By Scot Phelps
There are currently bills before the both houses of the Texas State Legislature which would permit paramedics to work in the emergency department directly under the guidance of a physician, without serving directly under the supervision of a registered nurse (House Bill 2020 and Senate Bill 1899).
In response to this bill, the San Antonio Emergency Nurses Association (SAENA) sent out a letter to all ENA members in Texas making a number of inflammatory statements regarding the role of paramedics:
1. They infer that paramedics are technicians and not clinicians who perform an assessment, make a diagnosis, and formulate and implement treatment plans. “The focus of the (paramedic) training is on skills.”
2. They infer that paramedics are “less qualified providers.” “This bill (will) encourage hospitals to utilized less qualified providers for staffing.”
3. They infer that nurses have more health care education than paramedics. “The registered nurse has) extensive preparation in pathophysiology, pharmacology, skills, and critical thinking/clinical judgment ... “
I understand that the SAENA is interested in protecting the jobs of their members and I hold emergency department nurses in the highest respect, but none of these three things are true. In fact, if nursing really wants to open that door, I think they are going to be surprised by the actual facts:
Paramedics are engaged in a delegated (but very constrained) practice of medicine; nurses are not
I am consistently amazed at the convoluted twists EMS and nursing takes to avoid stating the obvious: Paramedics are engaged in the delegated practice of medicine.
Both the American College of Emergency Physicians (“The American College of Emergency Physicians (ACEP) believes that Emergency Medical Services (EMS) is the delegated practice of medicine.”) and the National Highway Traffic Safety Administration (“EMS is a medical care system that involves medical practice as delegated by physicians to non-physician providers who manage patient care outside the traditional confines of office or hospital.”) have recognized this.[1]
This paramedic practice of medicine is not the general license granted to physicians. Instead, it is framed and constrained by multiple layers: education (the paramedic must be trained to do the skill or role), AND certification (the paramedic must demonstrate competence in the skill or role), AND licensure (the paramedic must have legal authority issued by the state to perform the skill or role), AND credentials (the paramedic must be authorized by medical director to perform the skill or role).[2]
But it is the delegated practice of medicine nonetheless, in which we perform an independent assessment of the patient, make a diagnosis, formulate (within the framework of physician-approved protocols) and implement a treatment plan, and re-assess response to treatment. Paramedics do this for a long list of emergency conditions- the National EMS Core Content has 17 pages of single-spaced conditions that are within the EMS Body of Knowledge which paramedics are responsible for understanding, diagnosing, and treating. This standard is explicitly based on the Model of Clinical Practice of Emergency Medicine of the American Board of Emergency Medicine.[3]
The State of Texas is even more specific regarding the role of paramedics versus the role of registered nurses, with the Texas Medical Board defining ‘delegated practice’ by physicians to EMS professionals as “Permission given by a physician licensed by the board, either in person or by treatment protocols or standing orders to a specific prehospital provider to provide medical care.”[4] In contrast, professional nursing in Texas explicitly excludes acts of medical diagnosis or the prescription of therapeutic or corrective measures.[5]
Paramedics are equally qualified emergency medical care providers
Paramedic education trains us to be emergency medicine specialists, while nurse education trains nurses to be nursing generalists, who acquire specialization AFTER their entry into practice. However, while we acknowledge the differences in the practice settings between the prehospital, emergency department, and intensive care setting, research by Reilly & Markenson found that the entry-level paramedic education covers approximately 90 perent of the knowledge, skills and competencies contained in nursing’s CEN and CCRN specialist certifications.[6]
There is no reason that paramedics with a deep-but-narrow education cannot be educated to provide a broader scope of practice into other pre-hospital and emergency settings in the exact same manner as nurses with a broad-but-shallow education more develop vertical specialization which encroach into the prehospital setting.
The well-accepted offshore paramedic programs, safety officer programs, and current movement toward community paramedicine are several examples of this broadening of skills, and extending our practice to full functioning in the emergency department and on hospital crash teams is natural growth. In fact, U.K. paramedics are already becoming interchangable with registered nurses in the emergency department under the uniform title “Emergency Care Practitioner.”[7]
Paramedic emergency medical education exceeds registered nurse nursing education requirements, in the Northeastern U.S., in Texas, and nationally
We know that paramedics are less likely to hold a college degree than registered nurses. According to the National Registry of Emergency Medical Technicians’ National Longitudinal EMTs Attributes and Demographics Study (LEADS ll), 43 percent of paramedics reported that their highest level of education was “some college,” 21 percent reported an associate degree, and 23 percent reported a bachelor degree.[8]
In contrast, in 2008, 13.9 percent of registered nurses held a non-degree diploma, 36.1 percent held an associate degree, and 36.8 percent held a bachelor degree.[9] Paramedic degree completion now is roughly analogous to nursing degree completion in 1980, when 55 percent of registered nurses held a non-degree nursing diploma.[9]
While degree completion may be a socially-desirable outcome, it does not, per se, have anything to do with the actual amount of emergency medical or nursing education provided to each group, respectively. We were interested in comparing the relative amount of professional education required for entry level licensure and six months ago, we completed a paper comparing paramedic emergency medical education versus nursing education at community colleges with a CAAHEP-accredited paramedic programs in the Northeast U.S. which is pending publication in the Journal of Paramedic Practice. In that paper, we looked at community colleges that had a Commission on Accreditation of Allied Health Education Program (CAAHEP)-accredited paramedic program and a Registered Nurse Associate Degree program.[10]
We looked at the actual number of college credits, taught by the department, for emergency medical and nursing courses (not general education courses like biology, sociology or math) required for completion of the two-year degree, or if no degree, the paramedic certificate. Since EMT is a pre-requisite for paramedic in virtually every program, that was included if taught for credit by the college, but not included otherwise.[11]
What we found was that, the average paramedic program was 41 credits of emergency medical education, compared to 37 credits of nursing education for the average nursing program.
