Future of ER nursing
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The document discusses factors that will impact the future of A&E nursing in New Zealand. It notes that the population is increasing and aging, which will put more pressure on emergency departments. It also mentions issues like globalization and rules around shorter emergency department wait times. To address these challenges, the document suggests that nurses will need to work faster, improve teamwork, pursue more education, and consider roles like advanced practice nurses to work differently and help meet future needs.
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Future of ER nursing
- 1. The Future of A&E Nursing in New Zealand
- 3. Where are you? You Are Here You Want to be Here
- 10. Globalisation
- 11. Inability to Divert Patients
- 12. Need for More Space
- 13. The “Shorter Stays in ED Health Target” (or the 6 Hour Rule)
- 15. Work Faster
- 17. Work Smarter
- 20. Work Differently
- 21. Advanced Practice RNs in A&E
- 22. So What Does This All Mean?
Notas do Editor
- I’d like to thank Kay Slattery and the conference committee for allowing me to join you today How many of you here have been my students in the past? It’s so much fun to talk to “the home crowd” I’d also like to thank Margaret Dreedon for her time and knowledge, and keeping me on track about the current events in the Whangarei A&E
- A friend is driving to visit you in Whangarei. They phone to ask you how to get here. What is the first question you ask them? Where are you now?
- In order to give directions to somewhere, you need to know your present location. Let’s look at our present location within A&E nursing in order to guess at where we’re going in the future
- There are some things happening now that we know will affect our future in certain ways…
- This graph shows the current population of NZ at about 4 ½ million (blue line) Expected to grow to almost 6 million by 2060 That’s 50 years from now, we’ll all be retired by then But what about in 2025 when we are expected to reach 5 million? That’s just 15 years from now, some of you will still be working What will that do to your daily census in A&E? Waiting times? Need for physical space? Need for staff?
- This graph shows the current population of NZ at about 4 ½ million (blue line) Expected to grow to almost 6 million by 2060 That’s 50 years from now, we’ll all be retired by then But what about in 2025 when we are expected to reach 5 million? That’s just 15 years from now, some of you will still be working What will that do to your daily census in A&E? Waiting times? Need for physical space? Need for staff?
- The left margin of this chart is 2009. Currently we have a LOT more 0-14 year olds (Blue line) than we do 65+ people. (purple line) In 2026 something interesting happens—the very old begin to outnumber the very young! The cause: The baby boomer bulge (1946 to 1964 birthdates) After that time ¾ of the population will be adults, with the number of children slowly declining (65+ people don’t have many babies) How many of us here are baby boomers? If you were born between 1946 and 1964 please stand up Your career may have begun with hospital-based nursing education. You likely remember a time when nurses wore hats, gave lots of IM injections post-op, didn’t worry about universal precautions, most of our supplies were re-sterilized rather than disposable But remember, we are not only the healthcare consumers, we are the healthcare providers—The average RN age across NZ is 46.44 years -- nurses aged 46-55 are the largest age category Go ahead and sit down, you need a rest
- The left margin of this chart is 2009. Currently we have a LOT more 0-14 year olds (Blue line) than we do 65+ people. (purple line) In 2026 something interesting happens—the very old begin to outnumber the very young! The cause: The baby boomer bulge (1946 to 1964 birthdates) After that time ¾ of the population will be adults, with the number of children slowly declining (65+ people don’t have many babies) How many of us here are baby boomers? If you were born between 1946 and 1964 please stand up Your career may have begun with hospital-based nursing education. You likely remember a time when nurses wore hats, gave lots of IM injections post-op, didn’t worry about universal precautions, most of our supplies were re-sterilized rather than disposable But remember, we are not only the healthcare consumers, we are the healthcare providers—The average RN age across NZ is 46.44 years -- nurses aged 46-55 are the largest age category Go ahead and sit down, you need a rest
- The left margin of this chart is 2009. Currently we have a LOT more 0-14 year olds (Blue line) than we do 65+ people. (purple line) In 2026 something interesting happens—the very old begin to outnumber the very young! The cause: The baby boomer bulge (1946 to 1964 birthdates) After that time ¾ of the population will be adults, with the number of children slowly declining (65+ people don’t have many babies) How many of us here are baby boomers? If you were born between 1946 and 1964 please stand up Your career may have begun with hospital-based nursing education. You likely remember a time when nurses wore hats, gave lots of IM injections post-op, didn’t worry about universal precautions, most of our supplies were re-sterilized rather than disposable But remember, we are not only the healthcare consumers, we are the healthcare providers—The average RN age across NZ is 46.44 years -- nurses aged 46-55 are the largest age category Go ahead and sit down, you need a rest
- Globalisation already greatly affects NZ A&E preparations for the Swine flu, the Avian flu, antibiotic-resistant TB, etc. We don’t have to actually experience these global medical disasters for them to affect our planning and daily operations. How much time, energy, and resources have you spent on disaster preparedness in the last year? And you can’t afford not to spend it. We will never be really isolated, as long as air flights reach us as readily as now.
