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TRAUMA NURSING
 

 

The Development of Trauma Nursing in the UK

UK Trauma Developments

It is generally widely acknowledged that the origins of trauma care stem from military conflicts and battlefield experiences (1,2,3). Despite the peacetime advances in trauma management e.g. the establishment of casualty departments; the introduction of trained personnel in the prehospital domain, key deficits in British trauma care still exists (4,5,6,7). In addition to health care reforms political and social influence have been brought to bear on the quest against accidental injury (4,7,8,9).

The pivotal change in UK trauma management came in 1988 following the reports of Anderson et al (10) and The Royal College of Surgeons (4). Together these papers highlighted that care of the multiply injured patient was sub-optimal causing poor management and premature deaths. The deficiencies in management were largely attributed to junior untrained medical personnel treating seriously injured patients on an infrequent basis. The remedial response to the 1988 review of UK trauma care was to adopt the Advanced Trauma Life Support (ATLS) system of trauma management.

Evolution of UK Trauma Nursing

The plight of UK trauma nursing was equally in disarray with many practitioners having little or no instruction on how to care for their trauma victims (11,12). In 1994 Lomas and Goodall highlighted that the role of the trauma nurse is 'difficult to identify' and 'not explicit'(13). Whilst this observation was made in direct reference to the trauma resuscitation team, it transcends throughout the whole trauma continuum wherein care is fragmented and poorly communicated thus perpetuating suboptimal trauma management (14).

British A & E nurses endeavoured to address some of the training deficits that were identified. In November 1990 the Trauma Nurse Core Course (TNCC) was imported from the States and the following February saw the advent of Advanced Trauma Nursing Course (ATNC). This latter course was of greater significance to British trauma nursing. For the first time British nurses articulated their beliefs and values about the care and management that trauma patients should receive. Central to this philosophy was that trauma patient had a right to be care for by specifically trained and educated nurses (14,15,16).

Much of the early opportunities for training were limited and focused on the immediate resuscitation and stabilisation post injury. In the first three and a half years of ATNC 230 nurses had acquired provider status the reality however was that this did not guarantee one trauma trained nurse per A & E department; and moreover a further 1500 nurses still required training (12,14,15).

Within the literature there are stark parallels between the evolution of UK trauma nursing and American trauma nursing. Beachley et al, 1988 report that within 5-10 years of establishing US trauma centres the need to train and educate practitioners became apparent (2). It is interesting to note that it was also the American ER nurses who took the lead in developing trauma education (18). In contrast the dissemination of TNCC in the States was far more rapid. Within the first three and a half years of TNCC 13,100 nurses had attended the provider course with an overall success rate of 86%; and by ten years this number had escalated to 75,000 (19,20). The accessibility and funding of such courses needs further attention within the UK if nurses are going to be adequately prepared to care for the complex needs of the injured patient (14,15,21).

Another landmark in the history of UK trauma care was the introduction of the ENB A86 Trauma Care Course at City University in 1995. This course was accredited at level three and embraced the 'road to rehabilitation concept' of trauma care thereby recognising that trauma care does not begin and end at the doors of the resuscitation room (22,23). Indeed it has been suggested that a trauma nurse requires a specific body of knowledge that encompasses the three phases of trauma care i.e. resuscitation, stabilisation and rehabilitation (17,18).

More recently specialist roles for trauma nurses are beginning to emerge. The Trauma Nurse Co-ordinator (TNC) for example is sporadically appearing in the UK. The interpretation and implementation of this role is frequently different to the recommendations cited in the literature by our US colleagues (2,24,25,26). For example, within the UK TNC's have been assigned to orthopaedic directorates only, or spend much of their time on data registry and audit. To date there has only be one prospective study to evaluate this role in the UK reported in the literature (28).

Conclusion

As this Millennium draws to a close it is time to address the wider needs of the trauma patient. Trauma care needs to be delineated as a separate entity. Acknowledging trauma nursing in its' own right should allow its' philosophical underpinnings and training needs to be considered, proactively developed and enacted.

The evolution of a new speciality should encourage the emergence and development of new roles, which should further expand the entire scope of practice of the trauma nurse. At this juncture that it is time to relegate the traditional image of British trauma nursing as depicted by Florence Nightingale to the past and develop a new era of UK trauma nurses.

