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ER Nurses in the Future
This month’s Nursing Notes newsletter takes a look at the fast-paced field of emergency nursing including sub-specialties in trauma care. In this episode, we brought together a panel of emergency and trauma nurses to discuss the roles nurses can play in this field and what they can look forward to in terms of advances in case which can impact emergency departments and their patients. We were joined by Elizabeth Seislove, Director of the Trauma Program at Lehigh Valley Health Network in Allentown, Pennsylvania and Randy Smith, Director of the Emergency Department at Nationwide Children’s Hospital in Columbus Ohio.
Jamie: I’m here with Randy Smith and Betsy Seislove to talk about advances and changes in trauma care and emergency nursing care – what kind of things are on the horizon. I guess I’ll start with Randy talking a little bit about – nursing, in general, have come so far but emergency nursing really has advanced right alongside of all the other things going on in the nursing career path in general. Many aspects of emergency care, the nurse is just an integral part of the process in assessment, in providing treatment and also instructions for someone that is not going to be your patient maybe ever again. There are some things that have changed over the years. What have you seen come along that has really changed the way that nurses have interacted with their patients and advanced the way that emergency nurses and trauma nurses care for their patients?
Respondent: I guess, from my perspective, I don’t know that up until maybe the last five, ten years or so that you [won’t] to see trauma nursing really had a true identity. I think that the certification piece, that’s really evolved the advanced training piece of that. It really helped to drive emergency nursing and trauma forward. I’ll give you an example. I know here at Nationwide Children’s, on the trauma side for example, we developed what is called a “Trauma Nurse Leader” role. This is a nurse that is chosen by their peer group as well as recommendations from our physician colleagues to go to one-year internship in trauma nursing. These TNLs have really drive to include the calling of the level of the trauma here at Nationwide Children’s. That’s certainly wasn’t the case five years ago. I don’t know that there really was a lot of value given to the trauma nurses in their role to not only in the initiation of the trauma but the care of the patients. A lot of things are being initiated and driven by the TNLs. I think we have that kind of a role that’s carved out because I don’t always think that nursing has done a good job of carving out roles for themselves. At times, I think [unintelligible] gets placed upon us because of necessity. I think we’ve been much more proactive as a profession to take more ownership in carving out and driving those roles inside the profession versus from a multidisciplinary group as a result of a [root] cause or unfortunately a bad outcome.
Jamie: Betsy, what are your thoughts?
Betsy: Well, I have to kind of echo some of what Randy has just spoken about his institution. What we did about – it was probably about five or six years ago – we also identified that trauma is such a complex disease process that if you throw a nurse back in a trauma bay and expect them to know exactly what to do without a lot of experience behind them, they felt loss. The team felt loss. What we did is we put together what we call our “Core Trauma Nursing Team.” They again are the select few nurses who are identified by their peers and by leadership as having that core concept and that core understanding of what the trauma patient absolutely needs following the ATLS concept. That core trauma nurse, her or his position, is really as a caretaker but also as facilitator back in that trauma bay. They work in concert with the trauma attending to assure that that patient is getting absolutely everything that they need after resuscitation. They are back there kind of orchestrating that whole trauma resuscitation. We really pooled all the finite pieces of resuscitation. We look back five or six years ago when the prehospital people would bring the patient, nobody paid attention to prehospital because they were too busy looking at the patient. Well, we’ve pulled back and said, “Wait a second, we need to listen to our prehospital colleagues.” Listen to what happened to the patient so that core trauma nurse with pre-hospital they say, “Time out. We give that report and then we start taking care of the patient.” There is always somebody absolutely assigned to listen to that prehospital report. We’re now building on that process. We’re doing – the new buzzword out there is “co-resource.” We are looking again at our process to make sure that we are truly – the team is working together as a team, that there is not an “I” in that team. Everybody is back there working for the care of that patient. We did process flows. We looked at how the patient enter; who is at the bedside; who should be there; who shouldn’t be there. By working through those processes we’ve been able to really finite that care in a very efficient way that our outcomes are fabulous. We’re really proud of that. Along with Randy having that nurse leader or that core trauma nurse back there, it is vitally important. That core trauma nurse also mentors new nurses to become that other trauma nurse to come back and help them. It’s not just these certain few. They also mentor and educate new nurses which they are more than excited about. They love to teach and love to educate. Again we’re kind of doing the same thing as Randy is at his institution as we are at Valley Health Network and really proud of that. The attending really foster that relationship and really count on the nursing staff to lead that with them.
Jamie: What do you see is the role, Betsy, for an advanced practice nurse, perhaps a nurse practitioner in the emergency or even in a trauma setting? Is there a position in the clinical setting beyond just the oversight role for patient care planning that happens in so many facilities associated with the discharge planning, in getting resources and working with social work, is there another location or a place for that advanced practitioner in the clinical setting of patient care itself?
