Nevada Nurses Association
Attached is the proposed job description developed by the Nevada Hospital Association for a new category of personnel-- an EMT / nursing assistant / technician position that would work in hospital emergency rooms.
The Nevada Hospital Association and the two ambulance services in Las Vegas presented this proposal to the State Interim Legislative Committee on Health Care a few weeks ago. This State committee was directed by the Legislature to study the ER divert problem and make recommendations to the State Legislature. Hospitals asked the State Senators and Assembly members to assist them in changing Nevada Law to allow this new position. The issue was discussed and tabled at the meeting to allow further dialogue of the interested parties and those with concerns about the proposal.
The Nevada Nurses Association was invited to participate in this dialogue at a hospital association meeting held on June 27 ( meeting minutes & participants attached). NNA was the only participant with concerns. Debra Scott, the new executive director of the Nevada State Board of Nursing attended and stated that current Nevada nursing law allowed RN's to supervise other health care personnel and that no changes in nursing law would be needed for the hospitals to proceed with implemention. The State Health Division would need to change the law that stipulates that EMT's can only provide pre-hospital care. The Division stated that this regulation change could be executed easily and quickly.
Scott Rolf, president of the Nevada Emergency Nurses Association attended and stated that his national organization was opposed to EMT's in the ER, but that he personally, as an ER manager at UMC, supported the proposal and felt that ER nurses wanted and needed this "help". He did not state the position of the local ENA organization on this proposal or elaborate on the specific concerns of the national organization and in my follow-up calls to members of the organization it appears that they DO have significant concerns and they are speaking with Scott about this.
At the meeting I expressed concern about increasing the use of any unlicensed assistive personnel and mentioned the other current proposals of the Nevada Hospital Association to expand the scopes of CNA's, LPN's, and others in all settings and the effect that this type of work re-design has had nationwide on high nurse turnover rates this last decade. I shared the statistic that we currently have almost a half million nurses in the U.S. who are licensed--but no longer practicing in the field of nursing anymore. I questioned Scott's statement that most ER nurses wanted this assistive personnel and recommended that a survey of ER nurses be conducted. I also questioned Debra Scotts' statement that RN's could already "supervise" any unlicensed personnel and her interpretation of "supervision" vs "delegation" and the distinctions she drew about EMT's not working "under" the RN's license---but that the RN would still be legally accountable for "appropriate supervision" and ensuring that these EMT's possessed the knowledge, skill, and competancy to perform the nursing tasks. Debra also stated that "supervising" RN's could be disciplined by the nursing board for failure to adequately "supervise" assistive personnel. I questioned the semantics and blurring of these terms and requested that clarification of these terms be made by the Nursing Board. I asked if the members of the Board of Nursing had dialogued on this issue and determined that no nursing law changes were needed for implementation. Debra said no dialogue had occured. I recommended that she speak to the Board members as the position she had stated was a departure from previous positions of the State Board of Nursing. The representative from the State Health Division also stated that the previous director of the Nursing Board had told him it would require a change to nursing law to implement. Debra told me yesterday that she later spoke with Cookie Bible, president of the State Board of Nursing and that she agreed with Debra's interpretation. Debra had not spoken with the other Board members as of yesterday. I again requested a dialogue with the full Board for clarification. I also expressed concern that the position could cause dissention and outcry from the nursing community and confusion because many staff nurses have been told by nursing managers that other assistive personnel such as respiratory techs, EKG techs, etc.. are not the RN's responsibility and that RN's are not accountable for their practice----that the hospital itself is responsible. I also shared that generally staff nurses are not informed of the educational preparation, scope, and competancy of assistive personnel such as techs and that many nurses believe and are told that they are accountable only for nursing tasks "delegated" to LPN's and CNA's. I extended an invitation for the State Board of Nursing to submit an article clarifying this issue for the August edition of the Nevada Nurses Association newsletter .
At the meeting I was asked by the group to comment on any compromises nursing would be amenable to on this proposal. I stated that I was not prepared to speak on behalf of ER nurses or nursing on any compromise--that I felt the nursing community and specifically ER nurses needed to be informed and surveyed on this first. The group asked if NNA could conduct a survey in the 10 days prior to our next meeting. I replied that that was not adequate time for a complete survey--but that I would contact as many ER nurses as possible by phone for feedback.
