The Circle Game

“We can't go back, we can only look behind from where we came and go round and round and round in the circle game.” Joni Mitchell

The longer one practices the art and science of nursing, the clearer the lyrics quoted above become. It is not that we run around in circles, but we do become “engulfed” in changes we have little control over. Two of these circular issues are staffing shortages and the use of assistive personnel (licensed or unlicensed) who collaborate with emergency nurses to deliver safe and competent care.

This month in JEN, we are publishing a paper by Oglesby entitled Recruitment and Retention Benefits of Emergency Medical Technician-Paramedic Utilization During Emergency Department Nursing Shortages.1 The author provides an overview of the issues related to nursing shortages and offers a description of the use of and the benefits of emergency medical technicians/paramedics (EMT-Ps) in an emergency department.

In 1967, paramedics were described as firefighters who were trained to perform some advanced life support procedures in the field. In 1970, the state of California legally defined the role of a paramedic.2 A national standard curriculum for EMT-P was developed in the 1970s.2 As paramedics worked in the field, their function and skills were recognized and some began to assume roles in emergency departments. In 1977 when I worked in an emergency department in Akron, our paramedic coworkers were of great assistance when we were overwhelmed.

It has always been a challenge to determine what the role of a paramedic may be inside the walls of a hospital, particularly an emergency department. McPherson et al.3 performed a systemic review of extended roles of allied health professionals, including paramedics. Most of the work of the paramedics involved the performance of specific skills. One problem that was identified demonstrated that the training for allied professionals in expanded roles was variable. There is a need for standardization in order to provide a framework to evaluate the quality of care delivered.

Another significant concern revolves around delegation. When assistive personnel have been trained to do procedures in an environment different from their own, what they are or are not allowed to do (particularly in the emergency department) becomes difficult to distinguish, especially when the emergency nurse is busy. Not all states license paramedics and many of their scopes of practice may vary depending on EMS boards or local medial directors. These variations can cause confusion for both nurses and the paramedics.

Anderson et al.4 suggest a delegation decision tree involving 7 questions that should be asked before delegating a task. The questions include:

The authors recommend that if any of the questions can be answered with a no, the task should not be delegated.

Oglesby notes in his article that EMT-Ps with supplemental training can provide interventions such as urinary catheterization, patient transport, point-of-care-testing, and activities of daily living.1 However, he does specify that “a clear understanding of the role and supervision of EMT-Ps in the emergency care setting by both employer and employee is vital to avoid the confusion that many fear with changes in staffing functionality.”1 (p. 22)

As you read the Oglesby article, think about the words of the song, “We can't go back, we can only look behind from where we came.” Must we go forward in the development of the role of the EMT-P in the emergency department? Will clarification of the role of the EMT-P not only make a difference in the recruitment and retention of staff but in the overall quality and safety of care delivered in the emergency department?