A limited definition of a minor injury
Having worked in a nurse led minor injuries unit for the last six years I would like to respond to Mr Leaman's article in the Emergency Medicine Journal supplement of January 2001. Especially as his definition of a minor injury is very limiting and bears little resemblance to the type of patients seen in our local units.
I work in East Kent which is 600 square miles and has a population of 580 000. We have three minor injuries units, two of which are nurse led and one, which has a doctor on alternate weeks and are supported by three major Accident and Emergency Units. Over 40 000 patients presented at the Minor Injuries units last year, demonstrating the high satisfaction among the population. The Emergency Nurse Practitioners work from agreed protocols and diagnose, treat and discharge 97% of our patients of every age including children and the elderly. While protocols can be limiting the Emergency Nurse Practitioners are well aware of their knowledge, skills and limitations and have excellent links to the A&E units and local GP's. This ensures the patient who attends with a condition or injury, which is beyond the scope of practice or competence of the Emergency Nurse Practitioner, is referred quickly and efficiently to the most appropriate health professional. This includes the orthopaedic, medical, surgical, gynaecological, paediatric ophthalmic and ENT teams, the A&E department or a local GP. This communication also facilitates the teaching and updating of conditions and expansion of practice.
I agree the move to introduce Emergency Nurse Practitioners was to reduce waiting times and to help address the staffing crisis. However many A&E nurses were keen to expand their role having taken on many extended nursing tasks and a desire to provide holistic care which they felt to be within their knowledge and skills base. Increasing specialisation is justified in medicine as doctors realise they cannot maintain the vast knowledge necessary to treat all conditions. This applies equally to nurses who wish to develop and maintain a higher level of competence and inlprove the focus of patient care . Nevertheless it is historically known that their many years of experiential learning has supported and guided junior doctors in providing a safe and effective service.
Our Emergency Nurse Practitioners are locally trained in clinical skills and develop their knowledge and skills by moving to a degree programme at the local university. However I am in total agreement with the problems of an ad hoc training with no definition of the role of the Emergency Nurse Practitioner or even Nurse Practitioner in any area of practice. All members of staff are very aware of this and would like it to be recognised by the UKCC. However I would argue that this doesn't put the patients at risk as the Scope of Professional Practice  ensures nurses, whatever their title, act only within their competence and confidence. I would hope every Emergency Nurse Practitioner would be able to acknowledge any limitations in their knowledge or experience and refer the patient to an appropriate health professional.
Many of our Emergency Nurse Practitioners want a regulated and clearly defined area of practice and are working towards recognition of their role. They are using communication, networking and participation in national and local groups, which are aiming not only to ensure recognition but also to standardise training to provide a nationally approved qualification with regular accreditation and to give credibility to an effective role.
Our Emergency Nurse Practitioners do not trivialize minor injuries, this is where their interest lies and they have chosen to work in this field due to their interest and knowledge base. Many are undertaking further academic education of which every course has a research component facilitating the nurses to research particular areas of interest to the field of minor injuries. If there is a large body of A&E Consultants who are interested in minor injuries and recognise its importance to the specialty they should or could work with the Emergency Nurse Practitioners. They could work collaboratively, ensuring effective management and care is recognised and published allowing research-based practice to be used countrywide.
In respect of holistic care, I would ask if this is just the consideration of cause, context and social background? Holistic care has been the aim of nurses for many years and the role of the Emergency Nurse Practitioner has enabled the fulfillment of holistic care in the Minor Injuries Unit. Patients receive true holistic care by the Emergency Nurse Practitioner ftom a detailed history of the injury, general health, medications and social background, examination, investigations, diagnosis, treatment, health promotion and safe discharge as well as concise, legible and relevant documentation .
Is it possible that A&E Doctors have not responded to this development as they have seen the safe and effective service that is provided by the Emergency Nurse Practitioners in the Minor Injuries Units. Mr Leaman states, they may be able to manage some minor injuries independently but the more serious should be managed by the A&E specialist. Is he unaware of the value ofprotocols, guidelines and well developed communication lines so patients who attend the Minor Injuries Units with a more serious condition are referred directly to the most appropriate specialist or A&E Doctor/Consultant providing a fast effective referral process.
In conclusion, I suggest Mr Leaman has little experience of the effective Minor Injury Units and would suggest while A&E departments continue to see all significant trauma it should be recognised other issues affect the A&E. This includes waiting times for beds, which impact on its ability to treat the minor injuries promptly, which add to their distress and increases the possibility of aggression in the waiting areas. The Minor Injuries Units and the Emergency Nurse Practitioners can assist the A&E's and improve care for the patients by providing the service the patients deserve.
Nursing Development Co-ordinator
Minor Injuries Unit
Supported by A&E Consultants
Mr Ramzji Freij
Mr Jalal Maryosh
(1) Castledine G (1998) The future of specialist and advanced practice in Advanced and specialist practice. Eds. Castledine.G. and McGee.P. Blackwell Science.
(2) United Kingdom Central Council for Nursing, Midwifery and Health visiting. (1992) Scope of Professional Practice. UKCC.
(3) Reveley S (1999) Development of the Nurse Practitioner role in Nurse Practitioners: Clinical skills and professional practice. Eds: Walsh.M, Crumbie.A and Reveley.S. Butterworth Heineman.