Putting the ER in Diversity

During her orientation as an emergency nurse at Kaiser Permanente Hospital in Hollywood, Calif., Katherine Bolden, MSN, RN, helped care for a man who had come to the ER after falling and hitting his head. The medical staff suspected that he had suffered a serious injury, and the doctor ordered tests. A CT scan revealed a brain bleed. The medical team rushed him to the operating room, and he underwent emergency surgery.

“We saved him,” Bolden says. “Later I heard he recovered and walked out of there.

” Bolden’s life was changed forever, too. From that day forward, she was hooked on emergency nursing.

Minority nurses can make a profound impact in emergency care—the front lines of today’s health care system. Emergency nurses treat an unusually diverse variety of patients and conditions, from infants with colds to elderly heart attack patients to victims of stabbings and shootings. They care for people from every walk of life and cultural background, including patients from the most vulnerable and underserved populations, many of whom come to the emergency department because they have no other access to health care services.

Emergency nurses thrive on unpredictability and variety. They don’t call themselves “adrenaline junkies” for nothing. Yet the rewards of this career come as much from comforting a patient’s family members as from saving a car accident victim.

“You’re [providing care to] patients at the worst times of their lives, when they need it the most,” says William Briggs, MSN, RN, CEN, FAEN, trauma program manager at Tufts Medical Center in Boston and president of the Emergency Nurses Association (ENA).

Briggs, who coordinates services for injured adult patients at Tufts, has been interested in emergency medicine since high school, when he taught first aid and became an emergency medical technician at 17.

“I was always kind of [drawn to] the emergency room,” he recalls. “I like taking an unsolved problem and solving it, creating order out of chaos.”

No Shortage of Opportunities

The nursing shortage hasn’t hit emergency care as hard as some other specialties, Briggs says. But career opportunities for current and prospective emergency nurses still abound. Hospital emergency departments employ clinical nurse specialists, pediatric and psychiatric nurses, transport team nurses and case managers.

Demand is also growing for emergency nurse practitioners (see sidebar), who provide care in a variety of settings, including large urban emergency departments, rural and military hospitals, ICUs, adult internal medicine units and even walk-in clinics.

Katherine Bolden, MSN, RNKatherine Bolden, MSN, RN

One of the primary reasons why emergency nurses are in such demand is that hospitals throughout the country are struggling to keep up with patient loads in emergency rooms. While emergency visits have risen by 36% since 1996, 5% of the nation’s emergency departments have closed, according to statistics from the Centers for Disease Control and Prevention (CDC).

Overcrowding is the biggest challenge emergency nurses face today, says Briggs. On busy days, patients may lie on stretchers in crowded corridors, waiting hours and hours for beds.

“It’s a national crisis right now,” he declares. “Every [emergency department] is busier [than it used to be].”

Five years ago, Massachusetts General Hospital in Boston saw 180 to 200 patients a day in its emergency department. Now it sees 260 a day, says Maryfran Hughes, MSN, RN, nursing director of the hospital’s ED/observation unit. A variety of factors are causing this surge in emergency room use: an aging population, a shortage of primary care physicians and a growing number of uninsured patients who lack access to other sources of health care.

This favorable supply/demand equation also makes emergency nursing an attractive option for career-changing nurses who are looking for a more challenging, exciting specialty. Bolden, for example, became an emergency nurse after working for more than eight years as a health educator.

“It was almost like being a new grad again,” she remembers.

“It was a little scary at first. I wondered, ‘Am I going to be able to handle everything that comes in?’ In the first six weeks I lost 15 pounds, because I went from working in an office to what I now call ‘real nursing.’”

She asked lots of questions and found support and camaraderie among her fellow emergency nurses and physicians, who trusted and consulted one another. A collegial relationship with doctors and other members of the health care team is one of the biggest benefits of the emergency nursing specialty, where nurses often have greater autonomy and more say in patients’ care than they would in other parts of the hospital.

“There’s no way you could do it alone,” says Linda M. Redd, RN, an emergency nurse at Massachusetts General. “Patients are overflowing into hallways and are constantly being moved. It would be easy to lose track of people if you weren’t working as a close-knit team.”

The Culturally Competent ED

In its position statement on diversity in emergency care, the ENA emphasizes that a diverse and culturally competent nursing staff is essential to meeting the needs of today’s multicultural patient base. The specialty has a great need for more minority nurses who can help break down cultural and linguistic barriers to provide better quality care in emergency settings.

“When [emergency] patients come in and are very anxious, it’s important for them to be in an environment where they know they’ll be comfortable and will be able to bond with someone,” says Hughes.