October 1999


References

  1. HOWELL, E., WIDRA, L., and HILL, M. G. (1988) Comprehensive trauma nursing: theory and practice. Illinois: Scott Foresman.
  2. BEACHLEY, M., SNOW, S., TRIMBLE, P. (1988) Developing trauma care systems: the trauma nurse co-ordinator. Journal of Nursing Administration. 18(7, 8) Jul/Aug 34-42.
  3. VIESE-BERRY, S. W., BEACHLEY, M. (1994) Evolution of the trauma cycle. In CARDONA, V. D., HURN, P. D., BASTNAGEL MASON, P. J., SCANLON, A. M., VIESE-BERRY, S. W. (1994) Trauma nursing: from resuscitation through rehabilitation. 2nd ed. Philadelphia: W. B. Saunders.
  4. ROYAL COLLEGE OF SURGEONS OF ENGLAND (1988) Report of the working party on the management of patients with major injuries. London: The Royal College of Surgeons of England.
  5. COOK, N. B. (1991) Prehospital care in the 1990's. Technic. 98 Sep 6-9.
  6. LLOYD, D. (1991) Driving force. Health Service Management. Dec 261-262.
  7. DEPARTMENT OF HEALTH (1992) The health of the nation strategy: a strategy for health in England. London: HMSO
  8. TONES, B. K. (1986) Health education and the ideology of health promotion: a review of alternative approaches. Health Education Research. 1(1) 3-12.
  9. SUTCLIFFE, A. J. (1990) A critical appraisal of the RCS working party report on the management of patients with major injuries. Care of the Critically Ill. 6(5) Sep/Oct 176-178.
  10. ANDERSON, I. D., WOODFORD, M., DE DOMBAL, F. T., and IRVING, M. (1988) Retrospective study of 1000 trauma deaths from injury in England and Wales. British Medical Journal. 296 1305-1308.
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  12. EYRE, G. (1993) Shock treatment. Nursing Times. 89(34) 25 Aug 30-33.
  13. LOMAS, G. A., GOODALL, O. (1994) Trauma teams vs non-trauma teams. Accident and Emergency Nursing. 2 205-210.
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  15. HADFIELD, L. (1993) Preparation for the nurse as part of a trauma team. Accident and Emergency Nursing. 1 154-160.
  16. ADVANCED TRAUMA NURSING COURSE (1994) Advanced trauma nursing course handbook. London: ATNC.
  17. BEACHLEY, M., SNOW, S. (1988) Developing trauma care systems: a nursing perspective. Journal of Nursing Administration. 18(4) Apr 22-29.
  18. BEACHLEY, M. L. (1989) Trauma nursing is a developing speciality. Journal of Emergency Nursing. 15(5) Sep/Oct 372-373.
  19. BRYANT, K. K. (1989) ENA's trauma nursing core course: an update. Journal of Emergency Nursing. 15(5) Sep/Oct 35A, 36A, 38A, 39A, 40A.
  20. ZIMMERMAN, P. (1996) Managers ask and answer. Journal of Emergency Nursing 22(5) Oct 439-442.
  21. GAUTAM, V., HEYWORTH, J. (1994) The value of the abbreviated ATLS course for accident and emergency nurses. Accident and Emergency Nursing. 2 100-102.
  22. ENGLISH NATIONAL BOARD (1995) Trauma care: a multidisciplinary approach to care (A86 trauma course manuel). London: unpublished manual by City University.
  23. WILLIAMS, J. (1997) Trauma nursing. In EARLAM, R. Ed. (1997) Trauma Care - Helicopter Emergency Medical Service (HEMS) London. 2nd ed. Hertfordshire:Saldatore.
  24. SIMMONS, F. M. (1992) Developing the trauma case manager role. Dimension of Critical Care Nursing. 11(3) May/Jun 164-170.
  25. DALEIDEN, A. L. (1993) The CNS as trauma case manager: a new frontier. Clinical Nurse Specialist. 7(6) 295-298.
  26. DEKEYSER, F. G., PARATORE, A., CAMP, L. (1993) Trauma nurse co-ordinator: three unique roles. Nursing Management. 24(12) 56A, 56D, 56H.
  27. VON ROTZ, N. P., YATES, J. R., SCHARE, B. L. (1994) Application of the case management model to a trauma patient. Clinical Nurse Specialist. 8(4) 180-186.
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