I N T ER N A T I O N A L N U R S I N G R O L E S

Evaluating outcomes of the emergency nurse practitioner role in a

major urban emergency department, Melbourne, Australia
Natasha Jennings CCC, Grad Dip Adv Clin Nurs, MN, BN, RN
Emergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia

Gerard OReilly MBBS, FACEM, Grad Cert CT, MPH

Emergency Physician, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia

Geraldine Lee BSc, PGDE, RGN

Postgraduate Course Coordinator, School of Nursing and Midwifery, Latrobe University, Melbourne, Vic., Australia

Peter Cameron MBBS, MD, FACEM

Professor, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia

Belinda Free Grad Dip Crit Care, BN, RN

Emergency Nurse Practitioner Candidate, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia

Michael Bailey PhD, MSc, BSc (Hons)

Consultant Statistician, Epidemiology and Preventatire Medicine, Monash University, Melbourne, Vic., Australia

Submitted for publication: 12 December 2006

Accepted for publication: 19 February 2007

Correspondence: JENNINGS N, OREILLY G, LEE G, CAMERON P, FREE B & BAILEY M

Natasha Jennings (2008) Journal of Clinical Nursing 17, 10441050
The Alfred Emergency and Trauma Centre Evaluating outcomes of the emergency nurse practitioner role in a major urban
Commercial Road
emergency department, Melbourne, Australia
Prahran
Aims and objectives. The aim of this study was to evaluate the impact of the
Vic., Australia 3004
Telephone: 613 9276 3405
introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times
E-mail: n.jennings@alfred.org.au and length of stay of patients presenting to a major urban Emergency Department
(ED) in Melbourne, Australia.
Background. As part of a Victorian state funded initiative to improve patient out-
comes, the role of the Emergency Nurse Practitioner has been developed. The
integration and implementation of this role, is not only new to the Alfred Emergency
and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing
holistic and comprehensive care for patients.
Design. A retrospective case series of all patients with common ED diagnostic
subgroups were included. The ENPC group (n 572) included all patients managed
by the ENPC and the Traditional Model (TM) group (n 2584) included all
patients managed by the traditional medical ED model of care. Outcome measures
included waiting times and length of stay.

1044 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2702.2007.02038.x
International nursing roles Emergency nurse practitioner

Results. Statistically significant differences were evident between the two groups in
waiting times and length of stay in the ED. The overall median waiting time for
emergency patients to be seen by the ENPC was less than for the TM group [median
(IQR): ENPC 12 (5528) minutes; TM 31 (11576) minutes (Wilcoxon
p < 0001)]. Length of stay in the ED was also significantly reduced in the ENPC
group [median (IQR): ENPC 94 (5351635) minutes; TM 170 (100274) minutes
(Wilcoxon p < 0001)]. The comparison of overall waiting times for ENPC shifts vs.
non-ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24
(952) minutes; ENPC not rostered 33 (13805) minutes (Wilcoxon p < 0001)].
Conclusions. This study has demonstrated that ENPCs implementation in Mel-
bourne, Australia were associated with significantly reduced waiting times and length
of stay for emergency patients. Emergency Nurse Practitioners should be considered
as a potential long term strategy to manage increased service demands on EDs.
Relevance to clinical practice. This study is the first in Australia with a significant
sample size to vigorously compare ENPC waiting times and length of stay outcomes
with the TM model of care in the ED. The study suggests that ENPCs can have
a favourable impact on patient outcomes with regard to waiting times and length
of stay.

