Working with Nurses and Alternate Practitioners

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The following is an excerpt from EMRA’s popular Medical Student Survival Guide, edited by Kristin Harkin, MD and Jeremy Cushman, MD. In this chapter about nurses and other practitioners, the authors explain the critical roles these care providers play and stress the importance of relationship-building within the ED. Please visit the EMRA website the download the FREE e-book, which covers such topics as the application and interview process, choosing a subspecialty, personal wellness in emergency medicine, charting, and much more.

It is common practice in the U.S. to use non­physician practitioners to deliver patient care and to perform specialized and often highly technical procedures in the emergency department. Medical students on rotation in the emergency department will undoubtedly encounter nonphysician practitioners, working as part of the emergency medicine team, or as partners with consultants from other specialties within the institution. It is wise for the prospective medical student rotator to develop a comprehensive understanding of the similarities and differences in education, training, clinical capabilities, and responsibilities of the various nonphysician providers most likely to be encountered. Knowledge of the competency, roles and responsibilities of this group of patient care providers will assist the medical student rotator in assimilating as a member of the patient care team and serve to enhance his or her clinical experiences and interactions during the duration of the ED rotation.

Nonphysician practitioners

Nonphysician practitioners credentialed to practice in the United States include licensed practical nurses (LPN), registered nurses (RN), clinical nurse specialists (CNS), nurse practitioners (NP), certified nurse midwives (CNM), certified registered nurse anesthetists (CRNA), and physician assistants (PA). The most frequently encountered nonphysician practitioners in the emergency department are registered nurses, clinical nurse specialists, nurse practitioners, and physician assistants, as detailed.

Registered nurses are recognized as vital components of the emergency department workforce. They triage patients, perform direct patient care activities (e.g., patient assessments, periodic reassessments, medication administration, phlebotomy, specialized nursing care/interventions), ensure effective information transfer when the patient is admitted/discharged, and foster open communication between patients, their families, and the emergency physician. Select nurses, generally with advanced education, also serve as department administrators, assisting with managing and overseeing staffing, patient throughput, and resolving patient complaints and staff concerns. Some nurses have specialized roles in academic institutions, serving as investigators in clinical, basic science, or translational research, as staff educators, or as sexual assault nurse examiners (SANE). Most RN training programs confer a bachelor of science in nursing (BSN), although many associate degree programs still exist. Nurses with expertise with regard to the practice of emergency nursing may be credentialed as certified emergency nurses (CEN) by meeting the prerequisites of the American Board of Nursing Specialties and the Emergency Nurses Association.

Clinical nurse specialists came into being in response to changes in health care tech­no­l­ogy that required nurses with highly specialized knowledge and skills. Clinical nurse specialists provide patients with advanced clinical nursing care and are often engaged in educational activities instructing and educating hospital staff and patients on clinical issues. They provide direct patient care, educate staff and patients, consult with other professionals, and provide leadership and supervision. Clinical nurse specialists work in various environments according to their specialty, but most work in a hospital setting. To become a certified clinical nurse specialist, one must have completed a master’s degree and on graduation be eligible to take the state certification exam for a CNS certificate as well as the professional certifi­cation exams for their specific study area.

Nurse practitioners and physician assistants are recognized as “physician extenders and mid level providers.” Their roles and capabilities vary based on location, institution, and individual education, training, and experience. Physician assistants and nurse practitioners in the emergency department most commonly provide patient triage and direct patient care under the supervision of emergency physicians. The medical director of the emergency department or a designee has the responsibility of providing overall direction of activities of nurse practitioners and physician assistants in the ED through formalized agreements. Select physician assistants and nurse practitioners may serve as department representatives responsible for quality management, performance improvement, service excellence, and/or benchmarking. They may also serve as investigators in clinical, basic science, and translational research, and as faculty for continuing medical education coursework. The requirements with regard to the education, certification, and licensure of nonphysician providers vary, depending on the training program and its curricular design, affiliation with a degree-granting institution, and state regulations.

