UT-H Students Learn About Life in the ER

It was the afternoon of injured fingers, among other things, in the emergency room at Memorial Southeast Hospital. There, three emergency nurse practitioner (ENP) students from The University of Texas-Houston School of Nursing (SON) were treating patients while receiving clinical supervision. SON faculty member nurse practitioner Elda Ramirez and physicians Victor L. Flagiello, M.D., and Hortencia Luna-Gonzales, M.D., provided clinical oversight as these nurses received advanced training in master's level emergency nursing practices.

One right after the other, two men with fingers injured in a machine shop and a home shop, respectively, had found their ways to the emergency room for treatment. One had already been X-rayed, had his finger numbed, cleaned, sutured, bandaged and had been sent home when nurse/ENP student Howard Barbour arrived.

Barbour calmly worked on the man with the home shop circular saw injury, while the injured man's daughter-in-law kept him company. Dr. Luna-Gonzales oversaw Barbour's work with the patient. She was there to provide the student with information, suggestions or physical assistance, if needed. Barbour says he enjoys emergency room nursing because it's "really rewarding. You get to see a lot of different people and different situations. The patients and families are for real, they're not wearing any masks."

Once Barbour and his fellow students complete their training in the only Emergency Nurse Practitioner program in the U.S., they will scatter to emergency rooms throughout the country where they "will do anything the supervising physician says is OK," says Ramirez. While all of these students have had previous experience in an emergency room setting, there is a difference between being an emergency room nurse and an emergency nurse practitioner, says Ramirez.

"The students have to change their thinking from the nursing model to the medical model," she says."A nurse's responsibility is care of the patient, but that care is dictated by the physician. Now, a nurse practitioner makes the decisions in collaboration with the physician." In addition, Ramirez says, the physical exam that a nurse does is thorough, but is an adjunct to the decision-making physical exam of a physician or nurse practitioner. And, while a nurse can suggest medication, a nurse practitioner can prescribe.

"The emergency nurse practitioner has to be knowledgeable from 'womb to tomb,' from OB to gerontology," she adds.

"The time was right," says Frank Cole, Ph.D., R.N., associate professor and head of the division of emergency care in the School of Nursing's department of acute and continuing care, of the early '90s decision to create the ENP program. "In the mid- to late-70s, five ENP programs existed and then closed down. The idea didn't catch on at that time because of resistance from physicians and problems with financial reimbursement.

"In 1992-93, the whole idea of nurse practitioners started to come alive, with the push for health care for all. There appeared to be a more favorable climate for an ENP program," he says. Dr. Cole, and then faculty member Cindy Able, started talking about their idea to colleagues and SON's dean, Patricia L. Starck, D.S.N., R.N.

"We have never had to deliberately recruit students," Dr. Cole says. The first class in 1994 had three students; there will be 11 graduates in 1999; and the class of 2000 has 21 students - the largest ever." He believes the strengths of the program include:

• A collegial faculty whose members are open and receptive to student comments, criticisms and perceptions;

• Having clinical sites selected and available at more than 15 sites throughout the greater Houston area;

• The amount of skills the students learn. "We are unique in that we teach invasive life-saving procedures such as chest tube insertion, wound repair, multiple layer closure (pulling the edges of uneven wounds together smoothly), lumbar punctures and central line insertions (putting an IV into a neck vein)."

So, are there any downsides to being a student in this program? It is very intensive with hundreds of clinical and classroom hours required. The students, says Dr. Cole, have to be very motivated, able to withstand a stressful, time- and labor-intensive program.

The students interviewed certainly agreed. Prior to coming to the program, Joel Mack was working in Cape Cod, Mass., as a travel nurse. "I had known someone who worked with Elda at UTMB. All the nurses at Cape Cod had heard about the program, too. I haven't worked in any other setting where I see the diversity of patients that I do here. I have to know all the specialties."

Christi Dutton has been an ER nurse for 10 years. "I had a lot of autonomy, but I was also being encouraged to learn more and do more. I didn't want to go into management, so I decided to join the ENP program. My husband says I'm an adrenaline junkie, which is probably true. I like to make a difference in people's lives."

ENPs have "a passion, not a fancy," for emergency department work, says Ramirez. And the excitement doesn't stop with the students. "It's the most exciting thing I've ever done in my life," says Dr. Cole. "Elda and I are more and more excited about the program as we see the neat things our graduates are doing out there. And we are working hard to get other universities involved in offering this type of program and helping to develop criteria for a national certification exam for emergency nurse practitioners."

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©2006 Texas Medical Center

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