I read an article this morning from my hometown newspaper, about the future of nursing.

It's a quick read.  Anything in there that is applicable to EMS?

http://www.buffalonews.com/life/health-parenting/health/article7344...

What do you think?

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Warren,

 

The individual instructor is pivotal, but the individual instructor is limited by the instututional setting, the amount of time in which the student is a captive audience, the ability of a college to provide more in-depth education on related topics compared to an EMS-only, non-degree program, and by the financial support available from the institution.  Then there's the pesky accreditation requirement...etc...etc.

Warren E. Shaulis said:



Ben Waller said:

I don't think the onus is necessarily on the instructors.  Instructors who educate past the bare minimum are great, but individual instructors typically have a fairly limited sphere of influence. 

 

The onus should be on the educational institutions, and more globally on those who want to make EMS a true profession to establish programs that are standardized, validated, evidence-based, that require education as well as training, and that requires instructors with educations at least one level above the degree granted to the students.  



Warren E. Shaulis said:

Gentleman, I believe that is a significant point, that our EMS instructors need to raise the bar a bit, not only for the students, but perhaps for themselves as well.

 

Ben. thank you as well for replying to my post, et. al. I spoke from a somewhat mixed skill set. I was acting as a Instructor/Coordinator , as well as acting as the lead instructor. I determined the content of the students academic participation (papers, discussions, etc.) as well as presentations. However, I believe that individual instructors may hold the key to educatinal excellence. I have had good and bad nursing instructors within a good curriculum and good and bad EMS instructors within a, so-so curriculum. I still believe that the individual intstructor plays a pivotal role in the student's educational experience

Not 1970s--I was a diploma nurse who graduated in 1987.  Used to be there were 3 ways to become an RN--associate (2 years), diploma (3 years, no summer vacation), and BSN (4 years).  Hmmmm...looks like they took the EASY way out.  And in my opinion, you can tell--nurses aren't what they used to be in a lot of cases.  (I am now a PA who interacts with a lot of nurses--many with much less knowledge and common sense than what I graduated with).  But that's because diploma nurses spent much more time in the hospital and much less time in the classroom, and to you, that does not equate to education in the book sense.  However, when I think of medical errors that occur now and those that occurred in the 1980s, I think that they are increased for 2 reasons--one is the dumbing down of the profession,and one is the financial cuts.  For example, all physician orders used to have to be checked by 2 RNs before they were carried out.  NOW--an untrained secretary is the one who checks them out, and in some cases they are directly carried out by an LPN (one year of training, has to always work under the supervision of an RN) and are never even SEEN by an RN prior to reaching the patient.  Instead, the pharmacist, who has no idea what is going on with the patient, is supposed to catch the error and notify the doctor!!!

 

So, if you

 want ALS to go that route, give them more courses in music appreciation, computer science, and creative writing and take them even further away from patients.  I'm sure it will help.  I'm just sayin'...
Bob Sullivan said:

Some time in the 1970's nurses drew a line in the sand and said you needed an associates degree to be an RN.  I am interested in learning how they dealt with the people who were content with the role of nurses being limited to repeating "yes doctor" over and over at work. 

I do not think it is unreasonable for the scene of every EMS call to be run by someone with at least an associate's degree.  I also think we need to get there before we can safely refer people somewhere other than emergency departments.

Actually, those who want nursing to be a profession are still fighting---they want the entry requirement to be a bachelor's degree.  Skip Kirkwood said:

I think that you're correct, Bob.  They got to the point, if I recall, where those who wanted a profession outnumbered those who wanted a job, and those who wanted a profession took over the organizations that controlled nursing, and made it happen.

Maybe that is the barrier - there are not enough in EMS who want more than a job (and too many who want it to stay a hobby, for such a change to happen.



Paula Miller said:

So, if you

 want ALS to go that route, give them more courses in music appreciation, computer science, and creative writing and take them even further away from patients.  I'm sure it will help.  I'm just sayin'...

 

I only wish the BSN had time for music appreciation but a Bachelors of SCIENCE rarely does.  Today in the year 2012 it is very difficult to not be literate in computers so yes, a computer science class is necessary.  Creative writing came after 2 semesters of the required composition classes. If you still wanted to do more writing after those classes, more power to you. I am a firm believer in reading and writing  classes especially in today's texting iphone shortcut language. Writing is now like adding without a calculator for some.