I have been on vacation in Laguna Beach, CA but was able to leave messages and speak to several ER nurses in Las Vegas and Reno about this. Those I contacted also discussed the issue with their colleagues at work and provided their feedback as well. Below is a summary of the feedback so far from about 30 ER nurses:
1)EMT's in the ER--- unanimous opposition
2)RN "supervision" of EMT's or other techs in the ER- most opposed to supervising, some stated they would rather have techs "under" nurses than "under" the hospital.
The attached job description was not developed or available--so no feedback on it yet. I will be distributing it this week for further feedback.
3)The # 1 concern expressed was that the management in their facility had not informed them of this proposal or sought their input prior to this decision that would impact their practice and patient care. As you know, this type of "communication" problem between staff and administrators has been identified in numerous surveys and studies as a top reason for high nursing turnover in the last decade. It was also identified by the Nevada Hospital Associations' Nurse Shortage Task Force as the # 1 work environment problem contributing to poor retention of hospital nurses.
4) All the nurses stated that there ARE enough nurses available to work in the ER--but that their management would not approve the use of ALL the available traveling nurses, nurses who work through local staffing agencies, or even ER staff who have stated their willingness to voluntarily work overtime. Scott Rolf, president of ENA also told me after the meeting that his facility had denied him the use of two available agency ER nurses that day. There is a rapidly growing number of nurses in Nevada who have chosen to work through agencies ( up to 50% in some hospitals ). Anecdotaly, many have said they prefer agency work because the pay is better, benefits are better, and that it allows them to control their schedules because hospitals cannot force them to work overtime, cancel their vacations, or change their work schedule at the last moment. I believe an effort needs to be made to collect hard data on this stated problem as the hospitals are claiming that the impact of the nursing shortage is a primary driver of the ER divert problem.
5) Not one of the nurses felt that having EMT's in the ER would ease the ER divert problem. They cited several other reasons for the ER divert problem such as HMO's that require patients to go through the emergency department for hospital admission because they don't allow their primary care doctors to directly admit them. Nurses stated that in many cases patients were seen by the primary care doctor in the morning and told to go to the ER for hospital admission and diagnostics, then they were held in the ER for 4-12 hours waiting for the HMO's 'hospitalist" to arrive and admit the patient. They also stated that ER nurses were spending a lot of time each shift repeatedly "calling" the HMO requesting a hospitalist and calling for authorization for procedures that could have been performed in other settings.
Other reasons cited for the ER divert problem were lack of hospital beds, and the unavailability of mental health and detox beds in the community resulting in psychiatric and detox patients staying in the ER for several days. These nurses also had many suggestions on resolving the ER divert problem that they felt would be effective and were disappointed that they had not been asked for input by administrators. They all stated that EMT's in the ER would not decrease the ER diversion problem.
6) regarding "compromises" to this proposal they could support---all were hesitant to compromise at all. A few said they would rather have EMT's in the ER than nursing assistants if they had no choice. A few also said that at a minimum--only medics educated at the advanced paramedic level could be considered as EMT's have only a total of 4 weeks training. Note: In the meeting I asked for the starting salary of a new graduate paramedic--It is $ 37,000 a year. At that point the hospital association said paramedics were not readily available and so they wanted EMT's. I regret that I neglected to ask the lower salary given to new EMT's--I will try to get that info.
Included in the attachments is the agenda for the 2nd meeting of the group which will be held tomorrow ( Thursday) at 10:00 am. I will be attending this meeting as the representative of NNA . Then the Nevada Hospital Association and the ambulance companies plan to put this proposal forward to State lawmakers again on Tuesday, July 30th at 9:30 am at a public hearing for all interested parties to weigh in on this issue and let State lawmakers know their position and concerns, and recommendations on the ER divert problem.
<There's no hope. This has discouraged me more than I can say...it will only be time before this happens in my ED and in ED's across the country.>
HEY!!! Come over here so I can shake that hopelessness right out of your weary body! Believe me I know how you feel but we are not helpless, as our history has shown. There is only no hope when WE give up. This article is proof of why staff RNs in the trenches ALSO need to get active in their states & not let these managers & administrators & HOSPITAL ASSOCIATIONS be the ONLY people the legislators hear from. This article is a prime example of how OTHER groups of non-RNs are trying to define RN practice & write state laws that rule our practice. If anything, this article should be a wake up call among ER nurses in Nevada (and all nurses there) & they should be contacting the ENA & the Nevada Nurses Assoc to add their voices.
The way I see it, The Nevada Nurses Assoc was the only one at that table speaking for the interests of the RNs who will be affected. Their points of concern were right on target.
