HEIKKI PAAKKONEN The Contemporary and Future Clinical Skills of Emergency Department Nurses Experts' Perceptions Using Delphi-Technique

Jari Kylmä, Markku Oksanen, D Soc, Philosophy, Kerttu Tossavainen, Tom Silfvast, Elina Eriksson, Senior Fellow, Julie Considine, Helena Leino-Kilpi
of the study: Emergency Departments (ED) worldwide are facing a growing challenge in proportion to the numbers of ED patients, and the fact that the numbers of beds available treatment is not increasing in the same proportion. EDs are in danger of overcrowding more seriously and more often. The majority of the workforce in EDs consists of nurses, whose vocational training is aimed at the competence of a generalist nurse, but the work seems to require specialised skills. Purposes and design of
more » ... ses and design of the study: The purpose of the study was to reveal and describe, and anticipate the future operational and educational requirements with special reference to ED nurses' clinical skills. The study belongs to the domain of clinical nursing science, and was conducted using the Delphi-technique as follows: the 1st round by semistructured interviews (N=34); the 2nd round by a mailed survey (N=208); the 3rd round by the work of a Delphi-panel (N=35); and the 4th round by the work of a review panel (N=4). The time span was set to culminate at the year 2020. The study questions were: I) What kinds of clinical skills are currently required from ED nurses? II) At what level are the clinical skills of ED nurses currently? III) What will the operational environment for future ED nurses be like? And IV) What kinds of clinical skills will be required from ED nurses in 2020? Experts were selected by purposive sampling techniques among stakeholders, so that all major areas of expertise, as well as interest groups (ED nurses, nursing managers, the medical leadership of EDs, emergency MDs, administrators, researchers, teachers), would be covered. Methodological triangulation in sequential form was applied. Qualitative deductive content analysis was used for the qualitative data, and descriptive statistical methods were applied for the quantitative data. Factor analysis was used to compress the quantitative data. Results: A figure named 'Skills for wise risk management' was assembled to describe the current requirements for the clinical skills of ED nurses. The figure consists of three main components: Basic skills of a nurse; Basic skills of an ED nurse; and, Advanced skills of an ED nurse. The very core of ED nurses' professional competence was related to their skills in controlling both the clinical situation of each patient and the overall situation in the ED. A need for improvement of clinical skills was discovered especially in clinical patient assessment, pain management, co-operation with pre-hospital Emergency Medical Service, management of theoretical knowledge with special reference to knowledge of the natural sciences, and the detection of as well as reaction to problems related to disturbances of vital functions. In particular, MDs evaluated the quality of ED nurses' clinical skills significantly more critically than other respondents. The most important tasks that should be considered to be transferred to the responsibilities of ED nurses turned out to be ordering of laboratory tests and x-ray studies according to their own judgement, suturation of minor wounds, pain management, triage of inflowing patients, and care of a lifeless patient according to protocols. Centralisation of emergency health care services will continue, and this will place further demands on the clinical skills of ED nurses. Nurses' training was unanimously regarded as excessively theoretical at the cost of clinical competence, and a clear wish for this to be changed was evident. The operational environment of EDs in the year 2020 was considered likely to be similar to the current environment, but it was generally hoped that there would be a training programme dedicated solely to emergency nursing. The scope of ED nurses' practice was desired to expand, and this was also considered probable. Nurses' receptions within EDs of specialised medical care were considered both probable and desirable by 2020, as well as a limited right to prescribe and write certifications for sick-leave. Skills to perform appropriate patient triage will definitely be required. An increase in the procedures and care initiated by ED nurses independently was considered both probable and desirable. Conclusions and implications: Nurses' theoretical and applied knowledge base should be strengthened, especially in terms of natural sciences including pathophysiology. Nurses' skills in reacting to clinical observations made as well as pain management ought to be developed. If it is considered appropriate to develop the scope of ED nurses' practice according to the findings of this study, the whole structure of nurses' education needs to be scrutinised critically. In particular, the current approach by way of aiming at the competence of a generalist nurse as well as the need to establish an official educational programme within the higher university degree of applied sciences in the field of acute nursing care will have to be reconsidered. Scientific research endeavour needs to be directed towards clinical emergency nursing, and an evaluation of the actual clinical skills of ED nurses would be of utmost importance. Furthermore, attention in terms of basic and applied research aiming at constructing universally applicable theory for emergency nursing might be beneficial for the whole discipline of nursing.