Subsequently, we began a broader project to replicate the initial research for every CAAHEP-accredited paramedic program in the United States, so we had the Texas results quickly at hand. In Texas, there were a total of 29 paired paramedic/nursing programs identified. Texas paramedic programs had an average 43 credit hours of emergency medical education, while the average nursing program had an average of 38 hours of nursing education.
Only four paired nursing programs in Texas were granted more nursing credit hours than paramedic programs were granted emergency medical credit hours at the same institution. There was one institution where the same number of credit hours were granted to the nursing and paramedic program, and 24 programs where the paramedic program was granted more emergency medical credit hours than the nursing program.. These results, both in the Northeast and in Texas, are not outliers; they are mirrored in our nationwide research.
If nurses want to question our abilities, we have ample evidence to counter their claims with actual facts- Paramedics, unlike nurses, are actually engaged in the (limited) delegated practice of medicine; we have already mastered 90 percent of the professional content required for ICU and ED care. When a college had both a paramedic program and a nursing program, it offered more credit for the emergency medical education of paramedics than the nursing education of registered nurse students.
References
1. American College of Emergency Physicians. Physician Medical Direction of Emergency Medical Services Dispatch Programs. Available at: http://www.acep.org/Clinical---Practice-Management/Physician-Medical-Direction-of-Emergency-Medical-Services-Dispatch-Programs/. Accessed on: May 5th, 2015. National Highway Traffic Safety Administration. State Of Connecticut: A Reassessment Of Emergency Medical Services. Available at: http://www.ct.gov/dph/lib/dph/ems/pdf/communication_statements/2000_CT_NHTSA_EMS_Assessment.pdf. Accessed on: May 5th, 2015.
2. National Highway Safety Traffic Administration (2007) National EMS Scope of Practice http://ems.gov/ education/EMSScope.pdf. Accessed on: July 18th, 2014.
3. National Highway Safety Traffic Administration. National EMS Core Content. http://www.ems.gov/education/EMSCoreContent.pdf. Accessed on: May 5th, 2015.
4. Texas Medical Board Rules, Texas Administrative Code, Title 22, Part 9, Chapter 197.2 Definitions, (4) Delegated Practice. Available at: http://www.tmb.state.tx.us/idl/21CF17CA-9AAB-05B9-E924-01227E0694E1. Accessed on: May 5th, 2015.
5. Texas Board of Nursing. Practice - Registered Nurse Scope of Practice. Available at: https://www.bon.state.tx.us/practice_scope_of_practice_rn.asp. Accessed on May 5th, 2015.
6. Reilly, M, Markenson, D (2010) Utilizing Paramedics for In-Hospital Critical Care Surge Capacity Am J Disaster Med. 5(3): 163-68
7. UK National Health Service Gateshead Health NHS Foundation Trust job advertisement for Emergency Care Practitioner. Available at: https://www.jobs.nhs.uk/xi/vacancy/b208d6a4ff855a22fc7d7e0c2821b591/?vac_ref=913746278. Accessed on: May 5th, 2015.
8. National Registry of Emergency Medical Technicians (May 2014) Leads Update https://www.nremt.org/nremt/downloads/Appendix %20C_Longitudinal_Fact%20Sheet.pdf. Accessed on: July 12th, 2014.
9. American Association of Colleges of Nursing (2011) Nursing Fact Sheet http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet. Accessed on: July 12th, 2014.
10. Sites were eliminated if they did not have both programs, or only had Bachelor’s programs, or did not offer paramedic program for college credit, or had a LVN program and a separate LVN-to-RN program what was not integrated as a single degree.
11. At the same time, for States which have Nursing Assistant licensure as a pre-requisite for entry into a Associate Degree in Nursing programs, we also included those credits if taught by the department at the college.
About the author
Scot Phelps, JD, MPH, Paramedic. Phelps is a Professor of Ambulance Science who teaches the Ambulance Science Fellowship Programs at the Emergency Management Academy.