Essential job functions of an ER nurse?

One1, BSN, RN · Dec 3, 2012

This is a hair-splitting question, but I'll play. My essential functions per job description require me to be COMPETENT in several procedures, including IV starts and specimen collections (plus many more procedures of course). My essential functions do not specify to delegate or not delegate IV starts to other trained personnel. In real life, it is my responsibility to see an IV started and labs drawn as soon as possible. I can hope for a tech to be around to start it but honestly, more often than not, I am starting my own IV, drawing my own labs, do cultures and lab redraws. Techs are wonderful when they are doing it for you but as an ED nurse you should be ok with doing your own IVs. Same goes for EKGs, foleys, and getting patients to bedside commodes or on bedpans.

XmasShopperRN, ASN, RN · Dec 3, 2012

Competent, absolutely. 100% successful at all times, no. If a nurse has consistently demonstrated his or her competency in performing a specific task in the past, an expectation of a 100% success rate at all times is nonsense. The hospital to which I'm referring has a "two stick" max per associate policy, added to a very challenging patient population in regards to obtaining vascular access of any kind; needless to say, many IV placements and/or blood draws are successful only after multiple attempts by more than one nurse/tech/etc. And every nurse I know has had an "off day" at some point when, for whatever reason, they couldn't throw a line into a PVC pipe if their life depended on it. Dramatic I know, but my point is that while ideally it is the nurse's ultimate responsibility to ensure that their patients receive adequate IV therapy, it is often a group effort. So then by definition, the physical act of placing an IV or drawing blood is a marginal function of an ER nurse as other people are available and often do such tasks themselves.

hiddencatRN, BSN, RN · Dec 3, 2012

All three hospitals I've been at have a 2 stick per practitioner policy. What, you want to keep poking away at a patient indefinitely before asking someone else to give it a shot? If you're not going to get it in 2 sticks, this just might be an off patient for you; best to let someone fresh give it a try.

But it's certainly not a "marginal" part of my task list. Just because I have resources available if I have an off day doesn't mean I don't depend on having great IV skills to get through the shift. If I delegated even a significant portion of my IVs it would slow down gaining access considerably. And, at two places I work at, only RNs are allowed to start IVs, so that means waiting on another RN to be available to come help me out.

It's quite a leap of logic to decide that because it sometimes is a group effort it's only a marginal function of an ER nurse. MI alerts, stroke alerts, codes, and septic patients circling the drain are group efforts. And frankly, swarming on a critical patient to get them stabilized quickly is a mark of an ER with strong team work. The skills needed to handle those situations are still pretty essential for an ER nurse to have.

psu_213, BSN, RN · Dec 3, 2012

Except when I am busy, I will attempt all my IVs. If I am unsuccessful x2, I will ask someone else. As an RN, it is my responsibility to make sure the IV is established and blood is drawn in a reasonable amount of time. When both myself and the PCT have attempted line/lab, it is essential that I figure out how to gain access and get blood (i.e. find another RN, the attending, a resident, etc...). There may be a 2 stick policy (I think there is something similar almost anywhere), but there are cases where the IV must be obtained and blood must be drawn. In those cases, you do what has to be done to get access.

P.S. I would rank IV skills as much more important that "lifting" as essential functions of the ER nurse.

One1, BSN, RN · Dec 3, 2012

Dramatic I know, but my point is that while ideally it is the nurse's ultimate responsibility to ensure that their patients receive adequate IV therapy, it is often a group effort. So then by definition, the physical act of placing an IV or drawing blood is a marginal function of an ER nurse as other people are available and often do such tasks themselves.

We have a 2 stick policy as well. I don't follow your jump to this conclusion though, and I am still not sure why you are so hung up on if it is an essential job function or not. I agree with hiddencatRN, I think it is absolutely an essential part of your functions to get IV access on a patient, given that you have orders for IV meds, labs, fluids, and other interventions you cannot perform without venipuncture. Although you might not be *physically* the one to insert the needle for whatever reason, you are definitely the one who needs to 1) find SOME way that access to the patient is gained, and 2) do so as fast as possible so you can continue caring for your patient. If all or most of your physician orders hinge on an IV, then IV access becomes one of your top priorites (read: one of the essential interventions/functions) with this patient.

XmasShopperRN, ASN, RN · Dec 3, 2012

One1, I apologize in advance for the novel below:

Everything being said on here is absolutely correct. IV and blood draws are actually some of my favorite nursing tasks; the more challenging, the more rewarding!

The reason for my original post was to get a sense of how integral IVs and blood draws are in various departments and organizations. I too prefer placing my own IVs and drawing labs, and agree that those tasks hold more importance than many other nursing tasks in the ER. With 3+ years of ER experience under my belt, my IV and phlebotomy skills went from nonexistent to excellent. Truth be told, I could start an IV in the dark....Okay maybe not the dark, but definitely dim lighting:)

I underwent hand surgery earlier this year for OA in my dominant hand. The expected 4-6 week recovery time was extended thanks to a serious post-surgical complication, CRPS. Prior to treatment and during the acute phase, the condition rendered me incapable of any wrist flexion; my hand was constantly cold and cyanotic; and the excruciating stiffness and burning pain became so intolerable that I sat in my hand surgeon's office while crying like a baby. Needless to say, at its worst, CRPS made any tasks that required manual dexterity an impossible feat.

