NP...to keep my job?

Altra, BSN, RN · Oct 25, 2012

Charting of a trauma is generally not exactly taxing for an RN ... but your administration wants to pay an NP to do it? Makes no sense to me whatsoever. But who is going to give needed meds and so forth? The NP certainly could, but this is why there are at least 2 RNs present with a trauma. Will they staff 2 NPs accordingly? Somehow I doubt it.

Though I work in a system where there is a mid-level -- not really IN triage, but sort of "immediately post-triage" -- I don't feel threatened at all by this setup. And any patients that I feel cannot wait go directly back per MY decision - the mid-level doesn't get involved with those patients at all.

JessiekRN · Oct 25, 2012

VicedRN- what do you mean by the NP "overriding triage decisions"? Not sure I completely follow.

Good Morning, Gil · Oct 25, 2012

Sounds like they're not quite sure what to do with the NP in your ER, so they're giving him/her responsibilities of the RN, as well. Probably just more of a unit/hospital thing. Some areas of the country/certain hospitals have more developed roles for the NP whereas others don't know what to do with them.

I wouldn't let this one experience dissuade you. Shadow a few in the specialty of your choosing (I'm assuming it's acute care NP), to determine if it's what you want. If you're going to be frustrated by having less responsibility now, then all the more reason to go back to school (assuming the acute care NP role has more responsibility in other facilities, which I'm sure it does, or nobody would do it lol).

I'm not an ER nurse, but I would feel the same way as you in that situation.

Esme12, ASN, BSN, RN · Oct 25, 2012

Hi guys-
I kind of wanted everyone's opinion on a topic that has been bothering me. I would prefer no judgmental comments about the thought process and invite constructive comments.
Starting several months ago, our large ER has staffed an NP or PA to our triage area during the busiest parts of the day. The end result of this has been that the NP now orders the overwhelming majority of labs, protocol meds, and radiology in triage. They also override triage decisions throughout the day. Needless to say, I don't like this. I enjoy the assessment and the implementation in triage and feel it improves my skills.
One of the NPs that I am friendly with told me that they are also hoping that the NPs will start charting moderate sedations and traumas such that RNs are not needed in sedations at all.
Certainly, we have a lot of RNs that could do with improving their skills and I have,myself, thought about getting an MSN but frankly, I feel bitter about spending a fortune on an education just to keep doing a job I was doing up until a few months ago and it looks like its gonna get worse with them doing the sedations and all.
Have you guys see or do you think we will soon see less of the autonomy that ER nurses have historically enjoyed in the ER? Do you think this is right or wrong direction for the er?

Why do they need to pay the NP when there are protocols in place. So the NP is going to become a bedside nurse? Ridiculous....what a waste of resources. I see they are well on their way to dumming down bedside nursing

Shameful.....and sad.

VICEDRN, BSN, RN · Oct 25, 2012

It is true that they are trying to expand the scope of practice of the NPs in our ER and yes, this would include taking on nursing responsibilities. I told the NP that I know well that I wouldn't want the liability of doing RN work and being an NP at the bedside.

When I say "override" triage decisions, I mean that we have a long wait time and few beds so if we say send someone back to wait in the waiting room, they will review the chart and instead take the patient back to be seen which slows the department down and results in less sick patients being seen first. This is especially irritating because many of these folks have NO experience as ER nurses before becoming NPs and thus, don't look at the whole picture. They will also change an ESI level. I actually argued with one NP who tried to tell me a migraine patient was an ESI 4, not a ESI 3 and could go to urgent care despite our guidelines that say otherwise.

And yes, they now order the protocols themselves as though we can't and they will add to the protocol which also irritates the heck out of me. A chest pain protocol is a chest pain protocol for a reason. We don't need an INR NOW and the aspirin can wait. We don't need to stop triaging to go get an aspirin for a pyxis in another area.

My biggest concern is that what Esme has said...that they are dumbing down nursing and NP at the same time. RNs can and do run triage just fine at my last hospital. I think its just a question of proper training and accountability but I wondered if this NP in triage thing is really a sign we are being dumbed down again and should expect more of the same.

Altra, BSN, RN · Oct 25, 2012

The impetus behind having a midlevel in triage is twofold: 1) to shorten the door-to-provider time (although this is generally mostly smoke & mirrors, rather than meaningfully shortening the time to diagnosis and treatment) and 2) to expedite the throughput of very low acuity patients who do not require physician involvement.

Oh, and if the migraine patient is not getting a CT or labs but will get both IV meds AND fluids ... this makes him/her an ESI level 3 but not necessarily inappropriate for urgent care. (One of my all-time favorite ED providers carefully evaluated migraine patients and for those with a hx of migraines, who had responded well to oral meds such as Imitrex in the past but had not taken any prior to arrival in the ED, and without hx of trauma or unusual s/s ... prescribed Imitrex and gave an Rx for the same. ESI level 5. Great stuff.)

VICEDRN, BSN, RN · Oct 25, 2012

My last facility allowed patients with a history of migraines to be treated in urgent care. My current one does not. Sorry about not being clear in that last post.Triage is a guesstimate of what kind of resources a patient might use. I too have met providers that treat those with a hx of migraines the way you describe, altra and I concur it is appropriate for those patients.Regardless, I triage all migraines as a Esi 3 since they are likely getting the iv meds and fluids and a scan (sadly so). I don't have a crystal ball so I assume the patient gets a standard course.I don't care why they are in triage. I care that my own autonomy is being truncated now that they are technically seeing a provider faster and yes, the screen handfuls of patients out to urgent care too.