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In 1911, a BMJ editorial expressed concern over what was viewed as “an increasing tendency for nursing associations to employ nurses who are not only allowed but apparently in many places encouraged to prescribe and administer drugs, to treat minor injuries and generally act as minor medical practitioners”. In the view of the editor “in her proper place a nurse is invaluable both to the patient and to the doctor but that the training and qualifications of a nurse do not fit her and were never intended to fit her to discharge the functions of an independent practitioner”.1 There are some who would still concur with this view, but just as no one conceived of a male nurse in 1911 (they are now 17% of the workforce), the evolution of emergency medicine, combined with social, political and economic forces in healthcare, have provided a fertile environment for innovation and role development. The ED holds great appeal for nurses who are prepared to challenge and step outside of traditional boundaries in the interests of patients although this has often been met with uncertainty and resistance.
The nurse’s official role in the emergency department of the late 1960s was mainly to undress patients and record a set of vital signs for the doctor whose role it was to assess, diagnose and treat the patient. From 1967, there has been an increasing recognition and acknowledgement of the contribution of emergency nurses to the specialty in the UK. Short falls in indigenous medical staffing led to casualty departments being staffed by overseas doctors who, although clinically able, were often unfamiliar with local culture, colloquialisms and patterns of frequent attenders. In these situations, experienced nurses often elicited and deciphered complex medical histories for the doctor. Thus, in a very subtle way they held sway over doctor–patient interactions offering cues to the doctor about the sequence of a consultation as well as often paraphrasing the doctor’s instructions for the patient.2 This was not to doubt the doctor’s clinical acumen or expertise but to support and often protect them in an unfamiliar clinical and social setting.
In 1972, the Royal College of Nursing instituted the A&E Nursing Forum; this was followed by the first national Accident and Emergency nursing course, which was designed to fit nurses with skills and knowledge specific to emergency care. This became known as the English National Board 199. Success in this programme was nationally recognised and a passport to promotion in the specialty. The late 1970s and early 1980s saw the beginnings of joint working between the Royal College of Nursing (RCN) Accident and Emergency Nursing Forum (now the RCN Emergency Care Association) and the then Casualty Surgeons Association. Recognising that there was specific knowledge and skills required by nurses who work in the area, these developments helped to develop and embed the specialty of emergency nursing,
In 1990, two trauma nursing programmes were introduced, the Advanced Trauma Nursing Course and the Trauma Nursing Core Course (TNCC). By 1997, the TNCC had trained over 1000 providers in the UK.
The year 1994 was a watershed in emergency nursing with the publication of the RCN document, Accident and Emergency Nursing: Challenging the Boundaries.3 This visionary document recognised the specialist role and potential of emergency nurses providing them with the mandate needed to advance their practice and break down barriers in the interests of better patient care. Most significantly, it offered substance and guidance to the fledgling nurse practitioner services that were emerging around the country, one of the first being in Old Church, Essex.4 From 1992 to 1995, there was a prolific expansion in the numbers of departments introducing nurse practitioners from 6% to 63% by 1995.5 6 Nurses met a significant degree of resistance in introducing this role, both from within and outside of the profession; for example, there was opposition to nurses requesting imaging for patients who they had assessed as needing X-rays. Concerns around the knowledge and expertise of nurse practitioners, first expressed in 1911, were echoed by some nursing and medical colleagues. However, evidence of safe practice and patient satisfaction encouraged acceptance and recognition of their wider contribution to the delivery of emergency medicine.
By this time, most EDs in the UK were practising some form of Triage and the publication of the Manchester Triage system in 19957 was a leap forward in ensuring evidenced-based Triage nationally. Joint working between the RCN A&E Association and the then British Association for A&E Medicine was being strengthened with the endorsement of a national triage scale in 1996.8
Attempts at introducing competencies and frameworks for all emergency nurses to standardise practice have been met with varying degrees of success. The first of these was with the establishment of the Faculty of Emergency Nursing.9 These initiatives have been superseded by Masters educational programmes and more recently by the publication of the RCN A&E Association National Curriculum and Competency Framework.10 These frameworks helped to make clear the knowledge, skill and clinical competencies fundamental to emergency nursing.
The introduction of the Consultant Nurse role in 2000 was further recognition of the supportive and complementary contribution expert nurses were making to emergency medicine. Consultant nurse roles are underpinned by a number of key principles: advanced levels of clinical judgement, knowledge and experience that allows them to contribute to better outcomes for patients. Many of them have been successful in improving patient pathways and service delivery through innovation, research and service development often influencing at NHS Board, regional and national level. While many Consultant Nurses develop a ‘niche’ area of clinical practice within the emergency setting, their significant experience and expertise underpinning their clinical academic role has inspired junior staff and raised aspirations, which augurs well for the future.
More recently, there has been a refocusing on the role of Matron. Bringing management back to a more clinical level, the matron role focuses more on clinical operations in the ED and staff management. Having very senior nurses working clinically has provided stability and expertise and has reaffirmed the primacy of clinical practice offering alternative senior career pathways to nurses. Senior clinical nursing leaders have been able to question and challenge outdated practices, promoting the fundamentals of emergency nursing with up-to-date evidence.
More emergency nurses today in the UK and in developed western economies are educated to Master’s level with a significant number achieving an MSc in Advanced Practice, MPhil or Doctorate. Preparation for this level of practice has encouraged further academic study and a spirit of inquiry to the extent that many are increasingly involved in research programmes, with a number choosing clinical academic careers where available. Notably, there are now three Professors of Emergency Nursing in England. Reforming Emergency Care in 200111 and performance standards have brought their challenges, not least that it has changed the nature of some nursing roles.
The recent emergency medical workforce crisis in the UK has sharpened the focus on developing sustainable multidisciplinary clinical teams and the role of the ED Advanced Clinical Practitioner (ACP). This development has strengthened the collaboration between the RCN, the The Royal College of Emergency Medicine (RCEM), the College of Paramedics and Health Education England. This unique collaboration has led to the development of a national curriculum and credentialing process for ACPs under the auspices of the RCEM. Following the successful pilot, seven ACPs have been credentialed by the RCEM, with several hundred more developing a portfolio of evidence in preparation for credentialing. There is an increasing recognition of the contribution of other professions to the delivery of emergency care; paramedics, physiotherapists and pharmacists are being employed as advanced practitioners in EDs, adding richness and diversity to the workforce.
Despite the changing nature, demographics, demand and expectations of the specialty, emergency nursing has been a stabilising, consistent and responsive workforce that has developed significantly over the past 50 years. However, it would be disingenuous and naive not to acknowledge the challenges and concerns facing emergency care and nursing in particular. The traditionally aspired to ‘Sister/Charge nurse post’ has become less attractive to today’s emergency nurses as it has largely lost its allure of ‘expert clinical nurse’. The focus on targets in the UK recent years has had a significant impact on nursing and particularly this leadership role where the key function has become the manager of patient flow as opposed to the clinical lead nurse and expert. Thus, the current challenge in recruiting to these senior nursing leadership roles is a growing concern. It is well recognised and documented that the pace and pressure of work in the ED is unsustainable over time and burnout, loss of compassion and indifference to suffering will affect some. Many nurses already leave and seek less pressured working environments.
More than ever, we need to draw on our history and natural resilience to promote emergency nursing and retain our teams by offering a working environment that is attractive and inspiring. But perhaps more importantly, we must continue to work collegially and creatively with our medical colleagues and allied health professionals to prioritise staff well-being in order to build a sustainable future emergency workforce that is resilient, empathetic and responsive to patient need for the next 50 years. As we look back over the last 50 years of development, we can be confident that the past portends the future and that our history of collaborative development bodes well for emergency care over the next 50 years.
RC and MD contributed equally.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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