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Advancing nursing skill on medical admissions units

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This is a summary: the full paper can be accessed at…


VOL: 103, ISSUE: 24, PAGE NO: 32

Ross Fletcher, BSc, RN, is clinical educator at Bradford Teaching Hospitals NHS Foundation Trust


This is a summary: the full paper can be accessed at nursingtimes.netThis systematic literature review explored the professional development of nurses in medical assessment units (MAUs). These units rapidly assess patients who are acutely ill and referred by a GP or casualty doctor. This review aimed to identify whether there is evidence that nurses use advanced skills on MAUs and whether advanced nurse practitioners (ANPs) can facilitate the professional development of other nurses.The published literature focusing on MAUs is limited and most studies relating to advanced practice originate from outside the UK. This may be because the MAU is a relatively new concept (Carroll, 2004).METHODOLOGYDatabase searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library and Medline were conducted and four published studies were examined in detail: Carroll (2004); Tennant and Field (2004); Wood (2000); and Mayled (1998).Each study identified the importance of professional development and the need for nurses to extend their skills to meet patients’ increasing demands and deal with the effect of changing legislation - for example, the European working time directive - on nurses’ autonomy.FINDINGSStudy 1: Carroll, 2004Carroll (2004) aimed to identify skills needed by nurses on an MAU, using a qualitative method incorporating surveys and focus groups. She included 38 ANPs working on MAUs and educated to master’s level who volunteered for the study. The fact that the participants volunteered rather than were selected could affect results.The aims and objectives of this study were clearly identified at the beginning of the report and a description of the methodological approach was provided. Carroll (2004) identified nurses’ skills according to their grade and found that those at the most senior grades had the more advanced skills.A range of assessment tools including questionnaires and interviews were used to assess how nurses perceived their role on the MAU by grade and the skills they used.Interviews were conducted using the Delphi survey technique. This allows interactive communication between the researcher and ‘experts’. Qualitative and/or quantitative questions can be asked of the experts. The information is analysed and fed back to each person, via further questions, until the aim of the study is achieved.Carroll’s results suggested that roles and responsibilities differed according to grade and seniority. However, some nurses may have had increased knowledge and skills because of experience and professional development but may not have applied for a promotion, which the author noted. She said the participants ‘argued that experience was imperative and the roles of prescribing and interpreting results were appropriate only to senior nurses’. However, the term ‘senior nurse’ was not defined in the study.Study 2: Tennant and Field, 2004Tennant and Field (2004) discussed whether CPD makes a difference in their study of nurses undertaking a specialist ICU course compared with those learning on the ICU without attending the training course.A convenience sample was used and this may be a weakness. Hek et al (2003) described this as the weakest sampling technique as it can increase bias. In addition, as the trust was paying for the ICU course, participants may have felt obliged to take part in the study.A group of five participants attended the ICU course while a control group of five did not. The nurses assessed their own abilities at the beginning of the study and their manager assessed them all independently.The findings of the study suggest that nurses learn and develop through experience regardless of training courses attended. The authors concluded that the ICU course did have an impact on practice but participants who did not do the study course also developed.Study 3: Wood, 2000Wood (2000) researched MAU provision in the West Midlands and nurses’ perspectives on this provision. The study used telephone questionnaires to collect data and 12 participants were interviewed.Wood identified that nurses had an important role to play in emergency admissions in ensuring that assessment, prioritisation and treatment are effective, and that nurses on the MAU acted as a source of information for junior doctors and accepted referrals. He suggested that nurses need to come from different nursing backgrounds and have different levels of clinical expertise. This contrasts with the view that ANPs need to be educated to master’s level (Mayled, 1998).The study was small and may not be generalised to all MAUs. Wood identified that nurses on MAUs need to develop as a new branch of emergency nursing.Study 4: Mayled, 1998Mayled (1998) identified the role of the ANP in improving the quality of patient care and described how the role developed on an MAU. The author used patient satisfaction questionnaires to analyse the role of ANPs. The sample size of 18 was relatively small compared with the 3,716 admissions to the unit that had occurred in three months.The author identified few previous studies in the literature search to support his findings and there is no evidence of any interaction with ANPs outside the unit where the study took place. The researcher assessed how satisfied patients were with their care. As he worked on the unit, however, a limitation could exist as nurses may perform in an exemplary manner if they know research is taking place - researchers may not be aware this is happening.Mayled’s study suggested that patients were relatively happy with the assessment and treatment provided by ANPs. Although it does not report on professional development in the MAU, the study offers an opportunity to learn about the role of ANPs on the unit and the competencies they need.DISCUSSIONIt is evident from the reviewed literature that healthcare workers require extended skills to carry out assessments and interventions for patients on an MAU but there is little evidence to suggest what these skills should be. Although patients on MAUs can differ from those in the A&E department, advanced skills and roles for nurses should mprove patient care and reduce complaints and waiting times.Tennant and Field’s (2004) study identified that professional development had an impact on practice but there was little evidence to suggest patient satisfaction and services had improved.Carroll’s (2004) study highlighted that skills required by MAU nurses could be identified for different grades of staff but Agenda for Change (AfC) banding now affects how her results could be applied. Protocols and policies need to be in place for nurses who are using extended skills (Carroll, 2004; Scrivens et al, 1998).The European working time directive, AfC and the Knowledge and Skills Framework have all given nurses an opportunity to achieve new skills and knowledge, and it is imperative that these skills are appropriate for the patients and have beneficial outcomes (Carroll, 2004). Without training, nurses cannot function in such an acute environment and operate safely and competently.Three of the studies included in this review were undertaken on MAUs and indicated the need for advanced skills. One study took place on an ICU and acknowledged the need for professional development in a specialist area. However, whether the results from the ICU are transferable to a MAU is questionable.CONCLUSIONThe MAU is an ideal environment for providing professional development. Nurses encounter a diverse range of medical conditions on such units and the experience is invaluable for health professionals wishing to increase their knowledge and develop their skills.CPD and life-long learning are essential in ensuring the provision of good-quality care for patients. Due to the development of new nursing roles, NHS trusts are increasingly looking for cost-effective, flexible training in order to educate the workforce quickly and efficiently (Ayers and Smith, 1998).Dissemination of knowledge is important in all areas of nursing and ANPs could circulate their knowledge to nursing staff on a variety of issues and aspects of patient care.The studies discussed in this review were small but relevant. The field of acute medicine is changing continually and nurses’ skills and roles should alter as new issues arise.IMPLICATIONS FOR PRACTICE- Nurses on MAUs should have extended skills in order to cope with the complex needs of patients who are acutely ill. They also require knowledge and skills to cope with a wide variety of medical conditions in order to facilitate the assessment process. There is very little research concerned with how the units function and the competencies that nurses who work on these units should have (Carroll, 2004; Wood, 2000).- Nurses have an important role to play in emergency admissions in ensuring assessment, prioritisation and treatment are effective (Wood, 2000).- Protocols and policies need to be in place for nurses who are using extended skills (Carroll, 2004; Scrivens et al, 1998).- MAUs should have access to ANPs in order to facilitate professional development in relation to enhanced clinical skills and provide cost-effective training.This article has been double-blind peer-reviewed.

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