Advanced-level nonphysician practitioners

The distinguishing features differentiating nurse practitioners and physician assistants from other nonphysician practitioners (in addition to education and training) is the increased autonomy they are given with regard to patient care activities and their ability to bill patients (or insurance carriers) for their services.

Hospital and medical staff policies and procedures, bylaws, and other institutional, state, and federal rules and regulations very specifically define the nature and governance of nonphysician practi­tioner patient care activities and clinical privileges within a specific institution and region. Generally, nonphysician practitioners are capable of provi­ding a wide range of services to patients in the United States. The services must be medically necessary and within the predefined scope of practice for the nonphysician practitioner.

In many circumstances, health care services provided by nonphysician practitioners are recognized and reimbursed by insurance carriers, including Medicare, Medicaid, and nongovernment insurance programs. The detailed guidelines for practice are different for each state; emergency physicians, therefore, need to be cognizant of the state and federal licensing regulations and registration requirements for nonphysician personnel with whom they work, so that an appropriate structure for documentation, coding and billing exists.

Practice models supporting advanced-level nonphysician practitioners

The American College of Emergency Physicians (ACEP) endorses guidelines for emergency department’s that employ nurse practitioners and physician assistants to care for its patients. The best practice models incorporating nonphysician practitioners are based on the “team” concept; nonphysician practitioners are integrated with and work alongside emergency physicians to ensure the most efficient, effective provision of emergent health care. The implementation of a successful practice model including nonphysician practitioners requires that the relationship between emergency physicians and nonphysician practitioners be formally defined; in particular, the scope of practice and the clinical privileges for each individual nonphysician practitioner must be clearly delineated and agreed on.

Several different practice relationships and structures are possible. The structure of the relationship and the role of nonphysician practitioners in the emergency department are influenced by local and regional practice standards, state law, federal Medicare guidelines, needs of the patient population the emergency department serves, and the current competency, experience, and expertise of the individual nonphysician practitioner. Some nonphysician practitioner models of practice bestow more independence and clinical autonomy than do others. Most, however, expect the nonphysician practitioner to collaborate with the supervising emergency physician during the course of each patient encounter; specifically, the attending emergency physician is expected to evaluate the entirety of care provided and supervise the key portions of any procedures performed as each is occurring. This requirement for performing supervision is similar to that required of attending emergency physicians who work with medical students and residents. If a nonphysician practitioner is expected to perform direct patient care that is not contemporaneously supervised by a qualified emergency physician, then he or she should demonstrate specific experience and training in emergency care.

Nonphysician practitioners should also be educated with regard to institutional and emergency department policies and procedures, their scopes of practice, and their delineations of privileges. Emergency department medical directors are expected to provide oversight of all nonphysician practitioner patient care activities; this responsibility includes implementing assessments and measures focused on quality assurance and performance improvement. Practice models that ultimately require emergency physicians to accept final responsibility for patient outcome and satisfaction usually represent the best means for ensuring high-quality patient care in the emergency department.

Working with nurses and alternate practitioners

It is helpful for the medical student presenting to any patient care unit at the beginning of a clinical rotation to develop a productive, collegial relationship with the professionals working on that unit. Establishing excellent rapport with the professional staff working in the emergency department is essential for the successful assimilation of the medical student as part of the patient care team. This is much more challenging in the emergency department. Given the demanding and time-sensitive nature of emergent patient care and the wide variety of patient presentations one will encounter, medical students rotating in the emergency department who do not interact well with the professional staff may easily become overwhelmed, overworked, overlooked, or, worst of all, ignored losing an important opportunity to learn. Medical students whose professionalism, altruism, and interpersonal and communication skills enable them to integrate into the patient care team more quickly will undoubtedly be encouraged to participate fully within the entire spectrum of clinical opportunities available to emergency department rotators, and, as a result, will observe, experience, practice, and learn more emergency medicine.