She cites the example of an elderly Muslim woman who came to the ED complaining of stomach pain. The doctor ordered an MRI, and the woman became upset at the idea of having to remove her headscarf. The medical staff only wanted to ensure that her clothing contained no metal fasteners, which would pose a safety hazard and ruin the images because of the machine’s powerful magnetic field. A nurse whose grandmother was Muslim talked with the patient, letting her know she understood her concerns, and explaining the procedure and safety precautions. Because she shared the woman’s cultural background, the nurse was able to make a personal connection with the patient. Together with the staff, they worked through the issue and the woman successfully underwent the MRI examination.

Bolden recalls an African American couple who took offense at a security guard’s instructions in the emergency room where she works. She intervened and talked with the couple to clear up the misunderstanding. “It helps to have a person from the same culture to smooth things over,” she says.

Redd agrees that minority patients are likely to experience less stress in the emergency care setting if there are nurses and doctors who look and talk like them. What’s more, she adds, a pool of culturally diverse nurses can help one another learn to provide better care to patients who are different from themselves.

“We teach each other,” she explains. “I’ve learned so much culturally from watching other nurses work with patients.”

Language differences can create enormous barriers. Briggs says more bilingual emergency nurses are urgently needed to bridge communication gaps with patients who speak little or no English. “If you have to find an interpreter every time you have to speak to the patient, you’re going to lose a lot of [time and] communication,” he emphasizes.

According to a study by Sharon M. Jones, MSN, RN, published in the June 2008 issue of the Journal of Emergency Nursing, five Caucasian, non-Hispanic nurses at a Midwest hospital reported that the language barrier impacted all aspects of care when they attempted to treat Mexican American patients. Only one of the nurses spoke a little Spanish, and she was the only one who described being able to establish a nurse-patient relationship.

Jones concluded that interpreter services should be available 24 hours a day and that emergency nurses should receive training to learn basic Spanish and to gain an understanding of Hispanic cultural considerations that can impact nursing care.

Ready for Anything

What does it take to be successful in emergency nursing? Nurses interviewed for this article stress that critical thinking skills and confidence are paramount.

“You’re kind of like a detective, and you have to be quick [in assessing what’s wrong with the patient], because if you dilly-dally patients can die,” says Thelma Kuska, BSN, RN, CEN, FAEN, who worked for 20 years in hospital emergency departments, including Christ Medical Center in Oak Lawn, Ill., 13 miles from downtown Chicago. “You have to be sure of yourself and be able to stand up for yourself [so you can advocate for the patient]. You need to be knowledgeable to make sure you are giving the correct care to the patient.”

She recalls a 22-year-old newlywed woman who came to the ER with belly pain. Kuska had a hunch, and after questioning the patient she quickly summoned an emergency physician, who ordered an ultrasound. It revealed that the woman had an ectopic pregnancy. Within 30 minutes, the patient was undergoing surgery. Later, when the young woman was recovering from the successful operation, the doctor pointed to Kuska and told the patient, “This nurse saved your life.”

Kuska received her nursing education in the Philippines and immigrated to the U.S. at age 20 to begin her career. Before finding her niche in emergency care, she originally worked as a surgical nurse, in an environment that was worlds away from the fast pace of the ED.

“[In surgery,] everything was laid out, you knew what the patient was coming in for, the instruments had been chosen the day before and the physician was there the whole time,” she explains. “In an emergency department, you never know what will present. It could be a heart attack patient, a car crash victim or a child with a fever. Our doors are always open, the ambulances come in, the patients come in and we treat them.”

There is no such thing as a routine day. “The emergency department is such a busy, busy place. It’s like being bombarded on all sides,” says Redd. “Emergency nursing [brings it all together] for me. I really have the chance to call my entire knowledge base into play.”

The variety can be as challenging as it is stimulating. “There are shifts where one minute you’re holding the hand of a family member whose mother has just died, and then you walk into the next room and you’re blowing bubbles with a four-year-old who’s having his chin sutured,” says Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the emergency nurse practitioner program at Vanderbilt University School of Nursing in Nashville.

What Recruiters Look For

At least a year or two of inpatient experience is recommended for nurses who want to work in the emergency setting. However, because of the high demand, some hospitals are now hiring new RN graduates and offering internship programs in the emergency department.

When hiring emergency nurses, Briggs says, he wants to see passion. “The worst thing an applicant can say is: ‘I want to work in the emergency room because you have the hours I like.’”

Hughes says she looks for nurses who have good clinical knowledge and decision-making skills, as well as the ability to work as a team with other clinicians. Above all, she wants nurses who know how to appreciate the patient as an individual.

“Sometimes [emergency nurses] have just a few seconds to establish a relationship with somebody before we have to give bad news and ask the patient to trust us,” she notes. “You really have to be able to reach the hearts and souls of patients and connect with them immediately.”