- Whangarei is a one-hospital town. Multiple-hospital towns are able to go on diversion (in theory, at least) when A&E is overwhelmed. We have to take whatever arrives at the door – or on the roof As St. John’s numbers go up, so will the A&E critical patient numbers
- This could be your waiting room of the future Margaret tells me the need for more space is currently one of Whangarei A&E’s biggest challenges No A&E is ever big enough, even immediately after opening a new expansion. To expand, We must compete with other hospital departments for construction funding, operating budget, out of a finite pot of money. Government financial support can’t keep up with expanding need.
- 6 hours target initiative—friend or foe? Goal: 95% of the time less than 6 hours from arrival to disposition of some sort Whangarei meeting goal 83 to 90% of the time The good result: a focus not only on A&E’s part of the process, but causes inpatient services to take responsibility for their effects on delays. Lab reporting times Queue for xrays Response time for medical specialists arrival Availability of inpatient beds
- These are the changes we can see in our future. We can’t control future events, but we can make plans to minimise their impact on our A&E, and we can control our individual response to future challenges How will we do that?
- We can try to work faster How many of you are only working at half speed? (raise your hands) How many of you have said, “I need a restful vacation, I think I’ll volunteer for extra shifts in A&E” We wear track shoes, and run from the time we enter the door until we end our shift! I can remember saying in the 1980’s “If we could just slow things down for a month or two, I’d have time to catch my breath and adjust” Nothing has slowed since then, the world has just gotten faster!
- We can maximise our use of teamwork. You are already doing that in response to the 6 hour target—getting more buy-in from in-house services to speed the process as they are able. At least now we’re all talking about it, admitting it isn’t just an A&E problem How could we increase our teamwork further? Who should decide? What can you do about it?
- We could work smarter. To do this we need to become smarter individually How do we define smarter? (more educated, more experienced, better trained) There are a number of ways of doing this.
- One is by taking appropriate post grad papers. Your new graduate program is already guiding new nurses in this direction. The Auckland University physical assessment paper is especially appropriate to A&E. Nurses assessing patients before a medical diagnosis is made happens every 5 minutes there. University Post grad certificates are a good way of acknowledging and documenting effort and learning
- Of course there are courses to take which are not university-based. These include TNCC, ACLS, PALS, etc. which certify a level of learning in a specific area without actually conferring university credits Another way would be nursing specialty certification. This isn’t happening in NZ yet, but it has been used in the USA for many years. CEN, CCRN, CFN A nursing specialty, such as A&E or Flight nursing or ICU nursing, has its own professional organisation/committee which decides on a core curriculum of knowledge specific to that specialty. Then an exam is written to test a nurse’s level of knowledge in that area. Courses are often provided which may be taken prior to the exam to increase success levels. The NZFNA already has a course developed for new flight nurses which has been very well received over the years. Who knows when a CFN certifying exam will follow? College of Emergency Nurses New Zealand could do something similar
- Sometimes we need to think about a challenge from a completely different angle. Rather than doing the same old thing the same old way and trying to do it better somehow, Why not do something completely new? In his Chief Nurse Newsletter, December 2009 , Mark Jones discussed (among other issues) the potential for expanding the RN scope of practice, and how we could determine standards for the range of new and exciting roles needed for nursing to play an ever increasingly significant part in our rapidly evolving health system. Unfortunately the response to this consultation did not reach a consensus and the Nursing Council was not given any clear direction I am reminded of a team meeting I was in where we all had to meet back at a certain time. We compared watches, and everyone had a different time. The meeting broke up with no one changing their watch No one was willing to adjust to have consensus. What this statement does tell us is that if nurses don’t decide together about scope of practice issues, someone else (doctors, politicians) will do it for you.
- Currently NZ has more than 60 NP’s in various types of practices. This great web page describes (among other things) the use of Nurse Practitioners in A&E’s in several hospitals in NZ. This practice has been used in the USA for many years. My hospital in California had a fast-track clinic attached to the triage area—simple cases were sent directly there, leaving the complex cases for the physicians in the main A&E. The nurse practitioners were completely autonomous unless they requested help from the physician. Their patient records were audited by an MD later for recommendations to their practices. You are doing something similar here in Whangarei—your senior nurses and nurse specialists have standing orders for common lab tests, xrays, etc. and can reduce the waiting times dramatically. All Whangarei patients still see a physician, but MD time is used more efficiently by the advanced preparation provided by the advanced practice nurses. Who knows? Perhaps this will be expanded when some of our local RNs become NPs.
- So what does all this mean? All A&E’s, including Whangarei—are going to experience More patients Older patients Sicker patients More pandemic scares Limited physical space Length of stay challenges Will we respond by being faster, smarter, different? All nurses born after 1965 please stand up – you are the generation following the baby boomers, generation X (birthdates 1965 to 1982) You are the future of A&E nursing What will be your response to the future challenges? You will have the opportunity to make changes to the specialty of A&E nursing, but you will have to work for it, get involved, I think you’ll be awesome—and that’s good, as you will likely be caring for the rest of us here!