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.