to Expert conceptual framework, and with the knowledge of clinical experts, they identify six key elements to trauma competence. Technical skill accounts for only one dimension. Others include leadership, decision-making and teamwork. Knowledge and expertise across all the dimensions is essential for effective trauma care. The participants recognised the importance of being able to analyse information, communicate with the team, and make effective clinical decisions, not just completing a procedure or investigation. What is really refreshing is that these broader skills are seen not just as the domain of the senior nurses or the medical staff, but are integral across the competency framework. It underpins the idea of teaching the skills of decision-making and leadership from the beginning of a nurses career, and that they are an essential component of ‘getting the job done’ for everyone. This seems more relevant for those nurses working with limited medical resources and poor skill mix, but I would argue that if these skills are integral in all training junior staff would have more confidence in communicating their concerns about patients, even in a medically dominant field and thus, truly influence patient outcomes.

In agreeing a national standard for trauma care, Unhasuta et al. have achieved something many other highly developed nations have failed to do. By involving clinical experts and large numbers of emergency nurses from across Thailand in this study, they have also generated a clinical network, paving the way for future collaborative work. The paper outlines a methodological process for creating and validating competencies which could be repeated for any element of care, or in any environment.

From a completely different perspective, Professor Sheppard and her colleagues address technical skill and proficiency in their review of the qualitative literature on patient experience (To be published in next issue). Although skills are discussed, the factors found to have the greatest influence on overall experience of emergency care include waiting, being treated with dignity, addressing patients’ psychological and emotional needs, and the environment. Family presence was seen as key to the experience, as they could act as an advocate for the patient. Patients appreciated staff who took time to listen and explain what was happening to them, and excused staff when expectations were not met, blaming the environment, or management.

Clinical skills are described in a primarily negative way, with patients feeling processed, rather than cared for. At times, patients used the staff’s technical proficiency to excuse the lack of ‘care’.

There is a sense from the paper that we do things ‘to’ them, rather than with or for them. Coming from a qualitative perspective, this is very powerful, as participants will not have been directed in their feedback, as might be the case in survey methods, but instead left to simply describe what was important to them.

There may be an element of assumed proficiency. Patients may presume that staff are competent, and that their treatment will be right. It is only when these assumptions are not met that they affect the patient experience. Or, in the same way that a shop assistant can easily make us feel uncomfortable and unwelcome without even speaking, it could be that experience is more about how we make them feel as patients (and humans), rather than the actions we take. Whatever the rationale, the paper suggests that technical skill, in itself, seems only to play a small part.

Emergency nurses are do-ers, they like action, often so repetitive or so busy they forget to think. Thinking might slow things down, and lead to inaction. The nurse, new to emergency care, is desperate to learn many of these skills – if only to fit in, or reduce the burden on the rest of the team. But there is little point in undertaking a skill if we lose the thought behind it. I regularly teach cannulation to groups of nurses, and encourage them to gain competency, but then challenge them if they put one in ‘just in case’ or because they were told to. What does that cannula actually mean to the patient who has poor veins and who may not need intravenous treatment? Surely, we are simply exposing them to greater risk, and discomfort? There is little point in undertaking an ECG if we have no understanding of what to look for, or its importance in the context of that particular patient. But we do it because we know they need it, or to save time.

Thinking will never be the enemy of doing, whether done at the time, or by reflecting on events later. Thinking not only allows us to question what we are doing now, but also to think of the effect of our actions on our patients. The two papers discussed look at technical proficiency from very different perspectives, by providing frameworks that generate knowledgeable do-ers, and by sharing the patients’ perspective. I hope they encourage our readers to examine how they function every day, and how they develop the emergency nurses of the future.