Key words: emergency department, nurse practitioners, nurses, nursing, triage

the implementation of the NP role has demonstrated several

Introduction
Emergency Departments (ED) are faced with rapidly
increasing healthcare service demands. Difficulties accessing
primary health care in the community, growth in the number
of emergency patient presentations and an ageing population
are contributing to these demands (Sykes et al. 2006).
Studies in Australia and internationally have found that this
increasing demand is leading to longer waiting times and
length of stay for patients in the ED setting (Sykes et al.
2006). At the same time, many EDs are having difficulty in
recruiting sufficient medical staff to service current service
demands.
The term nurse practitioner (NP) is a generic termed used
throughout the literature to describe a nurse who has
completed additional courses and specialized training to
provide a broad range of healthcare services that may include
autonomous and independent clinical decision making. The
scope of practice, requirements for authority to practice and
function of the role is dependent upon the country they work
in and its legislative requirements. The emergency nurse
practitioner (ENP) is a nurse whom primary role is based in
the ED providing emergency care to patients within
Melbourne, Australia. The NP role is an alternative model
of healthcare service delivery to patients. The role of the NP
has evolved as its inception in the USA 40 years ago
(Department of Human Services 2000, Hamric 2000, Tye
& Ross 2000, Loveridge 2001). The literature surrounding
themes: decreased waiting times, improved patient and staff
satisfaction and cost-effectiveness all leading to improved
health outcomes (Bruce et al. 1988, Tye et al. 1988, Cooper
& Robb 1996, Jones 1996, Roberts et al. 1998, Chang et al.
1999, Pinkerton & Bush 2000, Tye & Ross 2000, Loveridge
2001, Benger 2002, Fry 2002, Roblin et al. 2004). One study
suggests that ENPs can manage up to 30% of the ED
caseload using evidence based clinical practice guidelines
(Tye 1997).
The development of the ENP role in Melbourne, Australia
has enabled experienced registered nurses in the ED setting to
extend their skills in the development of clinical decision
making and incorporation of evidence-based practice. The
ENP practice broadens the nursing role outside the current
scope of practice for the registered nurse in five extended
practice areas. These extensions include prescribing medica-
tions, initiating diagnostic imaging and laboratory tests,
approving absence from work certificates, referral to special-
ists and admitting and discharging patients (Department of
Human Services 2005).
The aim of this study was to assess the impact of the
implementation of the emergency nurse practitioner candi-
date (ENPC) on waiting times and length of stay for patients
presenting to the ED. Only common diagnostic groups
commonly seen by the ENPC were included to allow
meaningful comparisons between the ENPC and traditional
model (TM) patients.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 1045
N Jennings et al.
Methods
Setting
The Alfred Emergency and Trauma Centre is one of only two
adult level one trauma centres in Vic., Australia. Annual
attendances have been increasing by a rate of 17% over the
last three years and in 2005 there were 40,084 attendances.
The admission rate was 33%. Two ENPCs were rostered to
cover peak patient presentation times which included all days
except Tuesdays. There was one ENPC rostered per shift
allowing greater coverage in the ED over the week.
Emergency nurse practitioner candidate role
In the state of Victoria, the NP role was introduced in 1998.
The Department of Human Services (DHS) began developing
the NP role in an action-learning model with key stakeholders
to fund and evaluate demonstration projects (Department of
Human Services 2005). The DHS funded the Alfred in July
2004 as a pilot site and two ENPCs commenced. The title NP
is protected by legislation and prevents unauthorized use
(Department of Human Services 2006). Nurses who are
practising within the role and seeking accreditation as NPs
are called candidates. Hence throughout this study the ENPs
are referred to as ENPCs. Initially, the ENPCs focussed on
Australasian Triage Scale (ATS) (Australasian College for
Emergency Medicine 2000), categories 35 emergency patient
presentations. The ATS is designed for use in hospital-based
emergency services throughout Australia and New Zealand. It
is a scale for rating clinical urgency. All patients presenting to
EDs are triaged on arrival and an ATS code allocated. The
ATS is the clinical tool that ensures patients are seen in a
timely manner that is commensurate with their clinical
urgency. Patients considered within ATS categories 35 can
wait from 30 minutes to two hours for treatment in the ED.
The ENPC completed the episode of care for each presen-
tation from initial assessment, intervention, prescribing, diag-
nosis, treatment and disposition, within a collaborative ED
team using Clinical Practice Guidelines for each presentation.
This new model of care was a change from the traditional ED
medical model employed in the ED. The TM group was defined
as medical officer managed care with assistance from nurses.
Patients
This study was a retrospective case series of ATS category 35
patients presenting to the Alfred ED for treatment between 1
September 200431 August 2005. To be included in the study,
patients must have presented between 07:00 and 23:00 hours
1046
Table 1 ICD-10-AM groups included
ICD-10-AM
code Description
L039 Cellulitis, skin, any site. Excludes cellulitis of finger
or toe L0301/L0302
S0180 Open wound of face (excludes eye)
S019 Bite (non-venomous) of head (excludes face)
S519 Open wound of forearm
S619 Open wound of wrist, hand, bite to wrist, hand
S628 Fracture of wrist, hand
S637 Sprain/strain of hand (includes finger)
S669 Injury to muscle/tendon of wrist, hand
S819 Open wound of lower leg, bite
S836 Sprain/strain of knee
S929 Fracture of foot (includes toes)
S9340 Sprain/strain of ankle
S936 Sprain/strain of foot (includes toes)
Z099 Attendance for follow-up (includes injections)/
Review following earlier treatment
Z480 Attention to or removal of surgical dressings
and sutures
(the hours ENPCs were rostered). Furthermore, patients were
selected by common diagnostic subgroup as classified by ICD-
10-AM (Statistical classification of Diseases and Related
Health Problems, 10th Revision, Australian Modification)
(Table 1). Common diagnostic subgroups were defined as more
than 15 patients for each diagnostic subgroup. This allowed for
the ENPCs most commonly encountered discharge diagnoses
to be directly compared with identical diagnostic subgroups of
the TM group.
Data collection
All outcome measurement data were entered on the ED
patient information system, a patient attendance registry
which has been used at the site for 10 years. The log is a
computerized system which collects surnames of individual
practitioners that manage ED patient care. All patients were
de-identified prior to data analysis. Identification of the type
of practitioner was analysed by the ENPC or TM surnames.
Data were collected on time of arrival, time waiting to be seen
by the ENPC or TM, length of stay and disposition. It is
important to note that the next patient to be seen in the ED
was identified by ATS category and time. According to
departmental protocol, patients were seen according to
highest ATS and waiting time. The ENPCs used their Clinical
Practice Guidelines within their scope of practice to assess the
next patient. The ENPCs initially started working in the fast
track area of the department and as their experience and skills
were enhanced they began managing patients in all areas of
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
International nursing roles Emergency nurse practitioner