The ability to establish bonds with patients’ family members is important, too. Redd recalls an elderly patient with urinary problems, whose wife brought him in to the emergency room.

The man was ill and mentally confused, and his wife was clearly beside herself. Redd took the time to have a heart-to-heart talk with her and helped her come up with an emergency plan so that when the couple went home, the wife would know who to call and when.

Opportunities Beyond the ED

Emergency nurses can also play life-saving roles outside the traditional emergency care setting. After caring for numerous young victims of car accidents, Kuska wanted to do something to help prevent more youths from ending up in the hospital. She volunteered for the Emergency Nurses CARE (EN CARE) injury prevention program.

Two emergency nurses from the University of Massachusetts Medical Center in Worcester, Mass., started EN CARE out of frustration and heartbreak from seeing young lives shattered or ended because of drunk driving. They began presenting alcohol awareness programs to high schools, based on the cold, hard facts of their emergency department experience. The program spread nationwide and became an affiliate of the ENA in 1995, as part of the association’s Injury Prevention Institute. EN CARE has now expanded to include other injury prevention initiatives, such as gun safety and bicycle safety.

By presenting alcohol awareness programs at elementary, junior and senior high schools, Kuska has made a difference in countless young lives. One mother told her that after seeing Kuska’s presentation, her children hid the car keys when their dad planned to go out after drinking. A high school girl who had heard one of Kuska’s talks later told her she had refused to get in the car with her prom date because he had been drinking. She found another way home from the dance.

After working as an injury prevention volunteer for several years, Kuska began doing contract work for the National Highway Traffic Safety Administration’s Region 5 office in Chicago, where she now works full time as regional program manager.

“It’s another face of the emergency nurse that I never knew existed,” she says. “When I worked in the ED, I was saving one patient at a time. Now I’m saving lives [on a much larger scale].”

Emergency Nurse Practitioner: An Emerging Opportunity

Nurse practitioners have been providing emergency care to patients for decades. But only recently have nursing schools begun to offer degree programs designed to train advanced practice nurses specifically for the emergency setting.

Currently, seven graduate schools of nursing around the country offer emergency nurse practitioner (ENP) programs, which incorporate emergency nursing courses and clinical experience into traditional family or acute care nurse practitioner programs.

The University of Texas started the first ENP program more than a decade ago, after a study showed a need for nurse practitioners with broader emergency training. Acute care nurse practitioner programs provided emergency care training but did not cover caring for pediatric patients. Family nurse practitioner programs did not include enough emphasis on emergency care.

Now, besides the programs at the University of Texas-Houston and the University of Texas-Arlington, there are emergency nurse practitioner programs at Emory University in Atlanta, Loyola University in Chicago, the University of Florida in Jacksonville, the University of South Alabama in Mobile and Vanderbilt University in Nashville. While the structure of the programs varies from school to school, the ENP schools stay in close contact to make sure their curricula are aligned with one another.

At Emory University’s Nell Hodgson Woodruff School of Nursing, ENP students take family nurse practitioner courses along with four additional classes in emergency care. They must also do clinicals in primary, urgent and emergency care. Vanderbilt School of Nursing’s program is unique because it prepares emergency nurse practitioner students for dual certification as both family and acute care nurse practitioners. “This allows them to not only care for patients across the lifespan, but also across the acuity spectrum,” explains Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the ENP program.

The majority of emergency nurse practitioner graduates find work in hospital emergency departments. But Michelle Mott, MSN, APRN-BC, FNP, an instructor and interim program director for Emory’s ENP program, says her students have also found jobs in prisons, specialty practices and retail clinics. One graduate now works for a primary/urgent care clinic on a remote Alaskan island. “I’ve never had a student who has had trouble finding work,” Mott adds.

In addition to her academic responsibilities, Mott also works in the emergency department at Grady Hospital in Atlanta. Advanced education in the emergency nursing specialty, she says, gives minority nurse practitioners a greater opportunity to improve health care for medically underserved populations. “You’re able to provide those skills that are the foundation of the philosophy of nursing, but you’re also able to provide management and bridge some of the gaps to provide greater access to care. It’s just a wonderful career path. It uses everything you learn in all of your schooling.”

While emergency RNs can earn such certifications as CEN (Certified Emergency Nurse) and CPEN (Certified Pediatric Emergency Nurse), there is no certification yet for emergency nurse practitioners. For now, these NPs hold either FNP or ACNP certifications, or both.

Wilbeck says more emergency nurse practitioner programs are needed. She believes the number of nursing schools offering ENP programs will grow as the nursing profession increasingly recognizes the value of these practitioners and begins to formalize standards for educating and certifying ENPs. Current ENP programs, she adds, are also looking at expanding and offering distance-learning courses.