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Role in acute paediatric care
This paper proposes that community based nurse practitioners are well placed to provide care to acutely ill children. The data provided from a nurse led primary care service in Newcastle upon Tyne illustrate that 98% of children presenting with everyday complaints are effectively treated by a nurse practitioner.
The role of the nurse practitioner in primary care, although innovative, can present challenges to historical practices in the National Health Service. Nevertheless the movement away from conventional roles and service delivery is a strategy that is recommended by current health service reform and policy.1
One such reform is the notion that experienced nursing staff can relieve doctors of certain tasks, which according to Pearce,2 are tasks the medical profession have been doing for many years, that other suitably trained staff could undertake, for example, clinically assessing patients and requesting x ray examinations.
Step forward the nurse practitioner! Nurse practitioners are experienced nurses who, after extensive training, are proficient in certain competencies such as consultation skills, physical examination skills, and clinical diagnosis. Equipped with these skills they are able to accept responsibility and accountability for the assessment, diagnosis, and implementation of a range of care interventions for patients who present to them with undifferentiated medical conditions.3
Most nurse practitioners have an Extended Nurse Prescribing qualification, which permits them to prescribe drugs and therapeutics for specific conditions. They are also able, with the consent of the patient/carer, to negotiate care packages, which may include commencement of investigations, liaison with multiple agencies, and onward referral to different care providers.
To sustain them in this challenging role the Royal College of Nursing advocates that nurse practitioners should have access to a comprehensive training package and ongoing education based on clinical/nursing competencies. This they propose will enable them to be competent, autonomous, and ultimately safe practitioners.4
So can the nurse practitioner provide safe, effective care to acutely ill children? Our evidence confirms that, in the majority of cases, the answer is yes.
We have developed an entirely nurse led primary care service to a deprived inner city population in Newcastle upon Tyne (approx 10 000) which has been open to the public since May 2002 and offers an appointment/walk-in service on a daily basis.
This generic service has evolved with the support of the local community, Newcastle Primary Care Trust, and local general practitioners. Our aim is to provide a holistic service to the local population by offering a range of services, which include, for example, undertaking cervical smears, blood tests, childhood immunisations, and advice and support for people who want to stop smoking.
It is our experience that this holistic approach is realised; for example, the father who attends with his asthmatic child is encouraged to share any concerns he may have about his own health. These can then be addressed within this contact or he will be actively encouraged to access the service again.
Although this nurse practitioner service is available to children, parents, individuals, and their extended families, paediatric consultations form the vast majority of our work, accounting for almost two thirds of all contacts (954 of 1515, May 2002–03).
The statistics relating to acute paediatric consultations illustrate that the total number of 0–16 year olds seen between May 2002 and May 2003 was 954; of these, 744 were 0–5 year olds. The commonest paediatric presentations were for skin conditions (23%), vaccinations (16%), ear nose and throat (14%), and respiratory conditions (10%). A total of 291 drugs were dispensed/prescribed within these 744 consultations (39%). These were predominantly for analgesics (11%), antibiotics (11%), and emollients (4%).
Further analysis of the 0–5 year olds data reveals that between May 2001 and May 2002, 59% of children, after clinical assessment, were offered “advice only”. A further 39% received treatment; 1% were referred to their own GP and a further 1% to paediatric secondary care.
The data show nurse practitioners can be seen as key care providers for children presenting with acute conditions in a primary care setting, as most conditions are self limiting and do not require any medical intervention. What the data do not illustrate is that as primary care nurse practitioners we also possess considerable knowledge of the determinants of health within our local community. This makes it possible for us to support the child and family beyond issues related entirely to the treatment of their presenting complaints.
To illustrate, one example from our practice was the many children who presented to our service with impetigo. It transpired that many of the affected children attended the same school nearby and there were no overt hand washing/hygiene practices in place. Having regular contact with local parents enabled us to discuss infection pathways and possible solutions with those concerned in a sensitive way to resolve the situation.
Comprehensive audit trails reveal that we are providing an effective, safe, primary care service while adhering to our Scope of Professional Practice.5 We have also sought the views of service users and the data confirm that nurse practitioners can provide a range of health care services for children that are acceptable to their parents/carers and that parents/carers attach high value to the fact that the service is an easily accessible point of contact.
Parents/carers inform us that they do not want unnecessary contact with their GP or lengthy waits in accident and emergency departments—services which can be miles away from their homes—for their children to receive treatment for minor ailments and minor injuries that often require advice only or simple treatments. Nurse practitioners can provide this level of care and can, after clinical assessment of the child, determine when a more specialised paediatric opinion is required.
There are many good reasons for introducing the nurse practitioner role in different settings and each must identify its own. The value of our nurse practitioner service is that it is a convenient, safe, effective health care provision for children presenting with acute illnesses.
Role in acute paediatric care