 

40 years ago the diploma nurse was okay. The RN was viewed basically as a technician who performed tasks over and over. Technology was still very simple and few specialists were needed. RNs did x-rays, respiratory therapy and labs. Now within the past 25 years these fields have exploded with advancements. 30 years ago saving a 23 week preemie was not heard of. Nor was the ARDS patient saved. They just died. Then medicine advanced and LTAHs were on every corner for both adults and peds as we saved patients that were dying just a few years before. But, the long term care brought a need for more specialized treatment and technology.  Nursing no longer could sit back and be techs. They had to become part of medicine as professionals.   Also, nursing in the US is very behind other countries where the equivalent of the Bachelors is already expected and the LPN or LVN is a 2 year degree.

 

The Associates degree is not working anymore. The mere 1000 hours of clinicals are not working. The curriculum needs to be updated to meet the needs of a growing profession.

Nursing is so vast that 1000 hours will not cover even a small fraction of what a nurse needs to know.  The diploma nurse focused primarily on "med-surg" basics. Now schools are trying to expose students to every department including intensive care which was unheard of 30 years ago.  A solid BSN program will provide a broad foundation with a lot of knowledge but there is a lack of direction for specialization until this education is complete and there is successful entry into a new grad program.  Many BSN programs have links to externship programs for an addition 3 - 6 months of experience in a specialty unit or floor as an RN instead of a student. These have proven successful. 

 

The Paramedic education is still very focused on a limited field of specialization. Even the A&P, pharmacology and pathophys classes are abbreviated and tailored just for EMS. It keeps the EMS provider separate from all other health care professions which usually will have at least a year's worth of similar classes before being admitted to a 2 year degree program. The clinicals are also very focused and somewhat inconsistent between schools especially when it comes to oversight at facilities and agencies. But, the Paramedic still comes out of the program prepared as the diploma nurses were years ago with a focus on technician style training rather than the academics.

 

The specialties are also more intense today. Educating the patient is also now a priority which requires more informed health care professionals.  Who would have thought 30 years ago that you would need more education  just to teach an asthma inhaler? Now it is recommended for RNs who work in the ED and clinics to take the Asthma Educator certification. Even RTs are now required in some hospitals to take it.  I would recommend that Paramedics considering being community health providers to take it.  It is an eye opener and today with many deaths attributed to asthma, especially pedi, it is a necessary part of patient care. But then there are also COPD educators which differs from asthma. Wound care, SCI long term care, developmental health issues and of course diabetes with all of the specialize care that goes into it are all areas the require not only education but experience in maintaining and managing.  The RN is expected to be proficient enough to recognize when they need to call for someone who is specialized in a certain aspect of care. I do not see how a Paramedic with limited education in today's curriculum and very limited exposure to the day to day management of long term care issues can be expected to be proficient in just 2 months which is what some community health programs are suggesting as education.  Any other health care professional would not be so bold to believe they are qualified for such as endeavor after such a short period of time even with a Bachelors. I believe some of the other countries require a Bachelors and then graduate work for their Paramedics.  The care of the diabetic patient alone is very challenging and then when you have COPD or Asthma and wounds from circulation problems, you have a very complex patient.

 

I also have to ask of those who are advocates of Community Paramedics, what about the skills which some believe are the backbone of the profession?  Intubation, ACLS and IVs would take a backseat.  You could get the same stigma that home health  or LTC nurses used to have and still are thought to be the low life of nurses by EMTs and Paramedics.

 


 

Nice reply, Geri.

As far as the community paramedics - at least in our system, they remain primary responders on the most critical emergency calls.  The expectation is that they will see MORE arrests and critical procedures than paramedics on ambulances (our stats show that they APPs will see 12+ ETTs per year, while an ambulance paramedic will see 1-2), because there are 5 of them on duty, while there are 35 ambulances on duty.