the ED. The fast track area is a geographical location of the Table 2 Number of patients seen (by ATS category)
ED where patients are expected to be assessed and treated Triage category TM, n (%) ENPC, n (%)
within a four-hour target usually encompassing minor injuries
including trauma and non-complex medical admissions. ATS Cat 3 504 (195) 35 (61)
ATS Cat 4 1509 (584) 364 (637)
ATS Cat 5 571 (221) 173 (302)
Outcome measures Total 2584 (100) 572 (100)

ATS, Australasian Triage Scale; ENPC, emergency nurse practitioner

The primary outcome measure examined was time waiting to
candidates.
be seen by a practitioner, either ENPC or TM groups.
Waiting time was defined as time in minutes taken for
Table 3 Patient wait to be seen time (by ATS category)
treatment commenced by either the ENPC or the TM. Other
outcome measures included comparisons between the ENPC Wait to be seen Wilcoxon
and TM with regard to: length of stay in the ED; number of time median rank-sum
min (IQR) TM ENPC p-value
patients seen and disposition. Length of stay was defined as
the time the patient spent in the ED from initial registration ATS Cat 3 22 (10435) 6 (415) <0001
on the ED computer log until time of disposition from the ATS Cat 4 37 (1387) 14 (630) <0001
ATS Cat 5 27 (982) 11 (525) <0001
ED. Disposition was defined as the final destination of the
patients acute care. An overall waiting time when the ENPC
was rostered and when no ENPC was rostered was also
Table 4 Patient Length of stay in ED (by ATS category)
measured. Waiting times for this comparison were limited to
ATS category 35 patients, with the same identical diagnostic Length of Stay Wilcoxon
in ED Median rank-sum
subgroups and presentation times from 07:00 to 23:00 hours.
min (IQR) TM ENPC p-value
It was considered that medical staffing was relatively constant
during these times and provided homogeneity of the com- ATS Cat 3 2525 (1624125) 144 (72230) <0001
parison. The purpose of this comparison was to ensure that ATS Cat 4 167 (102264) 106 (66175) <0001
ATS Cat 5 120 (72190) 74 (36118) <0001
the restricted practice of the ENPC did not impact adversely
on overall waiting times.
the sample, whilst the TM group accounted for 819%
(n 2584) (Table 2).
Statistical analysis
Patients in the TM group waited 19 minutes longer to be
Data analysis was performed using STATA STATISTICAL seen than those seen by an ENPC. Patients waited a median
software, release 8.0 (StataCorp, College Station, TX, USA) time of 31 minutes (IQR 11576) when compared with the
and no formal sample size calculation was undertaken. The ENPC group who waited 12 minutes (IQR 5528; Wilcoxon
data were not normally distributed and hence continuous p < 0001). When wait to be seen times were stratified by
variables have been described using medians and interquartile ATS category, patients were consistently waiting longer to be
ranges, with comparisons between groups made using the seen by the TM group. Table 3 describes the waiting times
Wilcoxon rank sum test. Retrospective power calculations stratified by ATS categories three to five.
indicated that based on a standard deviation of 1 hour, with The overall length of stay also differed significantly
311 cases and 3110 controls, this study had an 80% power to between the two groups. ENPC length of stay was 76 min-
detect a significant difference in waiting time equivalent to utes less than the TM group. ENPC length of stay was
10 minutes. A two-sided p-value of <005 was considered 94 minutes (IQR 5351635) compared with the TM group
statistically significant. 170 minutes (IQR 100274; Wilcoxon p < 0001). When
The Alfred Hospital ethics committee approved the length of stay were stratified by ATS category, the ENPC
research project as a retrospective audit for the purpose of group showed a significantly reduced length of stay than the
quality improvement. TM group in category 35 patients (Table 4).
The comparison of overall waiting times for ENPC shifts
(on duty) vs. non-ENPC shifts (no ENPC on duty) also
Results
revealed significant differences [median (IQR): ENPC shifts
A total of 3156 patient presentations were included in this 24 (952) minutes; non-ENPC shifts 33 (13805) minutes
study. The ENPC group accounted for 181% (n 572) of (Wilcoxon p < 0001)].