Betsy: Well, advanced practice certainly has a huge part in my heart. I think the role of the nurse practitioner, the role of the advanced nurse practitioner, has really kind of been put out there on the forefront where a couple of years ago, it was really kind of pushed underneath the rug. We have started to utilize nurse practitioners and advanced practice nurses in our daily practice. They have been a consistent factor in caring for our patients. Our residents, they come and they go. We have visiting residents who come in. We have found that the glue that keeps everybody together is that advanced practice role. The nurse practitioner has a very global process of taking care of that patient across the continuum. They can be in the trauma bay helping in the resuscitation. They can also be in the ICU. They can be upstairs on the floor. They can help with discharge planning. They can also be in the clinic. We have used nurse practitioners and starting to use advanced practitioners as well to really help facilitate that patient through that trauma continuum and making sure that whatever that patient needs, we’re making sure we’re ordering that. Because what we find is the residents, like I said, come and go but that nurse practitioner is a very consistent factor. The nurse also brings that global look at the patient. We also have physician assistants that also do a fabulous job. But there is a piece of nursing that has to be at that bedside because they are also teaching and mentoring not only the patient and the family but the other nurses at the bedside. I am a huge proponent for nurse practitioners and advanced practitioners.
Jamie: Randy, what about in your hospital facility and experience?
Randy: Here at Nationwide, I know the APNs are used pretty extensively throughout the hospital. I think where there’s opportunity is within the trauma’s program itself. I know there are APNs that support, for example, surgery. Again APNs working specifically in the trauma program in the ED do not happen. I totally support it. I think too often sometimes APNs are still looked at as a physician asset but not as much as a nursing adjunct. I think for a lot of different reasons. I think it’s ironic when you look at the role of the APN in the last ten, fifteen years across the healthcare environment how much it has expanded I think in intensive care units and other areas that it hasn’t I think evolved as quickly within trauma centers. In fact, I don’t think there’s very little data out there that’s even been published regarding the role of the APN in trauma centers. I know I worked critical care many years myself and I looked at the nursing adjunct. The APN provide the – in the management of these critical care patients. I see a lot of the same things happening with the advanced practice role. I think we’re going to have to be more proactive here in the trauma program. The president is set for that I think with another program to carve that role out. I know I certainly support it. Talking with the physician leadership, they support it. We’re actually at a good point right now because we are getting ready to open up a replacement hospital in 2011 and ‘12. So we’re really taking a pretty hard look and scrub down off our programs and manpower and those kinds of things that truly helping to keep that out there for discussion.
Jamie: So you’re looking constantly at changing the staffing structure for an ER or a trauma center. Do you see that role, with the Institute of Medicine report, an increased role for advanced practice? Is there really going to be a fundamental change in how we staff these facilities?
Betsy: I know our institution does have some APNs and again we have one within the trauma center. I think it’s going to take time to change the culture of how we look at that. You’re right, that report hopefully will help. I agree with Randy that APNs have not – especially in Pennsylvania, we finally got a white paper about a year-and-a-half, two years ago, kind of saying what APNs are able to do but it hasn’t been completely accepted. Really, the reason why I don’t think it’s been accepted, it hasn’t been understood yet and probably has not been used to the fullest capacity as it could be. I think we have a huge opportunity to definitely foster those physicians.
Randy: Betsy, I kind of make another point here. Betsy, I don’t know what you understand but I think what’s also limited to this – and I’ll go back to my experience on the critical care side – I think most people would acknowledge that we look at the acute care practitioner role, that is one that’s been slow to evolve. I know there really have not been a lot of programs that produce that level of an advanced practice nurse. I know that we only look at bringing nurse practitioners into the critical care units of Ohio State University Medical Center. There are a lot of challenges because there just wasn’t a lot of the acute care NPs out there. You are forced to take a look at FNPs and others and then bring them in and adopt a program. I think they train them and bring them to the level of practice that needed to be done. I don’t think that it has changed a lot. Some of the programs had been increased their capacity but I still think, if I’m understanding correctly, there’s still is not enough of the acute care NP programs out there that probably keep pace with what the demand is.
Betsy: No. I agree. I know just a couple of my colleagues are going back for nurse practitioner. I only know one school we’ve – local to me here in Pennsylvania that actually offers that acute care piece. Only if you pursue that on your own will you be able to foster that. But you’re absolutely right. I think there is a huge opportunity to try to get that more recognized. Because we have one, like I said, APN who really just – she just kept pushing and pushing and pushing to get that experience. The other APNs that we have throughout the institution are all kind of more medicine-based but not more in that acute care setting. So, yes, I agree with you. The opportunity is just ten-fold, I think.
Jamie: Let’s move along and look at the future of emergency care and trauma care in general. Nurses, we see how they’ve come so far. We’ve been talking about that. What have you been seeing on the horizon? I guess I’ll start with Randy here. What have you seen on the horizon that is exciting to you that’s going to change the way patients are cared for by your nurses?