The need for greater education will come to a highly visible place when the payment system evolves a bit, and where the end of every ambulance call isn't turning the patient over to an emergency physician.  Contrary to today's evidence (which says medics can't make destination choices safely), tomorrow's medics will have to be able to accurately determine who can be safely triaged to other modes of transportation, and other sources of health care.  To do that, you have to know more about differential diagnosis, more about communication, and much more about the health care system!  If you don't do this well, your service will not be paid as much as they would be if all of that worked out well.  It's called "pay for performance" - it's already coming to a hospital near you, and it will be coming soon to an EMS system near you.

If EMS personnel want to come over to the UK I am sure someone can put you up at their house and you can see first hand the education, role and impact that Emergency Care Practitioners (be they nurses or parameidics) can have in the delivery of treat and release/refer programs, primary care and a host of other 'new ways of working' in the community.

It works well and reduces unessary visits to the ED and offers an alternative care pathway to patients, often leaving them at home/leisure environment or workplace.

Nurses (and paramedics) in such expanded scope programmes work and are safe if education and decent guidelines are in place.

I would be more than happy to accommodate in Cornwall. 

kind regards

Mike



Skip Kirkwood said:

As far as the community paramedics - at least in our system, they remain primary responders on the most critical emergency calls.  The expectation is that they will see MORE arrests and critical procedures than paramedics on ambulances (our stats show that they APPs will see 12+ ETTs per year, while an ambulance paramedic will see 1-2), because there are 5 of them on duty, while there are 35 ambulances on duty.

 

This is where EMS differs from nursing and other professions.  Nursing does not give out titles such as Advanced Practice because you have done more of a skill especially if it is an accepted general skill in your profession. We consider Advanced Practice Nurses to be those who have completed at least a Masters and maybe a doctorate degree along with some clinical experience and completion of some standardized measurement of competency in their area of expertise. We have RNs who may do 10 - 25 IVs per shift and some who may do none but the group with the most IVs are not considered Advanced Practice. We also have RNs who respond to every code and rapid response in the hospital but again are not considered Advanced Practice. We have RNs and Advanced Practice CNS or NPs who may be required to maintain 20 intubations per year for their area of specialty. But the RN who has not completed the requirements to be an NP or CNS will not be given the title of Advanced Practice even if he or she did over 150 intubations that year.  The RN could do community health along with working at a job doing intubations and may still not be considered Advanced Practice unless the education (Masters or Doctorate) and standard competency testing are completed.

 

For nurses who do community health, most will now have a Bachelors (BSN) with an additional specialty education and certification in Public Health. Those in school nurse positions are also now being required a BSN minimun in many states. Those who are in Home Health may be expected to hold specialty certifications along with a few years of experience directly involved in the assessment, care and education in certain specialties.

 

As the nursing community has been watching the Community Paramedic bill in MN which recently passed, most of us are wondering just how 120 hours will be adequate to fill this role.  There is no degree requirement for the Paramedic in the states starting CP programs and as mentioned during the debate, the average training is less than 1 year for EMT and Paramedic combined. The nursing associations and other professional organizations argued on the merits of education and experience with chronically ill and post operative patients while the EMS and fire department side argued from a more emotional viewpoint of always being there when called and that they can provide the same services but much cheaper than a Public Health nurse, Social Worker or home health Respiratory Care Practitioner. Diversion of funding toward cheaper may not necessarily mean better.

 

HF262/ SF119* would allow experienced paramedics in communities to undergo 120 additional hours of training to become certified by the Emergency Medical Services Regulatory Board as “community paramedics.” Minnesota State Colleges and Universities recently approved the accredited training program that would teach and certify EMTs as “community paramedics.”

Skip Kirkwood said:

The need for greater education will come to a highly visible place when the payment system evolves a bit, and where the end of every ambulance call isn't turning the patient over to an emergency physician.  Contrary to today's evidence (which says medics can't make destination choices safely), tomorrow's medics will have to be able to accurately determine who can be safely triaged to other modes of transportation, and other sources of health care.  To do that, you have to know more about differential diagnosis, more about communication, and much more about the health care system!  If you don't do this well, your service will not be paid as much as they would be if all of that worked out well.  It's called "pay for performance" - it's already coming to a hospital near you, and it will be coming soon to an EMS system near you.