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 1047
N Jennings et al.
Discussion
This study has shown that the implementation of the ENPC
had a significant association with reduced waiting times and
length of stay for ATS category 35 patients in the ED setting.
These findings suggest that the ENPC role may be a useful
strategy in managing the increasing service demands on EDs
in Melbourne, Australia.
There has been a limited research on the emerging ENPC
role. Extrapolations of results from international studies to the
Australian context are made difficult because of different
funding and service models and definitions of the NP role. A
recently published casecontrol study conducted by Considine
et al. (2006) examined waiting times, treatment times and ED
length of stay between ENPC managed patients and patients
managed via traditional ED processes. Their study showed no
significant difference in the process measures used in our
study. Their study used a considerable smaller sample size
compared with the present study and the proportion of
patients seen in ATS categories was also very different.
Another possible explanation for the disparity between their
findings and ours may be that they conducted the study from
monday to friday between 08:00 and 22:30 hours. The present
study included patients seen in the ED, on all days except
tuesday. The ENPCs at the Alfred ED work 10 hour shifts on
days that have the highest number of patient presentations:
Friday, Saturday and Sunday evening. The ENPC appears to
have greatest impact on waiting time and length of stay when
the ED is busiest. The very restricted practice of shift times
may have also had a negative impact. Integration with the
medical staff for teaching and training may also be a factor.
A further Australian study reported no statistically signi-
ficant difference between waiting times in patients seen by
nurses who had extensions to practice, in comparison with
the TM group patients (Charles et al. 1999). However this
was a limited role, restricted to several specific skills only.
International studies appear to have findings more consistent
with our study (Tye & Ross 2000, Loveridge 2001, Bruce
et al. 1988, Tye et al. 1988, Cooper & Robb 1996, Jones
1996, Roberts et al. 1998, Chang et al. 1999, Pinkerton &
Bush 2000, Benger 2002, Fry 2002, Roblin et al. 2004,
Woods 2006, Beales 1997, Allerston & Justham 2000, Barr
et al. 2000, Byrne et al. 2000, Sakr et al. 2003). Although
several studies have methodological limitations that also
include small sample sizes and lack of statistical rigour.
Stratifying patients into each of their ATS categories
displayed statistical significant differences in waiting times
between the ENPC and TM groups. The greatest reduction in
waiting time was 23 minutes for patients within ATS
category 4. A study conducted in the United Kingdom
1048 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
demonstrated a reduction in the mean waiting time for care
by an ENP from 8622 minutes when compared with the TM
group (Barr et al. 2000). The study compared patients
presenting to a minor injuries clinic with similar patient
presentations to those used in the present study. This result is
consistent with our study with an overall reduction in waiting
times measured. Another study examined waiting times at a
minor injuries clinic, operated solely by ENPs. Mean waiting
times were 19 minutes compared with 56 minutes for the
TM group (Sakr et al. 2003).
The Work Analysis Report commissioned by the DHS in
June 2005, evaluated the innovation of the ENPC role in two
EDs in Melbourne, Australia. The findings of the report
suggested that the role of the ENPC would increase the
number of clinical practitioners able to facilitate health
service delivery and reduce waiting times in EDs (Sykes et al.
2006). A national study examining the role of NPs in many
specialities is planned and has been funded by the Australian
Research Council which will allow further investigation
into the role and its effectiveness on patient outcomes
(Queensland University of Technology 2006).
There were no previous studies to compare the impact on
length of stay following the implementation of the ENPC
role, except for the Considine et al. (2006) study. The
reduction in the median length of stay for the ENPC group by
76 minutes in comparison with the TM group has benefits for