Pity party over-there's a point fast-coming. Months of painful treatment, multiple steroid regimens, and countless OT appointments eventually lessened the effects of CRPS to a point where I'm "in remission" (CRPS is considered a lifelong diagnosis in which symptom relapses are common but can be controlled with nerve blockades, PT/OT, and medications). Based upon my significant recovery and readiness to return to work, my hand surgeon cleared me for full duty. End of story? Not so much....

As with many neurovascular/orthopedic disorders, residual effects are common. Mine: occasional hand fatigue provoked only after assembling my daughter's desk for more than 3 hours. Use of a CMC hand splint along with ROM exercises quickly alleviate the fatigue.

When I attempted to return to work with strong support from my surgeon, occupational health refused to grant me clearance. Apparently, any chance, whether actual or potential, that an ER nurse's hands may not be 100% 24/7/365 is reason enough to disqualify a nurse from working in the ER. Ironically enough, manual dexterity was not the issue at hand initially; the original reason that I was given was the potential danger posed if I was unable to safely lift a patient.

So I underwent a functional capacity evaluation (FCE) to prove that I am more of performing my job well and efficiently. I was able to demonstrate EVERY physical requirement including successful placement of a 20g IV, blood draw, foley, transfer of a patient from wheelchair to stretcher, and the list goes on.

Still, despite my ability to perform every single nursing task with zero difficulty, I was denied medical clearance required to return to work from occupational health because of a potential chance that at some point I would be unable to perform all of the essential functions of my job. Conveniently, the "essential function" under scrutiny was no longer lifting, but rather functions that require manual dexterity, specifically IV starts and blood draws.

Rather than consider the objective data provided by my hand surgeon and the FCE, I was terminated last month based on mere assumptions about how my hand might fare during a shift.

Apparently if my hand fatigues, I wouldn't be able to start IVs or draw blood, despite past proven competency and proficiency. I was actually informed that in order to work in the ER, a nurse has to be at "100% full capacity without need for any accommodation of any kind."

Call me naive, but that's just beyond unrealistic. Based on their reasoning, a nurse who just documented a 2.5 hour long code should be sent home due to the potential danger that the nurse's fatigued writing hand poses to patients.

That's my point in a nutshell. There are instances during many nurses' shifts when they're not "100%", but that doesn't mean they're not able to perform all of the essential functions of their jobs.

WHEW! Again, many apologies for the length!

hiddencatRN, BSN, RN · Dec 3, 2012

So, this isn't a thread about whether venipuncture is an essential job function of an ER nurse but about how your hospital handled your disability and return to work. I'm sorry you experienced this, but it sounds like we're not the ones you need to be having this conversation with.

XmasShopperRN, ASN, RN · Dec 3, 2012

hiddencatRN, I disagree. I think this is a very relevant emergency nursing topic, and I purposely posted the thread here because no one knows more about an ER nurse's job than an ER nurse.

While it's true that I suffer from a condition that has had a negative impact on my employment, I was and still am an ER nurse at heart. My experience is one that many nurses, ER and so on, are forced to endure: an injury, condition, or challenge, work-related or not, that directly affects the nurse's clinical practice and ability to work in a capacity for which they are fully qualified and competent. Essential vs nonessential functions is really a mute point; clearly for patients to receive adequate emergency care, they often require IV therapy and blood work.

It's no secret that due to the non-stop, fast-paced, physically and emotionally draining environment of many emergency departments, ER nurses are often subject to constant scrutiny and unrealistic expectations to perform effortlessly while understaffed and under immense pressure. The expectation that nurses must be "100% full-duty capacity" is one that many nurses, regardless of specialty, frequently fall victim to. Without getting into any legal discussion on the matter (as I'm aware is not allowed on allnurses.com), just because such expectations and policies have become commonplace in many healthcare facilities, doesn't mean they should or have to be tolerated. "Full-capacity" policies are inherently wrong, and have become a large focus of the Obama administration and target of many recent EEOC actions.

hiddencatRN, BSN, RN · Dec 4, 2012

But we're not going to give you your job back. And you're not really framing this as a vent about your situation. IVs are an essential function of the ER nurse. You state you can do them just fine, your employer disagreed, so it doesn't even sound like you're arguing that it's an unimportant skill.

psu_213, BSN, RN · Dec 4, 2012

To the OP: I feel very bad about your situation...I can't even imagine how I'd feel if I were in a similar one. If I, due to some sort of disability, were unable to start an IV or obtain blood work, I would be quite peeved if I had to give up my job. However (and I realize it is easy for me to say this, not being in that situation), IV starts are an essential part of the job for the ER nurse. There are some shifts when there is no tech available or care will be delayed until someone can be found to start your pt's IV. If an RN is physically unable to perform IV starts, the ER is not the place for them. I know it stinks to hear (it stinks to have to say that). None of us here are going to be able to judge if you are or are not capable of starting IVs. Sadly, your ER says your are not. It is very unfortunate, but it is going to mean giving up your job at that ER. :sorry:

hiddencatRN, BSN, RN · Dec 4, 2012

Or find a job in a ER that will take a different view of your abilities. Maybe less of a hard line.