Advanced skills of an ED nurse

This item seemed to be consisted of four (Figure 10) issues with close resemblance. The differences, albeit admittedly minimal-sounding, bear remarkable importance, and therefore should be neither misunderstood nor undervalued.

FIGURE 10. Essence of ‘Advanced skills of an ED nurse’.

Skills for pattern recognition

A skill having paramount importance in the clinical ED nursing seemed to be the ability to recognize the pattern of a seriously ill or injured patient with one glance. This was acknowledged to be characteristic for an experienced ED nurse. In order to be able to make reliable assessments of patients’ clinical condition, the ability to make a distinction between

anatomically and physiologically normal and abnormal findings was considered to be a requirement. Furthermore, to be able to discern what is abnormal and what is critically abnormal was regarded as more difficult, and a prerequisite for being able to react in an appropriate way to the situation in question. An illustrative example of the expressions used was:“To understand, what is normal, what is abnormal, and what is critically abnormal.”

The concept of recognition was related to the ED nurse’s ability to detect symptoms and phenomena that possibly, or obviously, are signs of impending threat to the patient’s life, or at least well-being. The material related to recognition was generous, and such descriptions were used as follows: “To find the things that put the patient in a risk.” “Immediately life-threatening conditions would become ruled out.” “You should have a good clinical eye.”

“You should quickly see if the patient is in need of immediate care.” “Recognition of clinical conditions.” “Recognition of alterations caused by sickness.” “Ability to integrate separate observations.”

A strong emphasis, especially among the more experienced nurses and most MDs, was placed on the ED nurse’s ability to make reliable patient assessment without any technical devices, i.e. through seeing, hearing, touching and listening. A concern was raised that along with the emergence of more and more sophisticated technical devices the clinical assessment skills are becoming rusty. Furthermore, what might be even more remarkable, the traditional clinical assessment skills are perhaps not any longer appreciated, mastered and trusted among the younger generation of health care practitioners. Justification for these worries were based on such comments as:“The bed-side methods should be emphasised more.” “Taking a patient’ s pulse just does not happen anymore.” “We should assess the temperature of peripheric body parts more often.” “They assess the patient’s breathing, frequency of respiration, they don’t, however, listen to the lung sounds, which should, at least with trauma patients, be an essential part of patient’s examination made by a nurses.”

One of the most characteristic features of the requirements set to ED nurses’ clinical skills turned out to be the ability to anticipate the clinical course of patients, as well as the proceeding of certain situations. It was described as an ability to somehow sense the next phase of a patients’ clinical state. For some reason the ability to foresee was more strongly related to anticipation of the clinical course of trauma patients than others: “In certain situations you should be able to foresee.” “It is a matter of being able to utilise the

knowledge of trauma mechanisms with the assessment, and to foresee possibly impending problems.”

Skills to assess patient’s risks

The assessment skills, including ability to make a systematic patient assessment as well as to prioritize both individual patients and tasks, will be discussed here. These were almost unanimously regarded as core assets of ED nurses’ repertoire of attributes. This became evident in many ways, along with the proceeding of the analysis of the data. Thus, several examples of the responses are provided:“They should be able to make an immediate primary survey.” “On a certain level you should be able to examine the patient clinically.” “They should be able to assess the risk of the patient.” “You must have the ability to interview and take an anamnesis.” “Every patient would be examined before they find their way to the MD.” “So there would be a triage nurse or somebody, who would go through all the patients.” “They should be able to assess the urgency and seriousness of the patient s situation.”

In particular, many emergency MDs seemed to regard bringing more systematics into the daily work in EDs as necessary. Systematic assessment was also considered to be a cornerstone, when aiming at enhancing the safety level of ED care. On the other hand, providing systematic assessment appeared to be one way of obeying the principle of equal care to all patients, which was expressed clearly by the respondents:“All groups of patients would be provided with a kind of structured system.” “We should establish a system of equal treatment for certain groups of patients.” “Ability to make a systematic assessment is a keystone skill of these nurses.” “We already have a system, according to which the patient’ s vital functions – breathing, circulation, the level of consciousness, and also the status of psyche – are always assessed.”

The existence of some kind of system which enables incoming patients’ classification according to their urgency and medical speciality was regarded as a prerequisite for running an ED successfully. The selection of patients to either primary health care or specialised medical care was considered to be a primary duty and responsibility of ED nurses. Also, the initiation of immediate measures needed to save a critically ill or injured patient was considered to be the responsibility of the triaging nurse. The importance of mastering the skills required for making a reliable triage was described as follows:“You should be confident in making triage so that you can put the patient to specialised medical care, or even to the

resuscitation room, if it looks like that.” “It would be like a fast triage.” “You ought to have the triage system in your head.”

The ability to prioritise seems to be close to the ability to make triage. However, prioritisation concerns both tasks and patients, and thus differs from prioritisation merely of patients and their urgency. In the everyday life of EDs there seems to be a tendency towards congestion of things to be done, and, at its worst, even the most important things have to be prioritised. The ability to differentiate between important and even more important things to be done, seems to be an essential requirement set to an ED nurse:“You must have the eye to tell apart a sick and less sick patient, and to make a prioritisation.” “You must be able to tell apart what is significant and what is not. “You have to able to prioritise both tasks and patients.”