Entering the ED as a medical student rotator is an exciting yet challenging learning experience. For many it will be the first time they encounter patients with high-risk, high-acuity medical problems since beginning their medical school training. The most important thing the medical student rotator must do when first presenting to the emergency department for a clinical shift is to introduce himself or herself to all staff members working on that shift. Medical student rotators should clearly state their names, their programs, and their year of training. Most academic institutions accept student rotators from prehospital provider training programs, nursing and other allied-health care professional training programs, and resident physician rotators from within and outside the department. Do not assume that the ED staff can distinguish the medical student rotators from these other student rotators.

It is important for medical student rotators to communicate professionally with everyone they meet (including the clerks, receptionists, transporters, and other ancillary staff working in the emergency department). Inappropriate, unprofessional medical student rotator interactions with emergency department staff usually have significant, long-standing consequences. More important, improved patient outcomes emerge when all members of the emergency department staff collaborate to provide care in accordance with a common set of core values that is patient-focused.

Nurses, physician assistants, and nurse practitioners can help medical student rotators assimilate more easily into the patient care team and enable them to more readily serve as functional team members with less difficulty.

It is essential for medical students to familiarize themselves with the dynamics of relationships in the emergency department. Interactions with nurses are regular events during medical rotations as well as throughout one’s career. Understanding the educational importance of those collaborative relationships and the true shared responsibility for patient care may be one of the greatest points a medical student can learn on rotation in the ED.

Teaching intuitions where medical students, residents, attending physicians, and nurses collaborate is a great place for students to learn from nurses as well as their physician mentors. Most students learn quickly that nurses can help students integrate into the unit and serve as a functional team member without difficulty. Multidisciplinary case management and excellent physician-nurse relationships are practices in health care that medical students will learn to master as they progress in their careers.

One area of anxiety and stress for medical student rotators new to the ED is dealing with the “seasoned” registered nurses working in the unit. The value of positive nurse-physician interactions is well recognized. Medical student rotators working and learning within the complex clinical environment of the ED will observe and appreciate just how much nursing care is required for the prompt, timely, accurate, and safe execution of emergent health care decisions and interventions. A critical issue is to learn the importance of excellent interpersonal and communication skills (especially with nurses), and how those skills contribute to fostering the cohesion necessary for the smooth functioning of the patient care team. Medical student rotators should learn how to write orders on their patients (legibly and correctly), and how to inform nurses that they require execution. Medical student rotators should understand that many nurses have excellent clinical skills and an uncanny ability to promptly distinguish between patients who are acutely sick and those who are not; their recommendations and suggestions should not be discarded without due consideration. A truly shared responsibility for patient care between medical student rotators and nurses should exist.

Summary

A positive working relationship and continued growth in mutual educational efforts will only strengthen a currently sound professional partnership between emergency physicians and nonphysician practitioners.

Emergency departments with teaching programs where medical students, resident and attending level physicians, and nursing staff are continuously working together as part of an integrated team are unique environments for medical students. The breadth of practitioners providing patient care, the depth of each practitioner’s experience, and the wide spectrum of patient presentations make the ED a great place for a rotating medical student to receive a broad clinical education that transcends the experiences available on other inpatient units. Medical student rotators can learn from nurses and other advanced-level nonphysician practitioners as well as from their resident and attending-level physician mentors. Nurses, physician assistants, and nurse practitioners can help medical student rotators assimilate more easily into the patient care team and enable them to more readily serve as functional team members with less difficulty.

More than ever, practicing emergency medicine in the twenty-first century requires emergency physicians to work well alongside a cohesive team of personnel dedicated to providing only the highest quality patient-oriented emergency care. The challenge of current and future health care providers is to continue to recognize and appreciate the importance of creating an environment where all members of the health care team can contribute toward excellent patient care; when this is achieved, positive patient outcomes are the result.

Michael Cassara, DO, FACEP

Michael Cassara, DO, FACEP

North Shore University Hospital, Manhasset, NY
Michael Cassara, DO, FACEP

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Andrew E. Sama, MD, FACEP

Andrew E. Sama, MD, FACEP

Chief, EM Service Line, Catholic Services of Long Island, Chairman, Dept. of EM, Samaritan Hospital, West Islip, NY
Andrew E. Sama, MD, FACEP

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