Task Shifting in the Emergency Department: Pain management, competence building and holistic care

Abstract

Background: By 2050, there will be 10 billion people on earth, compared to 8 billion today—and many of them will be living longer. Consequently, having fewer human resources available for healthcare services will be fatal. Therefore, it is more important than ever to ensure that the people working in healthcare perform the right tasks, at the right time, in the right place. Task shifting is one solution that has been identified to make more efficient use of the available human resources for health. Task shifting is defined as moving tasks 1) from human to machines; 2) horizontally, such as from a hospital physician to a general practitioner; or 3) vertically, from highly qualified personnel to those with less training and fewer qualifications such as from physicians to registered nurses. Despite the existence of studies investigating task shifting from physicians to non-physicians, acute care contexts such as emergency departments in high income countries have not been extensively explored. There is an urgent need for workplace-based evaluated training programmes, randomized clinical trials investigating the effect of letting nurses take over certain tasks and more knowledge regarding the experiences of physicians and leaders in terms of task shifting in emergency departments. Aim: The primary aim of this research was to explore new ways of working in the emergency department through task shifting by 1) developing and evaluating a registered nurse–led ultrasound-guided femoral nerve block training programme, 2) investigating registered nurse–led ultrasound-guided femoral nerve blocks compared to the standard of care in a hip fracture care pathway in hospital, and 3) exploring the perspectives of emergency department physicians and leaders on task shifting from physicians to registered nurses. Methods: To fulfil these three aims, three substudies were conducted in this multimethod project, each presented in its own paper. The data were collected between September 2019 and October 2022. Registered nurses, anaesthesiologists, hip fracture patients, physicians and leaders were included as participants. Study 1 consisted of a feasibility study with a mixed methods approach using qualitative and quantitative data analysis. In Study 2, a randomized controlled trial was performed to collect quantitative data. In Study 3, a qualitative study was conducted with semistructured interviews with physicians and leaders about their experiences with task shifting from physicians to nurses in emergency departments. An inductive manifest and latent content analysis were chosen. Results: In Study 1 quantitative data indicated that both registered nurses and anaesthesiologists concurred that the training procedures provided beneficial pain relief for patients. Pain intensity, initially measured at a mean baseline score of 6.0 (95% CI 4.9–7.1), decreased to 2.5 (95% CI 1.4–3.6) within 30 minutes after needle extraction. Qualitative data further revealed that all patients experienced pain relief and felt secure and well cared for; however, they felt that there were too many people involved in the care pathway. In Study 2, a total of 263 patients underwent screening between February 2020 and June 2021, with 42 providing consent and being randomly assigned to a registered nurse (21) or to an anaesthesiologist (21).The primary outcome in the randomized controlled study trial was not different between groups (p = 0.24) and displayed no substantial superiority of specially trained registered nurses over anaesthesiologists. No complications or adverse effects were observed in either group. The use of systemic analgesics and the development of delirium was similar between the two groups. In the registered nurse group, patients received their ultrasound-guided femoral nerve block earlier. In Study 3, from the interviews with emergency department physicians and leaders we identified three categories: 1) the rationale for task shifting, 2) team approaches to task shifting, and 3) implementation of task shifting. From these manifest categories an overall latent theme emerged: It’s not the tasks it’s the sifting – moving towards a person-centred culture. Conclusion: Study 1 showed that it is feasible to carry out a training programme for registered nurses to learn ultrasound-guided femoral nerve blockade consisting of a one-day course in a simulation centre and subsequent supervision in the clinical context in the emergency department. Furthermore, the randomized controlled superiority study shows that the registered nurses who had received training in ultrasound-guided femoral nerve blocks did not show any better effect than the anaesthesiologist group, measured on cumulative pain relief in the first 120 minutes after the procedure had been carried out. From the perspective of physicians and leaders in three different emergency departments in Norway, it emerged that task shifting from physicians to registered nurses in the emergency department involves more than moving certain tasks. It entails a process with clear boundaries, responsibility and care. Findings from the qualitative study indicate that future task shifting processes should focus on identifying healthcare professionals who are motivated to take on a new task and capable of taking responsibility it and on promoting teamwork and person-centred care.