If we all gave up a few years ago, the Hospital assoc & the Medical Assoc would have gotten away with making laws nationwide that created LICENSED care techs to replace RNs in the last RN shortage. They didnt because WE staff RNs stopped them. They had to improve conditions & salaries instead & that shortage was reversed in months, as soon as they did, as RNs came flocking back to work & student enrollments increased.
Its all well & good to have capable assistants in the ER TO HELP the RNs - but when the laws for RNs are being changed by non-RNs to allow for other categories of workers to have more responsibility under the direction of RNs - with us being held responsible for them - the line has to be drawn & drawn by RNs.
I get the feeling that the focus in things like this is not on fixing the problems that are driving RNs away or to attract them back, but on just bringing in other workers. The hospitals can get away with having fewer RNs - not having to spend the money to do what its going to take to attract RNs - thus putting more responsibility & pt load on the few RNs who remain.
This is no time to give up & let non-nurses make the laws that govern RNs practice. Where are the Nevada ER RNs who will be affected? They should be making their opinion heard to the legislature.
Last edit by -jt on Jul 25, '02
Theres a difference between that & expanding the UAPs role as a solution to having less RNs. Your EMTs are helping you. In Nevada, the hospitals want to use them for pt care because they dont have enough RNs. The focus should instead be on making workplace conditions improvements that will ATTRACT RNs to hospital jobs. AND according to the nurses who were polled, its freezing available nurses out of positions, refusing to hire them, at the same time it claims to the legislature that there are no nurses.
Hospitals are using the nursing shortage as an excuse to get away with hiring LESS RNs & use more UAPs & techs. Notice the part of the article where the nurses said the hospitals refuse to fill RN vacancies even when it has RNs available for them & refuses to allow RNs to work ot even when they want to? And refuses to utilize RN agencies? RNs are there. It seems the hospitals just dont want to hire & pay for them. So the solution as usual is bring in more less expensive UAPS instead.
The hospital assocs are manufacturing the shortage for their own benefit. EMTS cost less than RNs. If RNs there dont speak up about it, there may be no hospital jobs left for RNs.
Last edit by -jt on Jul 25, '02
<<I e-mailed the interim exec. director and the NV president Scott Rolf, basically demanding to know how somone could ram his personal opinion through a policy meeting, essentially ignoring the feelings of his constituents as well as the national organization's position.>>
They should know nurses are not only paying their membership fees but also paying attention.
The local specialty assocs, their national organizations, the state law-makers & the state nurses assocs need to hear from staff nurses.
Emergency Nurses Association
Nevada Nurses Association
Last edit by -jt on Jul 25, '02
<I am in favor of Paramedics that do not need an RN's supervision.>
according to the report, the hospital association said paramedics would not be considered - maybe their salary of $37,000/yr has something to do with that. But before they jump to pass off our jobs to other workers, & load the rest of us down with even more burden & responsibility for them, how about just hiring the RNs that are available and that the hospitals are now freezing out of work to cut its costs - at the same time that it claims it has to have laws that give more responsibility to UAPS because there just are no nurses to be found??? How about looking at the reasons WHY RNs are choosing to work agency - fix those & make the staff job more attractive to them?
<<<<4) All the nurses stated that there ARE enough nurses available to work in the ER -- but that their management would not approve the use of ALL the available traveling nurses, nurses who work through local staffing agencies, or even ER staff who have stated their willingness to voluntarily work overtime. Scott Rolf, president of ENA also told me after the meeting that his facility had denied him the use of two available agency ER nurses that day. There is a rapidly growing number of nurses in Nevada who have chosen to work through agencies ( up to 50% in some hospitals ). Anecdotaly, many have said they prefer agency work because the pay is better, benefits are better, and that it allows them to control their schedules because hospitals cannot force them to work overtime, cancel their vacations, or change their work schedule at the last moment. I believe an effort needs to be made to collect hard data on this stated problem as the hospitals are claiming that the impact of the nursing shortage is a primary driver of the ER divert problem.">>>>>>
So, according to the nurses who work there, they do have RNs available but REFUSE to let them work - because they dont want to spend the money - and then they blame the "nursing shortage" (not their refusal to hire the nurses) for causing ER diversions due to inadequate staffing??? And THEN say they have to have laws that allow less expensive UAPS to pick up the slack for the missing RNs because they just cant find any RNs. (never mentioning the fact that they DO have available RNs - they just refuse to let them work??).
Last edit by -jt on Jul 25, '02