Skills for independent decision-making

Ability and willingness to act in an independent manner was emphasized by ED nurses, and is the following subject taken under surveillance. This attribute might be regarded as the next step following the aforementioned skills to assess patient’ s risks. When the risks are assessed, a decision is required with regard to what the next step should be. The requirement of independence was connected both to ability for independent decision-making, and a more indistinct or blurred concept describing some ED nurses’ way of approaching their work. This concept seems to be hard to define accurately. However, it was clearly expressed as being a positive attribute, and consisting of attitude, willingness and ability to take responsibility for patients without immediately seeking someone else’s permission to, for example, conducting a thorough examination and drawing conclusions. Anyway, this was expressed as not being the same as exceeding one’s authority: “They should want to examine the patient independently.” “An independent approach to work.” “What is needed is ability to independent decision- making.” “Ability and willingness to face a patient.” “There, by the entrance, the right kind of attitude is required.”

Decision-making seemed to be connected with making observations and drawing the right conclusions, which should be transferred to appropriate action according to the needs of patients: “From the patients’ situation you should be able to draw certain conclusions.”

“There should be ability to medical decision-making and problem solving.” “All kinds of decision-making related to practical action, and such action that is required in a situation, when the patient is in the ED.”

There appeared to be concern about the perceptions of the role and duties of an ED nurse.

This was expressed in a way that connects the item closely to the clinical reality of the respondents:“The nurses don’t necessarily conceive for example defibrillation of patient’s ventricular fibrillation as a duty naturally belonging to them.” “There still prevails an attitude that it does not belong to the domain of nursing and nurses.”

Skills for detecting, processing, and responding

A very narrow gap separates this set of skills from the previously mentioned two issues. With the risk of splitting hairs the researcher claims the data to indicate that a skill to detect, process, and respond comprises an entity of its own. In a way this combination might be considered a special and definitely an advanced skill with the aforementioned components so tightly combined that they can’ t be separated in the clinical reality. Presumably the decisive factor for this elusive set of skills is the fact that they occur virtually almost simultaneously.

Comprehension can be explained here as a deep understanding of what has been discovered or observed, knowing the clinical relevance and importance of it, and being aware of the actions needed to be taken. Some concern was raised with regard to all these components, and it was described as follows:“Writing down your observations is not enough, you must also utilise the data.” “Utilising what has been observed does not necessarily always happen, even if the information could be found from the patient’s files.”

Reacting quickly, when this is in a patient’s best interest, was commonly considered a fundamental requirement of an ED nurse. In addition to reacting quickly, the response should be spontaneous and appropriate. It was also considered that the training of ED nurses should be on such a level that this comes about when needed. This phenomenon was described as:

“Such a preparedness should be with us all.” “A rapid, adequate response to appropriate situations – that is needed.” “You must act extremely fast.”

It was commonly regarded as desirable that an ED nurse would be officially delegated the right to initiate certain treatments in pre-defined situations. Starting the action, when a patient, requiring immediate attention, comes or is brought to the ED, was also considered as a major responsibility of and ED nurse:“It would be useful that we could initiate certain treatments there immediately.” “Even to start establishing the care in a way”

In order to be able to initiate the necessary treatment you should be able to make useful observations, process them in an appropriate way, and also have the necessary confidence and

skills for not hesitating at the initial phase of the care:“To do things, and to get things going based on the information obtained about the patient.” “They should start acting according to their observations, when necessary.” “The patient’s situation should awake some kinds of reactions.”

Both the ability to perform procedures independently, and assessing the need for them, was pointed out. In particular the skills needed in urgent situations were considered to be necessary to master without anyone’s help or assistance, and with an active approach to work:

“Certain procedures must be mastered independently.” “They should be able to use technical examination devices independently.”

It was frequently expressed that ED nurses should possess the skills for recognising the need for certain treatments, as well as to implement those at least life-saving measures, if needed.

Furthermore, even if a patient is recognised to need such a care that can only be performed by an MD, ED nurses ought to be able to initiate the first measures towards the care performed by an MD:“Taking care of pain medication and oxygen therapy, starting CPAP- care, all kinds of things like this could be started by us at the same time.” “Initiation of the care and all the help the patient needs should be done by us.”

The role of ED nurses was clearly wished to be active so that they would be willing to and capable for turning their knowledge into action in proportion to the needs of patients. It was widely acknowledged that ED nurses possess a high degree of theoretical knowledge, but this does not necessarily translate into appropriate action. The perception of the role of ED nurses as active performers was emphasised here: “Utilising the information gathered with monitoring equipment and other devices, and processing it so that it is turned into action – this is what they ought to be able to do.”

On the other hand, from the generous data a few mentions towards such a situation that clinical skills are not actually required so much, was observed. The justification for these comments appeared to be such that the role of an ED nurse is a passive one; they expect the MD on-call to give instructions concerning how things have to be done. Despite the low frequency, these seemed to be weighty perceptions:“I don’t believe that clinical skills are currently very much required from them.”