Int J Emerg Med (2010) 3:271–278 ED, particularly the degree to which the NP role and medical roles are interchangeable. The impact of the NP role on the junior medical staff experience emerged as a common concern. For example: “I think nurse practitioners have a complimentary role and they add value to the ED but they need to be seen as complementary not a substitute, we need the balance to get the learning experience for doctors, they need to get exposure to the patient types that NPs see”. “I think NPs have a valuable place in the ED but I don’t see them as a substitute for doctors and neither do they. The best comment I heard was an NP saying she is not a second class doctor she is a first class nurse. I think they have a specific skill set which is not a substitute for medical staff or nurses but they are able to function as part of the team. The function of interns and RMOs is more than just seeing patients it is for their educational develop- ment and understanding whereas NPs are there to help support other nurses and also pick up a specific patient load, so I think the concept of NPs replacing doctors is failing to recognise the relevant structure, it is like saying that NUMs [nurse unit managers] could replace FACEMs, to me it is a nonsensical discussion”. “An essential service for interns or other junior staff, but not a substitute”. “They remove training opportunities for junior staff”. “They don’t replace interns and visa versa”. “NPs won’t change interns’ teaching but it may influence interns’ exposure to low acuity patients, although we would still expect interns to be in fast track with an NP. We would not necessarily change what we do with interns”. “In the ED their role is still being defined, they almost compete with the more junior doctors”. Theme 4: needs of NPs Several interviewees responded by offering comments related to the perceived needs of NPs, specifically related to education, supervision, career pro- gression or structure, and whether or not needs are being met. For example: “At the moment our NPs are fully supervised by senior staff senior reg, consultants. They have a lot of learning needs, mentorship and regular in-service attendance but one thing that is good is they don’t 275 rotate so whatever you teach them they will maintain and they stay in the ED: the investment brings back good returns. With interns it is a neverending cycle of training and you don’t get the benefit of them putting back to the system”. “We have had positive experience with nurse practitioners, but we had very good candidates. They have not taken up the role as long-term careers, they have completed the training and then decided not to pursue it, they were good but unfortunately they have not continued in that area which is a negative—they felt the repetitive nature of the work was too restrictive. Both are very bright…so it restricted their practice because of confines on the nurse practitioner role”. Theme 5: barriers to role acceptance Some participants cited barriers to the broader acceptance of the NP role including lack of awareness of clinical governance structures and lack of support by hospital administration. For example: “The original appointment of an NP was a political appointment and there was not a great deal of structure or governance surrounding it, plans or introduction stuff; essentially they got to do what they wanted, and we are not sure of the governance structure which is interesting because one of them made a mistake which had a negative outcome so we are waiting to find out which one of us will be sued. Technically they answer up to the DON but I wonder if the person who was on floor that day will have some interesting discussion with their medical defence organisation”. “They have a place in the ED. We have enough [nurse practitioners]…but there have been problems regard- ing their clinical governance…” “The nursing admin/hierarchy at this hospital do not want NPs, the medical staff are quite keen on the idea”. “Coming from England there is a bit of an issue, the fundamental thing is that you are training someone up that is blurring the role between doctors and nurses, certainly in the UK they are taking the positions of doctors now, e.g. in surgery you have hernia nurses that basically perform surgery based at the expense of surgical doctors, you are using one person instead of another person which is going to cause conflict”.