Pay for performance is nothing new to hospitals and other professions. Many therapies are based on performance fees with strict oversight for regulatory criteria. CMS is even denying payment if hospitals perform poorly such as for hospital acquired infections.  Other professions have established their education standards first and then pushed for reimbursement and changes in health care bills. They did not say show me the money first and then we might raise our education standards.   RNs have put together their own stats where the BSN is working to improve outcomes. A better educated nurse is more open to Evidence Based Practice and changes. 

 

Mike Bjarköy

Nurses (and paramedics) in such expanded scope programmes work and are safe if education and decent guidelines are in place.

Agree.  But, if my research on the UK system is correct, the nurses and Paramedics have the equivalent of a Bachelors degree to start with and then graduate work as Emegency Care Practitioners and providers of home visits for non emergent treatment. These are more similar to the US NPs and PAs in terms of education and practice as Mid Level providers and not the average Paramedic in the US.  

I believe your invitation would be taken very seriously if you extended your offer to the US Physician Assistants and Nurse Practitioners.

I know here in the US some of the Paramedic programs are still taught largely through certificate programs of 1 year or even less in some places. Fire departments and private ambulance services having 6 - 8 month programs in place. 

 

Perhaps "nursing" doesn't give out titles, but there definitely are some titles for RN's who work in specialized fields and have specialized training--CFRN being one, and CCRN being another.  They are both exam-granted certifications.  In the same vein, the NR doesn't give out "titles" or have certification levels such as Critical Care Paramedic, Flight Paramedic, or Advanced Practice Paramedic, but there are such certifications which are attained by examination.

Where does any of this fall in the nursing world?

Geri Jacobson said:

This is where EMS differs from nursing and other professions.  Nursing does not give out titles such as Advanced Practice because you have done more of a skill especially if it is an accepted general skill in your profession. 

Are Advanced Practice Paramedics AP because they do a lot of intubations, or do they do a lot of intubations because they are AP, which means part of their job includes being dispatched specifically for critical patients? 

To the peanut gallery, with the push for APs to take the reins for critical patients, thus pooling the low use, high risk interventions among a smaller group of providers, are paramedics becoming the new EMT and APs the new paramedics in terms of tiered deployment?

Geri, I think you are taking pieces of programs from different places and forming erroneous conclusions.

I don't know much about what is going on in Minnesota, but Wake County's Advanced Practice Paramedics received much more than 120 hours of training.  Perhaps they could have been better names "Advanced Decision-Making Paramedics" or "Advanced Relationship Paramedics," but we purposely avoided going down the "legislation - rules - expanded scope of practice" route because (a) there was no need to, and (b) why would we want to tangle with turf-protecting, better organized groups.  Our APPs do nothing that is not already in the scope of practice of a paramedic - they just apply it a bit differently.

Joe, the APPs are more "AP" because of their injury prevention/illness control activities for frequent users, and for their ability to re-direct patients from the hospital ED to other, more appropriate sources of care.

They see a lot of critical patients because that is how we set up their dispatch scheme - so that they would have a lot more exposure to critical calls (there are 5 of them on duty at peak time, as opposed to 38 ambulances, so it's just arithmetic.  The APPs don't "take the reins" on critical patients, unless same is necessary for patient safety (which occurs rarely).  Think of the "rapid response teams" in the hospital - experienced resources, there to help if needed.  When they arrive, their first question is "How can I help you?"

I'd argue that a rapid response team (especially since said response can result in a patient going to a higher acuity floor) asking, "How can I help you?" is just a polite way of taking the reins.The reason the floor RN is requesting a rapid response team response is because the RN's patient took a turn and realized that the patient's needs no longer matches the capability of her and her floor. Similarly, if the rapid response team decides to transfer the patient to a higher acuity unit, then the patient is no longer the floor RN's patient.

Next, they have more exposure because you, as an organization, made the conscious decision to dispatch them to critical calls in addition to other resources. Sure, they're less of them, but if they weren't dispatched to critical calls, then they wouldn't see them.