Randy: I think some of the things that come to mind to me pretty quickly is the technology piece. We’re starting to see a lot more technology integrated into the emergency department in general, particularly with the advent of the EMR. I know it’s been exciting here because of the fact that my application specialist is an RN. I think you’re seeing more on the informatics side, nurses in those roles so they understand the practice of nursing. Certainly a big benefit but I’ve got an application specialist for our Epic system. She was one of my staff nurses for a little over three years. Because she understands the practice of emergency nursing, we will sit down at the table to talk about things that we can change on a level without having to go to the hospital because some things we can do departmentally that don’t really impact the rest of the hospital. We have the latitude to make those changes within our department. We’re able to do it more quickly because, again, because I got a nurse who’s in that role and she understands that. I think just the technology piece. I know that we are [getting] ready to go live in April. We all have the electronic trauma, the application record. I think this is also a huge area of opportunity in trauma nursing. I don’t know that a lot of programs have an electronic record out there. So this is certainly something we’re excited about the technological piece of things. I think also the orientation, the education. The hospital has bought into now for years, several years here. I think when you look at the fact that you don’t get that experienced RN in the numbers that we used to get years ago, you do have to rely more on nurses that maybe come from other acute care backgrounds like critical care where you happen to look at those new graduates. I think [all of these] are seen to a point that Betsy made earlier where there’s the trauma side and emergency nursing, you just can’t take people and give them a four, six, ten weeks of orientation and expect them to be able to practice. We all know the practice of emergency nursing is more diverse and complex than ever before. I think when hospitals start to recognize the ED as the front door of the institutions and the ED start to also drive. I think some of the downstream [tier] by the work and care we provide in the ED, I think it really open the door then for emergency nurses to have more of a voice in [tier] in general and they were recognized more as full partners in that care. I think that’s something that nurses have done very well here at Nationwide is they’ve taken ownership for that and they drive that. They are looked as full partners with not only our physician colleagues but also other disciplines within the system. We’re actually talking about as well the development of – in more advanced internship if you will. I know that if you look at nurses in general, we’re the only profession I think still cross the board. We did not have like a residency program. What always concerns me and a lot of other nursing leaders is, is even that you do a six-month orientation program, most of us recognizes it takes a good twelve to eighteen months that nurse out of orientation to really start to get comfortable in the practice of emergency nursing, to at least start to hone in on their own time management and critical thinking. You still need have some mentorship there. You still need to have some connection to bodies of knowledge for example. I think that’s something else would be the third thing I would talk about is that we are doing a much better job at integrating evidence-based practice into what we do here. I think nurses are starting to get much more excited about the scientific contributions that nurses can make to the practice of emergency nursing. I remember we hope that we can get this residency program develop. Again I think we do a good job overall with the orientation. But even within our ED, where there’s the trauma side or the ED side, I think it’s keeping those nurses connected or do you come back once a month or every couple of months and have maybe some type of a meeting where you’re taking a look at progression, how are things going. We all know that a lot of hospitals I have looked at for several years now, retention rates in those nurses, three years or less. Because if you’re going to lose them, you’re going to probably lose them in that first year because they don’t feel connected. They feel overwhelmed, all of those kinds of things.
Jamie: What about you, Betsy, the things that are exciting to you? Randy has just named a ton of just great topics. We could probably expand on all three of them but I think there’s a lot of good things that are out there on the horizon. What are you most excited about?