the ED as a whole. Increasing flow through the ED can have
direct impact upon quality outcomes and improve access to
ED resources. Reducing the pressure on already strained
resources can help to facilitate managing waiting time targets
and key performance indicators.
Limitations
This study has some limitations. Being retrospective, there is
the likelihood that some of the data collection was incom-
plete and inaccurate. Nevertheless, it is unlikely that patients
were not entered into the ED computer log. The possibility
exists that there were unmeasured variables that could have
contributed to the difference in waiting times and length of
stay between the ENPC and TM groups. The ENPC patients
suffered a lower acuity condition compared with the TM
group. We have attempted to address this issue by stratifying
the results by diagnostic subgroups and ATS categories. A
further possibility is that the ENPC selected patients with
short waiting times ahead of the queue. This seems unlikely
as the ENPC saw the next patient in order of priority
according to ED protocol. The fact that the ENPC had a
significant improvement in overall waiting times for the shifts
worked also means that this is unlikely.
International nursing roles
For the purposes of rostering, the ENPC was counted as
one of the nursing staff on each shift; therefore, there was one
less nurse performing traditional nursing duties with the
ENPC performing their nursing duties, as well as ENPC
duties on their patients. As the extended role of the ENPC
also included disposition and patient management, it was
anticipated that waiting times would be positively affected.
This extended role was not previously a nursing responsibility
so it could be argued that there was an extra medical staff
member rostered when the ENPC was on duty but there was
also one less nursing staff member.
Access Block is a major determinant of length of stay in the
ED. Access block is referred to as a prolonged wait for an
inpatient hospital bed after ED treatment. Stratifying patients
according to triage category showed that there was similar
disposition between ENPC and TM groups for ATS category
45 patients. These were the groups with the most significant
differences in length of stay. It seems unlikely, therefore, the
issue of access block would have resulted in significant
differences between the groups as most were sent home.
Throughout the study period, the knowledge and skills of
the ENPCs would have increased with their clinical experi-
ence, impacting upon the efficiency of their care and the key
performance indicators measured in this study. After initial
assessment and provisional diagnosis the ENPCs were
required to discuss their plan of care and disposition with the
ED consultant on duty. The requirements to complete these
processes for each individual patient may have resulted in time
delays in relation to length of stay for ENPC patients. It is
important to note that both ENPCs were candidates at the time
of the study and not endorsed by the Nurses Board of Victoria.
It is envisaged that when the ENPCs become endorsed that
further enhancement of the role and processes may have
greater positive impact on waiting times and length of stay.
Conclusion
This study has demonstrated that the implementation of the
ENPC was associated with significant reductions in waiting
times and length of stay in the ED. It is envisaged that the role
could be expanded into other defined areas of emergency
care. The ENP role in Melbourne, Australia has the potential
to be part of longer term strategies to manage increased
service demands on EDs.
Author contribution
Study design: NJ, PC, GL and GO; data collection and
analysis: NJ, MB, GO and GL and manuscript preparation:
NJ, GO, PC, GL
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
Emergency nurse practitioner
Competing interests
None declared by authors 13, 5 and 6. Peter Cameron is an
Assistant Editor and Section Editor (Original Research) of
EMA.
References
Allerston J & Justham D (2000) A case-control study of the transit
times through an accident and emergency department of ankle
injured patients assessed using the Ottawa Ankle Rules. Accident
and Emergency Nursing 8, 148154.
Australasian College for Emergency Medicine. (2000) Policy Docu-
ment: The Australasian Triage Scale. Available from URL: http://
www.acem.org.au/open/documents/traigeguide.htm (accessed
November 2005).