Do the regular paramedics turn over intubations (or other high risk, low utilization interventions) to APPs as a matter of choice, or as a matter of agency policy? I'm not necessarily against making it a matter of policy, but the practical implications and the terminology being used aren't necessarily matching up in my mind (I'm also more blunt than most people), especially since sometimes a suggestion isn't really a suggestion.



Chris Azevedo said:

Perhaps "nursing" doesn't give out titles, but there definitely are some titles for RN's who work in specialized fields and have specialized training--CFRN being one, and CCRN being another.  They are both exam-granted certifications.  In the same vein, the NR doesn't give out "titles" or have certification levels such as Critical Care Paramedic, Flight Paramedic, or Advanced Practice Paramedic, but there are such certifications which are attained by examination.

Where does any of this fall in the nursing world?

It is my understanding the NREMT is not the test used by every state nor is every level issued by each state the same. It is also subject to change in the near future as I have noticed a new level "AEMT" being talked about by the CCT EMTs.   The Community Paramedic in Minnesota is now a new level or title which was created with an additional 120 hours of training.   The NCLEX is the test used by nursing for the vocational and Registered Nurse in the US.  Those are the two levels recognized in the US for licensing. After that you have the Advanced Practice Nurse licensure.

 

There are some credentials handed out by testing in nursing and then those that are most recognized t/o the profession required additional hours of training. Usually those doing the interviewing for certain positions will be able to sort through the handed out alphabet and those which required a little effort.

 

For example, the AACN issues the CCRN certification.

Eligiblity includes:

Practice as an RN or APRN is required for 1,750 hours in direct bedside care of acutely or critically ill patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application.

  • Eligible hours are those spent caring for the patient population (adult, pediatric or neonatal) of the exam for which you are applying.

 

You must repeat the same requirements for each age group you wish to test for.

For Med-surg nurse certification:

  • Have practiced the equivalent of 2 years full-time as a registered nurse.
  • Have a minimum of 2,000 hours of clinical practice in the specialty area of medical-surgical nursing within the last 3 years.
  • Have completed 30 hours of continuing education in medical-surgical nursing within the last 3 years.

 

For Rehabilitation nurses CRRN: (CARF will know the difference for credentials in a unit or facility.)

  • Within the five years preceding the examination, completion of two years of practice as a registered professional nurse in rehabilitation nursing; or

  • Within the five years preceding the examination, completion of one year of practice as a registered professional nurse in rehabilitation nursing and one year of advanced study (beyond baccalaureate) in nursing.

 

The above certifications are recognized nationally but do not require additional state titles, certication or licensing. 

 

Certifications which can be obtained in just a day or two at a seminar or liked ACLS or ABLS are recognized for what they are which is additional training certs which anybody can take without prior experience or even a specific title or license. These are usually just used for CEs and sometimes to fulfill the requirements of continuing education mandated by certifications such as CCRN.

 

Advanced Practice Nurse or Nurse Practitioner requires extra education and is recognized by the state with a designated set of practice regulations.  It is not a level an RN can just test out for with an ADN degree.  The APN is usually in 4 different areas: Nurse Practitioner, Certified Nurse Anesthetist, Clinical Nurse Specialist and Certified Nurse Midwife.  The RN must achieve the higher education and pass the appropriate certification through the American Nurses Credentialing Center (ANCC).

For California, this is how we defined Advanced Practice Nurse:

http://www.rn.ca.gov/applicants/ad-pract.shtml

 

California also has the MICN (Mobile Intensive Care Nurse) certification which is county specific by the EMS authority in that county. Other states may have a PHRN  or  EMS- RN (Nevada) which is issued by their state BON. These titles are specific to that state are a region and not national.

 

Just like EMS, you must look at the source of the certification or title and whether it is national, state or local.  EMS also has hazmet, tactical, wilderness, CCT EMT and many other types of specialty certifications. I honestly don't know how many of these are recognized by their state licensing board. I believe in California these are all extra certs of special interest and you do not need to apply to the EMSA for another title or certification.

 

I am aware of one state, Tennessee, that does have a Critical Care Paramedic level but it requires no additional college education in the form of a degree such as an Associates. It consists of modules which are hours based in training and apparently can be done in less that a month.  Maybe someone here from that state could give a better explanation of how that works. 

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