Betsy: Well, first of all, as soon as Randy said he’s get an electronic trauma flow sheet, I was like, “Really?” like “Good for you.” I’ll tell you that is one of the areas that truly, like you stated, I think we are struggling nationwide from an electronic technology standpoint. I think we have done a fabulous job with the electronic medical record in certain respects. But for that trauma piece of it, it has been a struggle to get all of the pieces that we need to be electronically, for the nurse to be able to do it efficiently. We are still looking at it. We still do paper flow sheets back in our trauma bay. Good luck to you, Randy, and I think it’s a huge step forward. It would be something that would definitely – should be shared with the rest of us, emergency nurses and trauma nurses – how to do it, what it looks like, because people are going to be jumping at that. I really have to jump on that technology bandwagon as well because we actually – our physicians have their electronic daily note and we’ve been doing that for probably about six years now. We’re actually opening up a new template probably in the next three weeks which will allow finally the nurses to be able to see that. They see it after it’s printed and it’s put in the chart but now they can see it actually electronically and it actually coincides with their nurses’ notes. Again another piece of collaboration among the trauma service that the nurses, the physicians, respiratory therapy, nutrition, all those interdisciplinary people can now be on the same electronic medical record. We are extremely excited about that. Also our informatics person who works with our trauma team is an old trauma nurse who is a trauma nurse for fifteen years. Not only does she love the informatics piece but she understands the trauma piece of it which is very rare to find. To have that combination that has helped us tremendously. On the orientation piece, I agree with you, Randy, 100%. We actually did institute probably about two years ago, it’s not a full-fledged residency program, but we put the concepts into place that to be a core trauma nurse, there is X amount of time and X amount of expectations that you must meet. You must have so many of this complex trauma patient before you can do the next procedure. There is a lab. They are attached to a certain nurse for an extended period of time over that initial orientation and it has worked beautifully where that nurse feels so comfortable walking back into that trauma bay; whereas two years ago, they won’t even set close to the door. That mentoring and that “internship/residency” has helped our nurses really, really tremendously. The satisfaction of the nurses has increased ten-fold. We are a Magnet hospital not only once but twice and actually Magnets here this week for their third visit. We’re extremely proud of that because we really, really foster our nurses to do that ownership piece and really stand up for what nursing really is. We do look at evidence-based practice. They sit on committees that look at different policies and procedures and, “Well, why are we doing that?” We allowed the nurses to ask those questions rather than just hand them a policy and say, “Here, you need to do this.” They have ownership for that policy to say, “Wait a second, let me pull that article and make sure that we’re truly doing what we’re supposed to be doing.” So we’re doing everything you’re doing, Randy. It’s exciting. The nurses – I’m working on a lecture right now and I’ve been interviewing nurses and I’m telling you they’re happy out there. They want to get rid of the paper work. They’re excited about the electronic medical record. They see that as the future which will give them time to take care of the patient.
Jamie: That’s what’s it all about, it’s being there to take care of our patients. I think nurses are in their positions because they want to be at the bedside more than they are at the chart.
Jamie: Any final thoughts, Randy, for someone thinking about a career in emergency nursing or trauma nursing? What would you maybe some advice you would offer to them?
Randy: [Unintelligible] The biggest thing I would say to anybody is, I don’t know that today is probably is more exciting than at any point that I can think of in a long time. I think all the things we talked about, I think Betsy’s right, we’re not there yet with technology but it’s moving. I think we’re making great strides. I think when you look at hospitals to that – our Magnet organizations – I think that certainly has added a voice to the practice of nursing in general. I think where nurses like here, for example, our emergency nurses have really carved out a role for them. They’re taking ownership. They’re driving practice. They’re being looked at as full partners in care more than I can ever remember. I think that’s really exciting. I think nurses are looking for that autonomy. They want to know that they have a voice, that they make a difference, that they control and direct their practice. I think with the orientation strides, I think we’re doing good job. Most places are preparing nurses to practice. They’re being empowered. I just think it’s exciting. Although certainly, I think you hit it on early, Jamie, we know that one overcrowding probably isn’t going away. At the same token, I think it’s exciting to know that we’ve got more control than ever before of deciding what that looks like and the fact that more hospitals recognize the ED as they do away, or at least as they do away, to the hospital. I think it’s driven down tremendously – burnout, turnover, I think retention is higher. I think one of the things we’re talking about too is, how did you leverage out that experience? What kind of other roles you would maybe create? When that nurse gets to the point where they’re not able to keep up with maybe the physical demands of emergency nursing or trauma, what other kinds of rules are there out there that allows us to keep that genuine experience to keep the practice strong and vibrant.
Jamie: Betsy, I know you’re going to run, but final – just words of encouragement for a nurse considering or a student considering emergency nursing?
Betsy: Yes, I think emergency nursing, trauma nursing – again as I’ve been interviewing nurses the past several weeks, trauma and emergency medicine is a high-adrenaline rush for nurses. If you’re truly looking for that, it’s the place to be because you are truly ingrained into that patient. Number one, it’s never the same every day. Every patient comes in with something new so you are constantly investigating, constantly looking. It keeps you on your toes all the time. I agree with Randy. The fostering of nursing, it’s not just the nurse at the bedside anymore, it’s more than that. They are recognized as a nurse. They are recognized as part of the team. They’re recognized as making a difference within how they practice at that bedside and what is being brought to that patient. They have a voice and they’re being heard and they’re being respected and they’re part of that team. I’ve been in this over twenty years and still don’t find any dull days in my life, so I say go for it.
Don’t forget to check out the entire February, 2011 issue of Nursing Notes, featuring a peek inside the specialized fields of emergency and trauma nursing. You’ll find links to resources like the Nursing Campaign’s “A Day in the Life” video which follows emergency department nurse Laurie through her day while she balances family, hobbies, and a second career as an ER nurse, and the Emergency Nurses Association’s latest set of Emergency Nursing Resources. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where we brought together a group of emergency and trauma nurses to discuss the unique challenges associated with their jobs. You’ll find this and our other podcast episodes at www.NursingNotesLive.com and in the podcast area in iTunes.