Barr M, Johnston D & McConnell D (2000) Patient satisfaction with
a new nurse practitioner service. Accident and Emergency Nursing
8, 144147.
Beales J (1997) Innovation in accident and emergency management:
establishing a nurse practitioner-run minor injuries/primary care
unit. Accident and Emergency Nursing 5, 7175.
Benger J (2002) Can nurses working in remote units accurately request
and interpret radiographs? Emergency Medicine 19, 6870.
Bruce TA, Bowman JM & Brown ST (1988) Factors that influence
patient satisfaction in the emergency department. Journal of
Nursing Care Quality 2, 3137.
Byrne G, Richardson M, Brunsdon J & Patel A (2000) An evaluation
of the care of patients with minor injuries in emergency settings.
Accident and Emergency Nursing 8, 101109.
Chang E, Daly J, Hawkins A, Mc Girr J, Fielding K, Hemmings L,
ODonoghue A & Dennis M (1999) An evaluation of the nurse
practitioner role in a major rural emergency department. Journal of
Advanced Nursing 1, 260268.
Charles A, Le Vassuer A & Castle C (1999) Suturing of minor
lacerations by clinical nurse specialists in the emergency depart-
ment. Accident and Emergency Nursing 7, 3438.
Considine J, Martin R, Smit DV, Winter C & Jenkins J (2006)
Emergency nurse practitioner care and emergency department pa-
tient flow: casecontrol study. Emergency Medicine 18, 385390.
Cooper M & Robb A (1996) Nurse Practitioners in A & E: a
literature review. Emergency Nurse 2, 1922.
Department of Human Services (2000) The Victorian Nurse Practi-
tioner Project: Final Report of the Taskforce. Policy Development
and Planning, Melbourne, Vic.
Department of Human Services (2005) Nursing in Victoria, Nurse
Practitioner. Available from URL: http://www.nursing.vic.gov.au/
furthering/practitioner.htm (accessed February 2005).
Department of Human Services (2006) Nursing in Victoria: Nurse
Practitioner. Available from URL: http://www.health.vic.gov.au/
nursing/furthering/practitioner.htm, 2005. (accessed July 2006).
Fry M (2002) Triage nurses order X-rays for patients with isolated
distal limb injuries: a 12-month ED study. Journal of Emergency
Nursing 1, 1722.
Hamric A (2000) A definition of advanced nursing practice. In
Advanced Nursing Practice An Integrative Approach (Hamric A,
Spross J & Hanson C eds). W. B. Saunders, Sydney, pp. 5374.
1049
N Jennings et al.
Jones S (1996) An action research investigation into the feasibility of
experienced registered sick children nurses (RSCNs) becoming
childrens emergency nurse practitioners (ENPs). Journal of
Clinical Nursing 5, 1321.
Loveridge B (2001) The Boston experience. Accident and Emergency
Nursing 9, 8691.
Pinkerton JA & Bush HA (2000) Nurse practitioners and physicians:
patients perceives health and satisfaction with care. Journal of the
American Academy of Nurse Practitioners 6, 211217.
Queensland University of Technology (2006) News release. Available
from URL: http://www.news.qut.edu.au/cgi-bin/WebObjects/
News.woa/wa/goNewsPage?newsEventID9363 (accessed July
2006).
Roberts RF, Innes KC & Walker SM (1998) Casemix: moving for-
ward. Introducing ICD-10-AM in Australian hospitals. Medical
Journal of Australia 169, S32S35.
Roblin DW, Becker ER, Adams EK, Howard DH & Roberts MH
(2004) Patient satisfaction with primary care: does type of practi-
tioner matter? Medical Care 6, 579590.
1050 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
Sakr M, Kendall R, Angus J, Saunders A, Nicholl J & Wardrope J
(2003) Emergency nurse practitioners: a three part study in clinical
and cost effectiveness. Emergency Medicine Journal 20, 158163.
Sykes D, Pilla J, Berzins S (2006) Work Analysis Project: Emergency
Department, Intensive Care Unit and Radiology Department.
Final Report. Available from URL http://www.dhs.vic.gov.au/
pdpd/workforce/downloads/work_analysis_report.pdf (accessed
January 2006).
Tye CC (1997) The emergency nurse practitioner role in major
accident and emergency departments: professional issues and the
research agenda. Journal of Advanced Nursing 26, 364370.
Tye CC & Ross FM (2000) Blurring boundaries: professional
perspectives of the emergency nurse practitioner role in a major
accident and emergency department. Journal of Advanced Nursing
5, 10891096.
Tye C, Ross F & Kerry S (1988) Emergency nurse practitioner
services in major accident and emergency departments. A United
Kingdom postal survey. Journal of Accident and Emergency
Medicine 15, 3134.