The pressure to change processes and practices in health care is unrelenting. It seems like every week there is a new rule or requirement from federal, state, local, or institutional powers or an updated clinical practice recommendation from an authoritative body. Furthermore, because patients with every type of health care problem are eventually seen in the emergency department (ED), we commonly receive requests to "do just this one thing" for patients with ____ (fill in the blank). In isolation, the individual process and/or practice changes may not be a big deal but when multiplied by the number of different conditions and types of patients seen in the ED, things can get out of hand quickly. For already harried emergency nurses, even remembering the most recent documentation requirements can be a challenge, never mind actually completing them on every chart during a busy shift.
As advanced practice nurses (APNs), we are frequently tasked with the implementation of a change. Therefore, we are in a key position to advocate for appropriate change and also in a key position to challenge and to renegotiate inappropriate requests. Remember that the mission of emergency care is first and foremost to evaluate patients for life-, limb-, and vision-threatening conditions and to intervene as indicated. Anything that compromises our ability to complete that mission is simply not acceptable. We need to be cautious when inserting new items into an already complex and often chaotic setting. It would be nice if we had the time to provide "ideal" care and address all of the problems experienced by our patients and their families. However, nursing time is a precious commodity that is often in short supply.
Emergency nurses are rarely shrinking violets, and we do not hesitate to advocate on behalf of individual patients. As emergency APNs, we must advocate for both patients and nurses when changes are proposed to systems and processes. We need to use our well-honed skill of persistent inquisitiveness to evaluate proposed changes. First, is "it" really a requirement? If so, what exactly is required? In some cases, the requested change is actually overcompliance based on an erroneous interpretation of a regulation or an overcautious attitude. Go to the source and evaluate it yourself. When someone says "The Joint Commission says...," read the actual Joint Commission standard. If necessary, ask questions to seek clarification about standards, especially as they pertain to emergency care. What unintended consequences might result from compliance and what are the risks associated with noncompliance? And, consider challenging the regulatory agency if you really think that the standard is inappropriate or unsafe in your setting. Of course, you will want the backing of your institution in this situation but challenging a regulatory agency is appropriate if you have a convincing argument that the change is unnecessary or unsafe in the ED. For example, a requirement that all supplies remain in sealed packages until needed for patient care sounds good until you consider some truly emergent situations. Think about a vomiting patient who cannot easily be turned by a single person. In this situation, the suction canister and tubing needs to be set up and ready to go with the flip of a switch.
Next, consider the evidence on which a practice change is based. Obviously, in the presence of solid data that demonstrate improved patient outcomes in the same or similar care environment, every effort should be made to incorporate the change into practice. The use of waveform capnography to monitor endotracheal tube (ET) tube placement is one example where there is essentially incontrovertible proof that an intervention decreases morbidity and mortality. In the most circumstances, failure to monitor ET tube position with waveform capnography is considered a breach of the standard of care. Unfortunately, solid evidence of this nature is uncommon in emergency care. More often, someone in a position of authority has a theory or perhaps anecdotal data that a new practice will improve care. And, in today's environment, many practices are implemented to improve reimbursement. Therefore, it is important to carefully consider what evidence does exist and evaluate the consequences of noncompliance.
Patients count on nurses to provide safe and effective care and to advocate on their behalf. Nurses count on other nurses, specifically APNs and nurses in other leadership positions, to advocate on their behalf. This means that taking the path of least resistance, and agreeing to every requested change, is not an option. Combining your clinical expertise with your powers of reasoning and critical thinking will help you evaluate the risks and benefits of changing practice and develop a cogent argument against things that are unsafe, unreasonable, or unnecessary. We owe it to patients and nurses alike to be thoughtful and to strive for "realistic," not "idealistic," expectations for practice.
-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
Cornish, NH
-K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA