The emergency nurse as a professional

This chapter from Emergency Nursing: The Profession, the Pathway, the Practice provides a broad overview of the concept of professionalism as it relates to emergency nurses.

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In the general conversational sense, professionalism is often considered in the context of the behaviors and actions displayed by a nurse during an episode of care delivery or while working in a healthcare setting. However, the concept has significantly greater and far-reaching implications that extend well beyond the time a nurse is on duty. Professionalism involves a state of mind that manifests through intentions, words, actions, and deeds. It’s intrinsically linked to an individual’s core values as a human being and is connected to a moral code that is set within the context of societal expectations for ethical practice.

In this framework, you’re a professional 24 hours a day, 7 days per week, whether you’re working or not. A public expectation of professionalism is the basis for nursing licensure: a state or jurisdiction grants a license to practice nursing as long as the individual nurse demonstrates that he or she is worthy of the public trust. Any actions by the nurse while working or off duty that call that trust into question can be reported to the professional regulatory body and can result in discipline, including license revocation.

Categorizing professionalism only in the sense of licensure, however, is extremely narrow and limited. If there were to be a professionalism scale from basic to advanced, for example, those behaviors and actions that only meet the standards for licensure would be at the most basic level. Numerous other opportunities exist to advance along the scale to progressively higher levels of professionalism. These include making meaningful contributions to the profession through ongoing self-development, accountability, mentoring, advocacy, and involvement. Although professionalism is rooted in an individual’s core values, it can be further developed through positive role modeling as well as through the learning and insights gained from lived experiences navigating complexity, conflict, adversity, challenge, and opportunity. The personal commitment to scholarship is a key component. According to Conard and Pape (2014), “Nurses demonstrate scholarly values as independent thinkers who engage in activities that advance teaching, research, and practice” (p. 88).

Professionalism is often considered in the context of goal achievement or reaching certain career milestones in nursing. Rather than simply identifying self-oriented career goals, however, Hinds et al. (2015) advocate that you develop a “legacy map” approach instead. A legacy map encompasses “the nurse’s plan to contribute knowledge, practice changes, or other aspects of health care to benefit those who receive nursing care” (p. 212). These goals are considered to be of a higher order, more enduring, and intrinsically connected to a sense of professional wellbeing that stems from improving the experiences or outcomes of others (Hinds et al., 2015).

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Use a legacy map as a personal guide to accomplish the legacy you want to leave on the profession of nursing and through your life overall. Hinds et al. (2015) suggest these key questions to explore when creating a personal legacy map:

• What do you want to be better in nursing because of you and your efforts?
• What would you like best to be known for by others?
• What do you hope your legacy will be in life?

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Given the myriad of professional opportunities available to emergency nurses today, the only real boundaries are the ones that you impose upon yourself. Howard and Papa (2012) maintain that “as emergency nurses of the future, it is essential to focus on the changing health care system, consider personal career paths, establish goals, and meet the challenge to accomplish these goals” (p. 551). This chapter seeks to explore activities that promote professionalism so that emergency nurses can map their own career path to fulfillment and success. 

Fostering evidence-based practice
There was a time not that long ago in nursing history when the accepted rationale behind nursing interventions was purely based upon concepts taught in nursing school or handed down as tradition by nursing “experts.” According to Proehl and Hoyt (2012), “…nursing practice has always been based on some sort of evidence. It just was not necessarily good evidence” (p. 1). Similarly, nursing actions were often primarily guided by physician orders. For any given disease entity or injury, there were few if any research-driven, standardized approaches to the treatment plan among the various providers. The notion of employing outcome-based methods that were supported by scientific evidence in patient care was not part of the framework for typical day-to-day nursing practice.
 
The need for rigorous scientific inquiry to evaluate the validity and effectiveness of healthcare interventions as the basis for modern-day practice has only gained widespread recognition in nursing within the last 30 years or so. Our professional culture is finally shifting to one that questions the efficacy and necessity of the strategies and methods of delivering care that frontline nurses employ. The value of research as an essential component in professional nursing practice is now well accepted and mainstream. Not only is scientific evidence required to serve as the rationale for nursing actions, but the strength of that evidence is also critiqued to give practitioners a sense of how well-supported any particular strategy is in the current literature (Rishel, 2013).
 
Times have indeed changed, but process and attitude changes have been slow to take root in day-to-day clinical practice. There are still substantial obstacles to applying research findings and incorporating evidence into practice at the point of care delivery. In a study that evaluated staff nurses’ use of research to facilitate evidence-based practice (EBP), Yoder et al. (2014) found that although nurses’ attitudes were positive about research, lack of time, resources, and knowledge were the most frequently identified barriers. They discussed a general theme in which staff nurses believed that unit educators or clinical nurse specialists—as opposed to themselves—were responsible for ensuring appropriate research utilization and incorporating EBP at the unit level.
 
Research and EBP are actually complementary but different entities. Research yields findings related to specific study questions and is a component of EBP. The concept of EBP involves reviewing research findings, evaluating the strength of the findings based on study design, and even taking into account expert opinion when research in a particular area is lacking or inconclusive. According to Yoder et al. (2014), “EBP models consider many types of evidence, including empirical research, clinical expertise, the expressed needs of patients, and the opinions of thought leaders” (p. 26). It’s clear that EBP encompasses far richer sources of information than research results or scientific inquiry alone. Of significance is the integration of professional expertise, science, and patient-centeredness into the EBP construct. In this regard, Salmond (2007) nicely summarizes EBP in the following manner:

Evidence-based practice (EBP) requires a shift from the traditional paradigm of clinical practice grounded in intuition, clinical experience, and pathophysiological rationale. In the EBP paradigm, clinical expertise is combined with integration of best scientific evidence, patient values and preferences, and the clinical circumstances. (p. 114)

Following clinical practice guidelines
Ultimately, expert critical thinking is required to synthesize evidence into models or clinical practice guidelines (CPGs) that can be applied directly to patient care.

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Clinical practice guidelines—Documents that provide the framework to care for a particular clinical situation. Clinical practice guidelines provide an assessment of the benefits and harms of alternative care options and help to optimize patient care by standardizing care based on scientifically sound research.

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Emergency nurses on the frontlines can support true EBP in a variety of ways. Using CPGs that contain the best available evidence to inform clinical decision-making is essential. CPGs serve to facilitate the translation of EBP into actual care delivery at the bedside (Clutter, 2009). Emergency nurses “…should have foundational knowledge of EBP CPGs and deliver care using EBP guidelines” (Clutter, 2009, p. 460). Because the quality and strength of the evidence are of paramount importance, pre-appraised evidence sources are available that have been rigorously evaluated to help busy frontline clinicians (Salmond, 2007). An excellent public resource that contains a very large collection of evidence-based CPGs is the National Guidelines Clearinghouse, sponsored by the Agency for Healthcare Research and Quality (AHRQ), available online at http://www.guideline.gov (AHRQ, n.d.). You can access this site, search, and download CPGs across a wide range of healthcare topics. The strength of the evidence to support interventions listed in the CPG is included. This site is an excellent repository of high-quality information that you can utilize instead of reinventing the proverbial wheel when the need arises for a new or updated CPG in your own practice setting.

 Other valuable sites that offer access to a variety of evidence-based CPGs include: 

• Centers for Disease Control and Prevention (CDC), which focuses on public health and disease prevention. This website can be accessed at http://www.cdc.gov/.
• U.S. Preventive Services Task Force (USPSTF), which contains recommendations for preventive health services, can be accessed at http://www.uspreventiveservicestaskforce.org/.
• The Emergency Nurses Association (ENA) has a dedicated “Practice Resources” section on its website that provides a host of excellent materials for EBP, including CPGs, position statements, standards of practice, and tool kits to help emergency nurses elevate their practice. These resources can be accessed at https://www.ena.org/practice-research/Practice/Pages/default.aspx.

Searching evidence-based literature
Given the rapid pace of scientific advancement, you should strive to engage in practice with an open, inquiring mind that formulates questions and pursues answers to clinical and operational questions through searching evidence-based literature. Conard and Pape (2014) suggest that “nurse scholars immerse themselves in the literature and become experts in their topic” (p. 88). No longer should you simply accept at face value what is told to you as fact; nor should you depend upon long-held beliefs or view rituals in patient care as sacred truths. Salmond (2007) provides a different and much more robust EBP framework in which to consider all aspects of professional nursing care delivery:

The new values of EBP call for all practitioners to adopt a mindset of informed skepticism. The EBP clinician asks the wicked questions: Why are we doing it this way? Is there a better way to do it? What is the evidence for what we do? What practice guidelines are available to support my practice? Would doing this be as effective as doing that? and What constitutes best practice? (p. 118)

To stimulate professional growth and foster a vibrant practice environment at work, you can pose such clinical questions or controversies and share results of the literature review with colleagues at staff meetings or through unit-based newsletters. Forming an ED journal club is an excellent strategy to communicate information from the literature, promote evidence-based practice, introduce the value and evaluation of research, and build interprofessional collaboration skills (Rishel, 2013). Questions can be developed which help to guide you in a critical review of the articles selected for discussion (Rishel, 2013). In this way, the staff-at-large can participate to the degree that they are comfortable, and new information can be appraised and carefully considered for possible integration into practice.
 
Applying research to the bedside
The critical competency for emergency nurses is the ability to effectively translate the results of evidence-based research from the literature to the bedside (Carman et al., 2013). Even though the study results might indicate that a particular intervention, process, or practice appears to be successful, Carman et al. (2013) caution that the quality of the study, the efficacy, and the applicability of the findings to a particular emergency department setting have to be carefully considered; the “fit” may or may not be appropriate, and adjustments may be necessary before implementation is attempted. Otherwise, unrecognized or under-appreciated differences in the ED environment from the study setting (such as the physical structure, culture, policies, resources, and politics) can affect the success of translating the research into practice. Similarly, Wolf et al. (2013) warn that practice changes are typically not made based upon a single study alone: “One should not take a single study and use the results to implement change, unless the study is so large and so well done that professional practice organizations are suggesting changes” (p. 199).
 
An excellent strategy to stimulate interest in evidence-based practice and apply the findings in the clinical setting is to have research experts involve emergency nursing staff directly in a research project. Based upon their interest and aptitude, staff can be invited to participate in any phase of the study process, from reviewing the literature to assisting research experts with study design considerations, implementing the intervention, collecting the data, or analyzing the results. Tanabe, Gisondi, Barnard, Lucenti, and Cameron (2009), for example, found that a staff-based participatory research methodology led to positive operational changes as a result of having charge nurses help to design, implement, and evaluate a process that involved closing the ED waiting room during certain hours of the day.
 
Academic teaching hospitals, particularly those that have achieved Magnet® designation, often employ PhD-prepared nurse scholars who can guide the design of a research project and help to obtain the necessary institutional review board (IRB) permissions to conduct the study. In Magnet® hospitals, these nurse scholars can advise and facilitate the work of frontline nurses who are members of evidence-based practice councils or research councils. Emergency nurses certainly have the option of joining these councils if they have a sincere interest in research, or they can participate in approved research by serving in a data-collection capacity. For the majority of hospitals that do not have research experts readily available, developing partnerships with nursing faculty in a university setting can be mutually beneficial for both the healthcare facility and the academic institution. When information on a particular subject is lacking in the literature, you can then pose a study question to experienced faculty as a means of stimulating a possible collaborative research effort.
 
ENA also has an Institute for Emergency Nursing Research (IENR) that promotes EBP through advancing research efforts in emergency nursing. Its website (https://www.ena.org/practice-research/Pages/about.aspx) includes a listing of both current and completed research studies, CPGs, research priorities, requests for feedback via surveys, external research and funding opportunities, and white papers. In an article series written by members of IENR’s Advisory Council to stimulate bedside nurses’ interest in and understanding of research and EBP concepts, authors made a compelling argument as to why research is essential on the frontlines of care delivery: “As the most direct person providing care to persons in their most dire hour of need, it is imperative that we ask the questions, find the evidence, and translate it into the best of care” (Wolf et al., 2012, p. 591).
 
Seeking lifelong learning/maintaining competency
The pursuit of continuous learning is not only an obligation to maintain competency, but also the cornerstone of professionalism in emergency nursing. The Institute of Medicine’s (2011) Future of Nursing report specifically cited lifelong learning as an essential component of nursing practice. Given the rapidly evolving healthcare system, professional and societal expectations also dictate the need for nurses to pursue lifelong learning (Rishel, 2013). It’s important to recognize that lifelong learning and competency are fundamentally related. The Emergency Nurses Association’s (ENA) Code of Ethics (2015a) explicitly identifies your obligations related to competency by stating, “the emergency nurse maintains competency within, and accountability for, emergency nursing practice” (p. 1). However, Harding, Walker-Ciollo, Duke, Campos, and Stapleton (2013) assert that “competence occurs not in isolation but needs to be tailored to the current best evidence, quality initiatives and indicators, and safety” (p. 255). Because maintaining competence is a duty for the duration of your career, and the science that underlies nursing theory and practice is being constantly updated, a commitment to lifelong learning is vital. As new knowledge is integrated into the literature and incorporated into standards of care, you must “remain abreast of new technology, treatments, and trends across health care” (Howard & Papa, 2012, p. 551).
 
In the fast-paced, highly acute, and complex world of emergency nursing, lifelong learning is especially relevant because the scope of practice encompasses the full range of illness, injury, and associated human responses from birth through death across the entire age spectrum. The knowledge necessary for expert emergency nursing practice is extremely broad. Because you deliver care to patients at some of their most vulnerable periods, time is often of the essence. You must possess a ready, actionable knowledge base that is up to date. Your initial actions can directly affect patient outcomes by what you do, or do not do. Harding et al. (2013) categorize emergency nursing competencies in the context of specific ED processes such as triage, the use of assessment tools like the Broselow Tape, and the ability to utilize commercial products such as a high-volume fluid infuser. Remaining current in regard to assessment techniques, priority setting, care delivery standards and tools, the patient’s anticipated clinical course, diagnostic modalities, and outcome evaluation is critical to safe and effective nursing practice.
 
Equally important to safety and overall professionalism are the competencies related to maintaining collaborative inter- and intradisciplinary relationships, risk management, hand-off communication and care transitions, as well as efficient emergency department operations. All together, these aspects of the emergency nursing role clearly dictate the need for ongoing education to inform professional practice. You must make a conscious effort to assess your learning needs in an ongoing manner to have an accurate sense of the type of educational opportunities that you need to pursue. Scholarship and self-directed learning are hallmarks of professional practice.
 
Approach to learning
Your core attitudes and beliefs about lifelong learning as a professional obligation are key determinants of professional success. From a worldview perspective, you may perceive learning as either a burden or a growth opportunity. This worldview influences whether you approach educational experience passively or actively:

• In the passive approach, an educational activity is a job or licensure requirement that must be accepted, tolerated, or even endured. You only participate because you know the activity is required and not participating would likely result in a negative consequence. However, depending upon your overall interest in the topic and the effectiveness of the educator in stimulating new ways of thinking or practicing, your degree of engagement with the learning activity may be negligible.

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  “Individual professional development starts when nurses acknowledge that they must be a lifelong learner” (Rishel, 2013, p. 539).

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• In the active approach, you enter the learning event with an openness and intellectual curiosity that enables critical thinking and integration of new knowledge into practice. You also seek opportunities for ongoing learning. With an inquisitive mind, you pursue answers to the question why in clinical practice and research best practice approaches using high-quality, evidence-based resources and appropriate point-of-care references. An active pursuit of learning is both in the moment as well as deliberately planned to incorporate a variety of educational opportunities over the course of a career.

Learning venues
There are multiple formal and informal learning venues for emergency nurses. These include hospital-based in-service education, both of the mandatory and elective varieties; conferences external to the healthcare institution; and academic programs that lead to a BSN, MSN, MBA, or doctoral degree (DNP or PhD). All certainly have significant value. Ideally, you should take advantage of the offerings as your professional needs, time, resources, and personal circumstances allow. Technology has added to the repertoire of available options. In the past, nursing education has been offered in lecture-based formats for learning. However, many nurses expressed a clear preference for hands-on or case-based learning opportunities. The growing popularity of simulation labs both in nursing schools and in hospitals speaks to the value of both learning and applying new knowledge in a realistic clinical scenario. High-fidelity manikins offer opportunities for full participant engagement in the scenario and hands-on competency development in relation to acquiring or honing practical skills. The use of healthcare actors who play a patient role provides nurses with challenging situations in which interpersonal communication skills may be challenged and ultimately improved. These types of learning experiences are frequently conducted using teams that include physicians, nurses, and allied health personnel to promote more effective teamwork, collaboration, and the development of interdisciplinary competence in patient care.

Stepping outside of your institution to attend local, regional, or national conferences, such as the Emergency Nurses Association Annual Conference, brings significant benefits. You have the chance to update your knowledge base regarding the latest developments and thinking about current topics in emergency nursing. You can also derive value by networking with colleagues from other facilities who may be dealing with similar issues or challenges. Professional relationships can form, which can evolve into long-lasting connections that are beneficial over the course of your career.

If the conference attracts international participants, you can come away with a very well-rounded view of current emergency nursing challenges and how they are addressed on a more global scale. Learning about the nursing or healthcare issues in another country helps place perspective on the significance of the issue and enables innovative approaches to problem solving. It’s especially interesting and often eye opening to learn of the resource constraints that exist in other healthcare settings and how other emergency nurses deal with the situation. This cross-cultural exchange supports rich dialogue, deeper professional connections, and the ability to look outside of the usual ways of thinking about issues.

Funding learning opportunities
Unfortunately, institutional funds to support emergency nursing education may be limited in many settings. When they are available, the employer may only fund attendance at facility-based or local educational events. Participation in a regional or national conference often requires that you finance part or all of the expenses out-of-pocket. Typical costs include travel, meals, incidentals, as well as the fees associated with conference registration and any special pre-conference workshops. Although these costs may be prohibitive, several effective strategies can help to manage the financial impact:

• Set up a workable personal savings plan to fund attendance at a high-quality conference every 1 to 3 years. This strategy entails the ability to create a realistic budget for conference participation as well as the discipline to save the necessary amount of money, factoring in possible price increases.
• Itemize taxes to deduct costs as business or professional expenses. Personal recordkeeping is essential in this endeavor to show evidence of and validate legitimate tax-deductible expenses.
• Utilize frequent flier miles or hotel points that are part of brand loyalty plans to reduce conference travel costs. Check to see whether local hotels have arranged for reduced rates for those attending the conference. You could also consider sharing a hotel room with colleagues as a cost-saving measure.
• Join a professional organization that provides membership discounts for conference attendance. A benefit of active participation at the local chapter level is that it sometimes comes with opportunities to apply for conference scholarships. There might also be an option to serve as a chapter delegate at the conference itself with funding from the organization, particularly if you are a chapter officer.

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  The Internal Revenue Service (IRS) allows many legitimate educational expenses to be deducted from a nurse’s income, reducing the amount of income subject to tax. To qualify, the education must be required either by law or the employer to keep present salary, status, or job and serve a bona fide business purpose to the employer or maintain/improve the skills needed to work as an emergency nurse (IRS, 2015). It’s important to work closely with your tax professional to ensure that all deductions meet the requirements of the law.

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• Apply to be a poster presenter or podium speaker. Such participation, particularly as a speaker, frequently leads to reduced or waived registration fees and perhaps even reimbursement for selected travel expenses within specified limits by the conference organizer.
  
  The other benefit is the lifelong-learning opportunity to develop or refine skills in poster presentation, public speaking, and even publication that arise from this level of conference participation.

Completing an academic program
Academic programs are very much a part of a successful educational plan for lifelong learning. Pursuing baccalaureate education is a must if your entry-level nursing education was from a diploma or associate’s degree program. The American Nurses Credentialing Center (ANCC, 2013) requires that all hospitals seeking Magnet® designation or re-designation must achieve an 80% rate of baccalaureate education in the nursing staff by the year 2020. Not having a baccalaureate degree in nursing will serve as a significant rate-limiting step for both jobs and career-enhancement potential. Nursing employers, particularly those with Magnet® hospital designation, may offer some degree of tuition assistance to offset the costs of returning to school.

The baccalaureate degree is the springboard into master’s, doctoral, and post-doctoral academic programs. Deciding how far to go in the academic realm is determined by your career aspirations and the corresponding formal educational preparation requirements. As you move through your career, scholarly aspirations may shift in different directions as new interests develop and personal or professional needs change. The key to success is to plan so that no barriers stand in the way of moving from one educational level to the next when the time is right. That means maintaining excellent grades, building lasting professional relationships with faculty, and selecting quality academic programs that support seamless transitions.

Gaining certification
Certification in a nursing specialty area represents an objective mark of professional excellence and commitment for the emergency nurse. In the broad perspective, it validates that you’ve successfully acquired an up-to-date body of knowledge, skills, and experience that encompasses the scope and standards of practice for a particular nursing specialty (Rishel, 2013). Certification engenders a measure of professional recognition and achievement for the recipient. In that context, it may be a requirement for advancement or promotion if your healthcare facility has a nursing leadership structure that offers a formal clinical ladder. Attaining certification might also entitle you to receive a certification pay differential or a higher salary overall.

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According to the Board of Certification for Emergency Nursing (2015), more than 30,000 emergency nurses are currently certified.

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The healthcare institution also benefits from employing certified nurses. Certification serves as tangible evidence of your commitment to and individual responsibility for professional development (Kaplow, 2011). A high rate of professional certification is very favorably viewed and even expected by a number of hospital accrediting agencies such as The Joint Commission, the American College of Surgeons Consultation and Verification Program for trauma centers, and the American Nurses Credentialing Center’s Magnet Recognition Program®. Patient outcomes are also positively affected: Kendall-Gallagher, Aiken, Sloane, and Cimiotti (2011) found that for every 10% increase in hospital nurses who had both their BSN and professional specialty certification, the risk of 30-day inpatient mortality and failure to rescue decreased. However, Altman (2011) found that some key barriers can negatively affect certification rates in the hospital: “Fear of test-taking or failure and lack of resources or organization recognition are reasons many nurses cite for not becoming certified” (p. 68).

Professional certification requirements vary depending on the type of specialty exam but typically include a practice requirement in the specialty, passing a standardized test, and either periodic re-testing or maintaining a specified composition of continuing education credits and professional activities, such as presentation or publication in every certification review cycle. Recertification intervals are dictated by the certifying body and generally fall in the 3 to 5 year range. Some certifications also mandate specific academic credentials like a bachelor’s degree or master’s degree in nursing as a qualifier to sit for the exam. For example, certification as a clinical nurse specialist or nurse practitioner requires a graduate degree in the appropriate nursing specialty area.

Each certification exam has its own unique application process and fee schedule. The application includes standard demographic and academic information. It may also contain questions about your practice setting and license or registration number. An unrestricted registered nurse (RN) license is an admission requirement. Depending on the exam, practice hours or years of service may be either recommended or required as a qualification to sit for the exam; a nursing supervisor signature may be needed to substantiate that the applicant has attained the specified work experience. Application fees vary by exam type and usually fall within a $200 to $400 range. If the certification exam is associated with a particular professional nursing organization, discounts on testing fees are usually available as a benefit for active membership. Some hospitals do offer reimbursement for exam fees and preparation expenses associated with the exam as both an incentive and a reward for successfully passing the test. In the same manner, institutions may also reimburse the expenses related to recertification.

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Unrestricted license—A license to practice nursing without active disciplinary action by the professional licensing board.

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Once the application is processed, you’re sent a letter or electronic communication confirming that you can sit for the exam. Also included in the correspondence is pertinent information about how and where the test is offered and any special requirements such as having a valid driver’s license with picture identification available for admittance to the testing site.

Although some exams may still be offered in a paper and pencil format, the most common testing modality is via the computer in a designated, proctored testing center. Fear of test-taking is a common concern among nurses (Teal, 2011). The most important success strategy is devoting sufficient time and effort to test preparation. Exam preparation books, sample questions, review courses, and other educational resources should be obtained well in advance of the testing date to support test-taking readiness. Forming a study group is another excellent strategy to facilitate learning as well as build a peer support network for two or more emergency nurses studying for the same exam.

Another common option if you have specialized training in forensic nursing is to obtain the Sexual Assault Nurse Examiner–Adult (SANE-A) and/or Sexual Assault Nurse Examiner–Pediatric (SANE-P) certification through the International Association of Forensic Nurses. There are also several certification exams available that cover a wide range of nursing specialties and have relevance to various aspects of emergency nursing practice, including adult or pediatric critical care nursing, gerontological nursing, nursing leadership, staff development, as well as a host of advanced practice certifications if you have a graduate degree. As long as the requirements are met for initial certification or recertification, you can achieve a number of certifications to represent your expertise. The challenge becomes the time, effort, and expense in maintaining all of them.

Adhering to institutional policies and procedures
As an emergency nurse, you have a professional obligation to maintain knowledge of the institutional policies and procedures that govern practices and operations in your workplace. These policies and procedures are often established to meet regulatory requirements set forth by federal, state, and local government agencies as well as hospital accrediting bodies such as the Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and the American College of Surgeons Committee on Trauma. Other policies and procedures may be connected to standards of care based on evidence-based practice sources as well as institutionally derived protocols and processes. At the most basic level, knowledge of the laws that govern nursing practice as well as institutional policies, procedures, and processes is an important defense against professional liability (Balestra, 2012).

In that regard, failure to follow institutional policies and procedures can lead to personal, professional, and institutional liability; regulatory consequences such as institutional citations or de-accreditation; and employer sanctions up to and including termination of employment. An important caveat, however, is that an institutional policy or procedure cannot override federal or state law or regulations if the documents are at odds. Laws and regulations supersede hospital policies.

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For example, if the Nurse Practice Act in a particular state does not allow nurses to delegate intravenous catheter insertion to unlicensed assistive personnel (UAP), but a hospital policy authorizes this practice, the nurse who follows the hospital policy could be found guilty of professional misconduct by the nurse licensure board.

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Given the vast number of policies and procedures in most institutions, it’s typically not possible to retain detailed information about all of them through memory alone. It’s your professional responsibility to know how to locate the relevant policies and procedures and consult them as needed to inform practice and ensure that care delivery conforms to institutional expectations. The professional obligation does not stop there, however. In cases when the policy or procedure does not adequately address the issues at hand, use the ED’s administrative chain of command to seek expert clarification of the appropriate course of action when needed. In this case, you’re in an optimal position to raise awareness about gaps in policies and procedures that demonstrate the need for policy revision or development, and also participate in the effort to update or create the document based upon a review of current standards or best practices in the literature. This effort gives you an excellent opportunity to expand your knowledge base on the subject matter, take a leadership role in problem resolution, and become a resource for other staff on the topic. If the policy or procedure is not available at the point of care in a user-friendly format, you can also advocate for system changes that improve access to essential information when it is most needed in clinical practice.

Though the rationale underlying most institutional policies and procedures is rooted in good intentions, some may impose barriers to appropriate care delivery or add unnecessary burden. With that said, the policies or procedures cannot simply be ignored. Change is needed. When the policy or procedure is institutionally derived and not based on accreditation, regulatory requirements, or the latest best-practice evidence, the process simply requires that you make the effective argument for revision to the institutional leader(s) who maintain(s) the documents. Having data, current literature, or expert opinion to support your recommendations enhances the strength of your argument for change. This revision process may still take significant time, especially if new processes have to be developed, reviewed, tested, signed-off on by all key stakeholders, and then successfully disseminated to staff. If the policy or procedure that requires modification is linked to a regulation or statute promulgated outside of the healthcare facility, the change process is much more complex and time consuming. It may require statutory change that ultimately must undergo legislative action. The take-home point is that if you see a need for modifications in institutional policies and procedures, an important aspect of professionalism is advocacy for positive change.

Serving on institutional committees
Having the opportunity to serve on an institutional committee can significantly contribute to your professional growth. Emergency nursing leaders are often asked by organizational leaders if they can appoint one or more members of their staff to institutional committees or work groups. These committees are generally focused on system-level concerns that may also be relevant to various aspects of emergency care or operations. You can offer critical insights as an emergency nurse into issues as well as support the development of organizational strategies and goals. At the same time, “…soliciting staff input on goals, specific targets, and solutions may lead to an overall sense of ownership and investment,” inspiring a culture of shared responsibility for achieving organizational goals in frontline nurses (Berkow et al., 2012, p. 167). Emergency nursing leaders may solicit participation from the nursing staff-at-large and then appoint a nurse in good standing who volunteers. The leader might also choose to select a nurse who has previously expressed a specific goal or interest area that fits well with the committee’s mission or purpose, or one who has demonstrated a complementary skill or competency that will prove valuable to the committee.

Becoming a committee member enables you to step outside of the ED worldview, build new connections, and gain a broad-based perspective on issues pertinent to the healthcare facility, the community, the state, and perhaps the nation. This perspective can help you better understand key organizational initiatives and decisions as well as translate their relevance to ED co-workers. At the same time, your professional perspective contributes to a more robust approach to strategic analysis, planning, and problem resolution, especially when committee goals, objectives, or issues touch upon the ED in some way. Needleman and Hassmiller (2009) corroborate the value of frontline nurses’ participation in decision-making:

Nurses develop substantial knowledge of the strengths and weaknesses of hospital systems and how they fail … nurses’ perspectives must be represented at the highest levels of hospital leadership and integrated into hospital decision making. In addition, consistent with process-improvement research that identifies the active involvement of front-line staff as a critical factor in making and sustaining change, processes for engaging nurses and other front-line staff also need to be expanded. (p. w627–w628)

When considering an appointment to an institutional committee, you should make a sincere effort to understand the goals and objectives of the group, as well as all of the expectations of the members, ahead of time. If the requirements do not appear feasible, it’s best not to accept the appointment and allow another representative who can meet the expectations to serve.

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Common areas of focus for institutional committees that you may participate in as an emergency nurse include access to care, hospital operations, quality and safety, process improvement, infection prevention, human resources, patient flow, standardized care pathways, nurse staffing, employee engagement, electronic medical records, and accreditation.

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To be successful as a member of an institutional committee, you should engage in professional meeting etiquette. It’s extremely important to be present for the duration of each meeting. Depending on the committee, there may be a set standard for attendance. Failing to meet that standard can mean loss of membership. A proactive conversation with the ED manager or scheduler about the meeting requirements may help prevent scheduling issues. Like attendance, punctuality is expected. Although circumstances that cannot be predicted do occur, making a habit of arriving late is disruptive to the meeting proceedings and results in missing agenda content.

Expectations for behavior or ground rules are typically set by the meeting chair or through consensus with meeting members. Some meetings have a much more formalized structure based upon their purpose. For example, an institutional grievance committee or peer review forum may be run with a very rigid framework to ensure that all required administrative steps are taken in compliance with bylaws, hospital regulations, and any applicable employment laws. Similarly, institutional committees that include members of the board of directors or public officials may be run in a more conservative manner. On the other hand, there are also highly dynamic institutional committees where dialogue flows freely and the active exchange of thoughts and ideas is encouraged. Time is often allocated to discuss any issues that are not listed on the agenda in an open forum format.

The manner in which you conduct yourself at meetings can add value or detract from interactions at the table. During the meeting itself, you should be actively engaged in the proceedings. Set electronic devices to silent mode. Unless absolutely necessary, avoid checking email and text messages. If you anticipate multiple phone calls, arrange to have your phone calls covered while in the meeting. If you must answer a phone call, step away from the meeting so that the conversation cannot be heard. Direct your attention to those speaking. Body language should not convey disinterest, negativity, or hostility, no matter what the nature of the topic. If you have concerns about what is being said, ask clarifying questions and voice specific concerns in a professional manner when it is appropriate to do so.

Although you provide perspective on emergency department issues, it’s important to take a balanced and wide-lens view to avoid being perceived as rigid or argumentative when challenging topics are raised. Focusing narrowly on how your ED has always done something as opposed to what might be a national best practice can inhibit effective dialogue and, ultimately, improvement efforts. At the same time, if the committee recommends actions that would pose significant concerns or will require changes in ED processes, you should enlist the active involvement of ED leaders as key stakeholders in the overall approval process. They can provide input and guidance, leverage resources, and plan strategies to facilitate the rollout of any mutually agreed upon process changes. If you’re given an assignment with specific tasks to be completed (often referred to as deliverables) and an update or report is anticipated at the meeting, you are expected to either follow through or notify the chair in advance of any barriers or delays. The committee chair may be able to help you get the work done if aware in advance.

Overall, although taking on the responsibilities of committee membership will increase your workload, the professional benefits are significant. They include the satisfaction of having a designated place at the table in institutional decision-making, the opportunity to develop relationships and network with a wide variety of leaders and employees from other areas of the hospital, a chance to see healthcare from a wider perspective than may be experienced in a single department, and the chance to gain skills in problem solving and strategic planning. Serving on the committee builds personal leadership abilities and may qualify you for a higher performance rating or advancement on a clinical ladder. Participation can also help to position you for a new avenue in your career. For the healthcare facility engaged in quality initiatives, active nursing participation yields the best opportunity for successful outcomes. Needleman and Hassmiller (2009) assert that “improvement must be institutionalized in the day-to-day work of the front-line staff, with adequate time and resources provided and with front-line staff participating in decision making” (p. w631).

Joining professional organizations
Joining a professional organization is a voluntary activity that demonstrates your desire to connect with a nursing generalist or specialty group external to your workplace. In this regard, it can be viewed as evidence of commitment to the profession beyond that which is expected by the employer. According to Guerrieri (2010), “a professional organization often is the public image of the specialty or profession” (p. 47). Professional organizations perform several valuable functions for the members they serve. These functions vary somewhat with each individual group’s mission and scope but generally have several roles in common:

• A forum for members to exchange ideas and collaborate through meetings, online forums, and blog posts
• Collective efforts to improve nursing practice
• Continuing educational opportunities
• Standards of care for generalist or specialty practice
• Areas for research as well as research funding opportunities available through grants
• Political advocacy and actions that support the mission of the organization

Many professional organizations also offer a complementary subscription to newsletters or a general or specialty journal. Other typical benefits include discounts on books and a variety of personal and professional resources (e.g., discounts on continuing education courses, certification fees, liability insurance, and home/auto/life insurance). The organization may also establish a clearinghouse or repository for institutional policies, procedures, protocols, and templates as resources for members trying to avoid “reinventing the wheel” when developing these documents for their own facilities.

Joining is generally very straightforward for most professional organizations—you usually only need to complete a membership application and pay the dues. For some professional organizations, however, membership is only granted after you meet specified criteria and are accepted through a specific review process, which may include having letters of endorsement or sponsorship from other active members. A good example of such an organization with restricted membership is Sigma Theta Tau International, the Honor Society of Nursing.

Membership in a professional organization demonstrates commitment and a willingness to be involved on a professional level beyond the typical workplace responsibilities. Joining is a voluntary act—you’re choosing to support the mission of the organization through membership. By joining, you gain the membership benefits offered by the group and also support the mission of the organization through paying dues, making charitable contributions to fund special projects, and through active participation in the group’s undertakings. Because strength lies in numbers, each individual member adds to the collective power of the organization. For those professional organizations that have local chapters, the opportunities for involvement increase and make active participation more feasible for some nurses.

The benefits you derive from a professional organization are very much dependent on your degree of involvement. You can choose to simply pay the dues each year and enjoy the publications, membership discounts, and continuing education offerings. This level of involvement is important and does support the organization through yearly dues but does not fully leverage all of the opportunities that a group offers. If you’re a member of multiple professional organizations, choosing to only be a dues-paying member for some may be very reasonable, especially if you’re highly involved in committees or projects of a particular organization at a local or national level.

Direct participation in the professional organization’s meetings and events enables active networking, socialization, peer support, and leadership development (Guerrieri, 2010; Rishel, 2013). Socialization helps to instill professional values and perspective. You gain insights that extend beyond your workplace and find that many issues are actually quite common in the emergency environment or within the profession as a whole. In fact, there may be opportunities for collaboration to address shared concerns through local or national committee work. Collaboration confers a sense of professional satisfaction that stems from helping to shape the organization’s direction or even by influencing health policy. In this regard, professional organizations serve to both inform members of current health policy or political issues and enhance their abilities to advocate (Wilmot, 2009). The Emergency Nurses Association (ENA), for example, nominates members to serve on federal advocacy groups and supports them through leadership education to enhance their confidence and competence in the political process (Howard & Papa, 2012).

Active involvement offers additional leadership development opportunities as well. Becoming an officer of the organization and engaging in governance activities at the local chapter, region, or national level builds leadership and administrative competencies. Achieving publication in the organization’s journal confers professional recognition (Guerrieri, 2010). Likewise, annual conferences provide avenues for members to present posters or podium lectures and gain professional speaking experience. Exposure to professional achievement at these venues can inspire new goals for your own professional accomplishment (Guerrieri, 2010).

Professional organizations can be intradisciplinary or interdisciplinary:

• Intradisciplinary organizations include members from only one discipline, such as nursing. Some intradisciplinary organizations may extend associate memberships to individuals from other disciplines. Similarly, a nursing professional organization can have a generalist focus and address issues that span the universe of nursing practice and serve to elevate the profession as a whole, or it can have a specialty focus and concentrate on a particular area of nursing practice. An example of an intradisciplinary, generalist nursing organization is the American Nurses Association.
• Interdisciplinary organizations allow membership by a variety of disciplines (e.g., physicians, nurses, pharmacists, paramedics, etc.). An example of an interdisciplinary, specialty organization is the American Trauma Society.

Deciding what type of organization to join really boils down to your personal and professional goals. Ideally, the best option is to choose one or more professional organizations whose mission and member benefits align most closely with your interests and needs. There are several excellent and well-established professional organizations that are relevant to the specialty of emergency nursing.

The following list of professional organizations for emergency nurses is by no means all-inclusive or exhaustive but provides a flavor of the professional membership choices available for emergency nurses. Membership and active involvement at the local chapter level of a national professional organization may offer a more personal experience as well as the chance to directly influence chapter functions and strategic directions. This level of participation is exceptionally rewarding due to the peer interaction opportunities and the deep sense of accomplishment that stems from elevating emergency nursing practice.

Emergency Nurses Association (ENA)
The ENA is a widely recognized national intradisciplinary specialty organization for emergency nurses. This organization has a long and robust history of offering professional education to emergency nurses in support of lifelong learning (Howard & Papa, 2012). It also provides myriad opportunities for professional growth and development, as well as numerous resources and initiatives to elevate emergency nursing practice. ENA’s official scientific publication is the Journal of Emergency Nursing. ENA is also the national provider of the Trauma Nursing Core Course (TNCC) and the Emergency Nursing Pediatric Course (ENPC).

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To learn more about the mission, resources, and activities of the Emergency Nurses Association, visit the website at www.ena.org.

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Society of Trauma Nurses (STN)
The Society of Trauma Nurses (STN) is a national intradisciplinary specialty organization devoted to trauma nursing and improving trauma care delivery. This organization recognizes that “trauma nurses” work in a wide variety of settings across the trauma care continuum, from the pre-hospital realm through rehabilitation, injury prevention, and education. The emergency nurse who provides care to trauma patients in his or her ED would be viewed as a trauma nurse by this society. Like the ENA, STN offers its members substantial resources, education, and opportunities for involvement in a broad spectrum of activities related to trauma care. STN’s official scientific publication is the Journal of Trauma Nursing. STN also provides the Advanced Trauma Care for Nurses (ATCN) course, which runs in conjunction with the Advanced Trauma Life Support Course for physicians.

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To learn more about the Society of Trauma Nurses, visit the website at www.traumanurses.org.

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International Association of Forensic Nurses (IAFN)
Some EDs have a forensic nurse examiner (FNE) team to both improve care delivery and evidence collection/preservation procedures for patients who are victims of sexual assault, domestic violence, child abuse, and elder abuse. Depending on the scope of the FNE program, these emergency nurses may also become involved in evidence collection/preservation during trauma resuscitation for patients who have sustained interpersonal violence, including gunshot wounds and stab wounds. The International Association of Forensic Nurses (IAFN) is a national nursing specialty organization that provides education, training, practice resources, and professional connections to forensic nurses. Their official scientific publication is the Journal of Forensic Nursing. They offer sexual assault nurse examiner (SANE) training and certification to nurses.

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To learn more about the International Association of Forensics Nurses, visit the website at www.forensicnurses.org.

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Influencing legislation
Involvement in the political process as an advocate for legislative action or regulatory change is an important aspect of the emergency nurse’s role. Understanding the political system and gaining skills in serving as a change agent in this arena enables you to expand your sphere of influence and make a positive impact on the profession as a whole or at a population level. Legislative action is a very effective strategy to hardwire change when other approaches fail. Whether you engage in advocacy activities to improve some aspect of health for individuals or direct efforts to better working conditions for nurses, the outcome can ultimately benefit patients (Oestberg, 2012). The key professional competency for effective advocacy is your ability to influence others. The American Nurses Association (ANA) Code of Ethics for Nurses defines advocacy as “the act or process of pleading for, supporting, or recommending a cause or course of action,” and further states that “advocacy may be for persons (whether as an individual, group, population, or society) or for an issue, such as potable water or global health” (ANA, 2015, p. 41).

Nurses must lead, serve, and mentor on institutional or agency policy committees within the practice setting. They must also participate as advocates or as elected or appointed representatives in civic activities related to healthcare. (ANA, 2015, p. 28)

The first step in any legislative involvement is recognizing that a compelling need for change exists and wanting to engage. How you proceed from that point depends upon the degree of personal commitment that you’re willing and able to put forth in influencing health policy or the regulatory decision-making processes through advocacy activities (Hearrell, 2011). Fortunately, there is a wide range of options for involvement. One of the most fundamental forms of advocacy involves contact with a legislator through written communication via email, letter, or fax; and verbal communication through a phone call or a face-to-face meeting to discuss an issue and make recommendations. In this situation, you offer the legislator an expert perspective on issues pertinent to emergency nursing practice or healthcare in general.

If a change requires a more concerted group effort, you can connect with other emergency nurses on the issue, bring evidence to the table in the form of data and real stories that validate concerns and recommendations, and work to garner the support of key constituents in the healthcare facility, professional organization, or the community-at-large. Next steps might include proposing new regulatory language based upon the recommendations for change and then following them through the political process. You may be asked to attend a legislative meeting or hearing and provide expert testimony on the subject. The scale of this effort might involve advocacy on a regulatory board or coalition, local government, or state, regional, or national level (Hearrell, 2011). Being involved in these activities may sound daunting, but the professional growth experience is unparalleled, especially when your efforts serve to improve patient care.

Political involvement can represent new territory for some emergency nurses. Fortunately, there are many avenues to gain experience with the political process. As a good place to start, Oestberg (2012) recommends forming a mentor relationship with an experienced nurse advocate to learn the political process. There are also formal continuing education offerings as well as academic courses that teach concepts related to navigating the political system and gaining knowledge about how a bill becomes law. Master’s or doctoral degrees in health policy or public health are available for those who want to develop significant expertise in this area. Many professional nursing organizations have a political action component or special interest group that provides templates to assist with letter writing campaigns (Montgomery, 2012). Some offer legislative internship opportunities that enable you to gain firsthand experience in the political arena.

You can also establish an ongoing connection with one or more political figures and serve as an expert in an advisory capacity on healthcare issues (Montgomery, 2012). Similarly, you might choose to build a more formalized relationship with a politician by supporting his or her campaign as a volunteer to learn about the political process from an insider’s vantage point. This relationship can build effective political networks and lead to key connections when support for various types of legislative action is needed (Hearrell, 2011). After gaining experience in the legislative realm, you might even choose to run for political office. Oestberg (2012) places the need for nurses to become involved in the legislative process into perspective by asking a poignant question: “Do you really want someone that isn’t a nurse (or who isn’t getting input from a nurse) deciding how nurses do their jobs? Nurses need to have their voices heard!” (p. 49).

Volunteering
Volunteering is an element of professionalism that represents an orientation toward altruism and citizenship. It demonstrates a tangible commitment to service as an individual core value. For society, the knowledge base and abilities of emergency nurses make them a highly beneficial resource in a multitude of settings that range from clinical practice and public education to serving on boards of non-profit community organizations. Of course, there are those individuals who believe that financial compensation should be provided for all nursing-related activities or else the effort is not worthwhile. However, this mindset is extremely self-limiting. It fails to take into account how volunteer work can enhance your career as well as instill a deep sense of personal and professional satisfaction. Although you don’t get paid in the monetary sense, the potential rewards are rich.

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According to the Bureau of Labor Statistics (2015), 62.8 million people volunteered between September 2013 and September 2014. The average number of hours spent volunteering per person was 50 hours per year. Volunteering is essential to the U.S. economy.

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Volunteering offers opportunities for both life and work experience that may not be available in the typical employment setting. These can include gaining new competencies in varying aspects of teaching, leadership, clinical practice, finance, publication, and organizational skills. Volunteer work can also build networks and connections with individuals and organizations that can aid in career development. Service on community non-profit boards, for example, exposes you to health policy issues and offers opportunities for you to help shape future policy directions (Dawson & Freed, 2008). The travel involved in humanitarian or disaster-aid volunteer work affords contact with diverse cultures that can stimulate fresh thinking about innovative ways of delivering care. For those interested in research, the volunteer experience may yield questions and ideas for more in-depth study. Serving as a volunteer may qualify you for a higher rating on a performance evaluation or for promotion to the next level on a clinical ladder in the work place. Similarly, volunteer community service is often listed as part of the selection criteria for various honors and awards. It’s an excellent avenue for professional recognition and may be a key differentiating factor when applying for highly competitive scholarship funding or a new professional role.

You have multiple options available to serve as a volunteer. Deciding which opportunities to pursue requires careful consideration. Dawson and Freed (2008) advise nurses to “match your passion and your available time, energy and money with an organization” in the context of pursuing an appointment to a community service board or agency (p. 268). This advice stands, however, as an ideal framework for assessing whether any particular type of volunteer work is feasible in relation to your current life circumstances. Understanding personal capacity is critical to avoid taking on unrealistic commitments that can overwhelm or lead to a failure to meet expectations. Fortunately, many volunteer choices are available that offer a wide range of commitment options for emergency nurses.

At a very basic but important level, there is often a great need for volunteer instructors to teach classes in cardiopulmonary resuscitation (CPR) or first aid to members of the general public. The commitment involves successfully completing the instructor classes through the sponsoring agency and meeting the ongoing teaching requirements to maintain instructor status. Similar short-duration and episodic opportunities can include participating in health screening and community education events, and manning first aid stations at fairs, summer camps, and athletic competitions, including adventure races and marathons. Longer-duration volunteer engagements that generally require more time and effort might involve supporting the activities of faith-based organizations by serving as a parish nurse, or staffing community clinics in resource-constrained areas. In remote locations, you may be called upon as a volunteer to aid the local emergency medical services workers during rescue operations or when prolonged patient transport is required.

If you want to travel, consider participating in national and international humanitarian aid as well as disaster response or relief efforts. These missions require a willingness to step out of a known comfort zone and work in extremely resource-limited environments with diverse cultures. Missions can last from 1 to 2 weeks or much longer, depending on the type of work to be done and the location. Spry (2009) advocates carefully researching the financial expectations, time commitment, working and living conditions, local practice standards and customs, safety considerations, and travel requirements before committing to go.

Many mission trips require the volunteer to use personal financial resources to fund a portion or all of the travel, including supply costs. It’s also vital to make sure that your employer will support volunteer deployment if you’re away from your regular job for an extended period. Employers have a duty to ensure that their own institutional staffing needs are met for patient safety. They are under no obligation to authorize participation in volunteer activities that may potentially jeopardize nursing services on the home front. You may be asked to find coverage for the shifts that you expect to miss.

Working and living conditions may be very different from your usual experience in the United States, warranting careful consideration of personal factors such as stamina, health, flexibility, and adaptability to change. The volunteer hours may be long and the duty difficult; there may be no support services that you have come to expect, leaving you to perform tasks like housekeeping and instrument cleaning; single-use items may be in short supply and must be sterilized and reused (Spry, 2009). Personal safety is also a significant consideration. Food and water may be contaminated in areas that lack proper sanitation. Other threats to consider include crime and dangerous insects or animals.

A current passport or visa, a nursing license, and medical insurance may be required to gain entrance into the country. Customs regulations may also require proof of vaccination against endemic diseases. You must factor in the time necessary for immunity to develop before deployment. Prophylactic medications against malaria or other infectious diseases may be indicated. Travel and medical insurance is highly recommended in the event you require medical care or evacuation to home. You will also need to research language barriers, religious practices, and local customs, including the use of healers and folk remedies, to work effectively among people of a different culture. Spry (2009) places these issues into perspective by observing that “… most sites where volunteers are needed are not so fortunate. In these settings, basic skills, a commitment to making a difference, and a desire to help is what is needed most” (p. 195).

Having background education in wilderness medicine can be very helpful prior to embarking on a trip to an austere area, especially one in which the basic community infrastructure has been destroyed by a natural or man-made disaster. Wilderness medicine courses offer instruction to healthcare personnel on how to provide patient care in austere conditions, including strategies to improvise equipment and supplies while incorporating appropriate personal safety and survival skills (Wilderness Medical Society [WMS], n.d.).

Whatever venue is pursued, whether local or abroad, volunteer service promotes respect for nursing and widespread recognition of the positive contributions nurses make to society (Dawson & Freed, 2008). Perhaps most importantly, volunteering is exceptionally gratifying at the deeply human level; it can reinvigorate your passion for nursing and be a springboard for significant personal and professional growth.

Personal professional liability insurance
The emergency department can be a high-risk and unpredictable work environment from a legal perspective. Although most nurses are not named in lawsuits, the question of whether or not to carry a personal professional liability insurance policy is one that is commonly considered by emergency nurses. Unlike physician policies that can be very expensive, the typical cost of a policy for a registered nurse is quite reasonable and is generally less than $200 per year. Advance practice nurses do pay higher premiums based upon their specialty and scope of practice.

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The cost of insurance and individual coverage is partially dependent on your state of residence and the malpractice burden the insurer must bear in that particular state.

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When you’re employed by a healthcare system, the facility’s corporate liability insurance policy generally provides coverage for any malpractice claims that might be brought against you. Therefore, given the out-of-pocket costs, you might think that carrying personal professional liability insurance is an unnecessary expense. However, the decision to carry your own policy must be considered in the context of several very important factors:

• You’re considered a professional 24 hours a day, 7 days per week. Any claims lodged against you for giving healthcare advice or rendering nursing assistance outside of the employer relationship would not be covered by the employer’s liability policy and would be borne by you if a claim ensues.
• If a complaint is made to the professional licensing board about your professional conduct or failure to meet professional obligations in some way by the employer or by a member of the public, the employer’s coverage generally does not cover defense costs for licensure protection.
• If you separate from an employer and a subsequent claim is made against you, the employer’s policy may no longer cover your defense costs.

A personal liability insurance policy provides not only professional liability coverage but also licensure protection for professional regulatory claims. Depending on the insurer and the type of policy, it may also offer other valuable benefits such as legal representation during a deposition, defense expense reimbursement, and educational resources regarding risk-mitigation strategies. Of note, a professional liability policy does not typically cover expenses related to charges brought against you for criminal acts.

To protect themselves, RNs and NPs are encouraged to select an insurance company that (Balestra, 2012, p. 42–43):

• Supports RNs/NPs by providing an advisory board where they can present issues and seek solutions
• Includes license protection to help defend an RN/NP in an administrative or disciplinary situation
• Covers an RN/NP for incidents that occurred at a previous place of employment
• Provides adequate levels of coverage (i.e., malpractice coverage of $1 million/$3 million and disciplinary coverage of $25,000 per occurrence or aggregate). It’s important to note that the state’s attorney general’s office will charge for its time representing the state’s Board of Nursing (BON), and this is not covered by any insurance. Also, a complaint against an RN/NP in one state can have a domino effect in any other state in which he or she holds a license. This means the RN/NP will have to pay for defense costs in every state.
• Allows the RN/NP to select an attorney for representation in disciplinary actions
• Provides a website that addresses risk management issues and solutions
• Gives a discount if the RN/NP gets continuing education credits in a course related to risk management

Promoting health/injury prevention/community education
One of the unique aspects of practicing as a frontline emergency nurse is the opportunity to care for patients experiencing the full spectrum of injuries and illnesses from birth through advanced age. So often the injury or illness may have been avoidable or of lower severity if the individual had made different conscious choices or engaged in behaviors that decreased health risks or promoted a healthy lifestyle. These encounters and insights make you exceptionally well-suited to play an active role in injury prevention, community education, and health-promotion efforts. A key aspect of professionalism in emergency nursing is the commitment to educating the public about strategies that decrease illness or injury risks and promote health. These efforts include education in both the clinical setting and in the community-at-large. The ENA Code of Ethics (2015) clearly articulates the emergency nurse’s duty in this regard:

The emergency nurse is dedicated to providing care and knowledge to the public, which includes a healthy lifestyle, general well-being, and injury prevention. Through individual and institutional support, emergency nurses should become involved in strategies to educate the public, foster healthy lifestyles, and encourage legislative efforts that promote these ideas. (p. 3)

Although health promotion and injury prevention information is often incorporated into standardized or commercially available ED discharge instructions, the more comprehensive approach is to integrate it into the overall episode of care while the patient and family are in the ED whenever possible. In this way, you can leverage the teachable moment when there may be a higher level of motivation to make positive behavior changes because the patient or family member better connects the current health issue with the modifiable risks or problematic choices. In addition, you can spend more time assessing the patient’s level of understanding and explaining concepts that are unclear, rather than rush through discharge instructions when the patient and family are impatient to leave the ED. Examples might include how dietary choices that are high in sodium can exacerbate heart failure, or how a high carbohydrate diet or failure to perform blood glucose monitoring can be a factor in poor glycemic control.

With a similar intent, the ENA has advocated implementing Screening Brief Intervention and Referral to Treatment (SBIRT) while the patient is in the ED to both identify problem drinkers who need substance abuse treatment and help patients to recognize at-risk drinking patterns (Désy, Howard, Perhats, & Li, 2010). In a quasi-experimental study evaluating the impact of ED nurse–delivered SBIRT, Désy et al. (2010) found that “… the SBIRT procedure conducted by existing staff nurses in the ED setting can also contribute to reducing alcohol consumption, drinking frequency, and repeat emergency care visits” (p. 543). Though not necessarily representative of all ED nurse–delivered SBIRT programs, their study results demonstrated the following positive outcomes:

Alcohol consumption decreased by 70% in the intervention group compared to 20% in the usual care group. Drinking frequency also decreased in both groups. Fewer patients from the intervention group (20%) had recurring ED visits compared to patients in the usual care group (31%). (p. 538)

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To learn more about SBIRT, visit http://www.integration.samhsa.gov/
clinical-practice/SBIRT.

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These researchers identified ED crowding from high patient boarding and lack of privacy as key factors that produced suboptimal conditions for implementing SBIRT. There are other factors to take into account that can also negatively impact effective implementation of SBIRT by frontline ED nurses. Ong-Flaherty (2012) identified “staff buy-in of the concepts” as one of the challenges to recognize when instituting an SBIRT program (p. 54). Quite frankly, staff buy-in is essential for the success of any initiative related to ED patient care. Overcoming staff resistance can be a significant hurdle for anyone attempting to elevate ED nursing practice. Here is where concepts of professionalism in emergency nursing must be leveraged to demonstrate that health promotion is indeed both a core competency and a role expectation of emergency nurses. With that said, it’s incumbent on nursing and hospital leadership to support the staff by removing barriers to incorporating health promotion into ED care, such as provision of training programs, promoting ED throughput, and ensuring adequate staffing plans.

Pediatric emergency nurses have both the child and the family to consider in their health-education efforts. The habits and behaviors of the family can directly influence the health of the child. The parent’s proper use of seat belts and child passenger safety seats, for example, is a good topic for discussion to promote injury prevention. Similarly, the smoking habits of people in the child’s household represent another area of opportunity for both health promotion and disease prevention. Exposure to environmental tobacco smoke (ETS) poses significant health risks to children. According to Deckter, Mahabee-Gittens, and Gordon (2009), “when registered nurses (RNs) are caring for a child with an illness that may have been caused or exacerbated by ETS exposure, they are given the unique opportunity both to educate parents about the health effects of ETS on their child and provide parents who use tobacco with tobacco cessation advice” (p. 402).

Another area for health education of patients and families in the ED is related to the appropriate use of the healthcare system and resources for follow-up after discharge. Patients and families may need assistance to both understand and navigate the health system. In an effort to reduce the need for return visits to the ED, Gozdzialski, Schlutow, and Pittiglio (2012), emphasized the role of the ED nurse in discharge teaching:

Appropriate nurse-directed patient education after an ED visit may help both the patient and family better understand the challenges, needs, and expectations during the recovery process. In addition, this education can anticipate and assist in aiding patients and their families with physical limitations, role changes, and emotional struggles after injury or illness. (p. 293)

Although the ED does enable a point-of-care approach to health promotion, there may be very real barriers to effective screening and patient education that must be considered. There are challenges inherent in the ED setting as well as in the staff’s willingness and ability to educate and the patient’s personal capacity to engage in learning. The dynamic nature and demands of the ED environment, including high ED census and acuity, can pose challenges to an ED nurse’s ability to educate effectively overall. Creativity and innovation are necessary to support health teaching, especially in challenging circumstances. Strategies might include selecting educational videos for the patient to view in the ED if available, providing quality printed educational materials written at the appropriate reading or health-literacy level, supplying contact information for health educators in the facility or community, offering information about community resources, and instituting a formal discharge phone call follow-up program for selected patients.

When you choose to participate in community-based education programs, the opportunities to influence choices about health promotion and injury prevention expand dramatically from the single patient encounter in a challenging emergency environment to engaging a much broader audience. The community, in essence, becomes the patient. These programs are commonly offered through schools, faith-based groups, senior centers, police agencies, and non-profit community organizations such as local chapters of the American Heart Association, the American Cancer Society, or the American Trauma Society. Professional nursing organizations also typically sponsor programs that provide targeted health education to the general public as part of their mission. Offerings might include CPR classes, first aid courses, lectures or group discussions on healthy lifestyle choices or health risk mitigation strategies, disease management, substance abuse, fall prevention, and protective gear for sports.

Another possibility for community-based education is the creation of innovative programming by ED nurses in a specific hospital, community, or region that addresses health risks significant for that area. A great example of such an initiative came out of North Carolina. Nurses at an ED located close to the ocean noticed a very concerning number of drowning victims being brought into their hospital for resuscitation, as well as a rising incidence of marine-related injuries (Pelton, 2012). In response, several ED nurses and two of their support staff created the “ED Beach Reach” community outreach program. “Hydration, sun protection, child safety, marine life dangers, fishhooks, tetanus vaccinations, rip currents, and drowning prevention were identified as the highest priority for safety and injury prevention education” (Pelton, 2012, p. 79). They developed printed educational materials and give-away items as part of their strategy to educate the general public, and then went to the beaches to interact directly with beachgoers at various times over the course of the summer. Although they did recognize a slight decrease in the incidence of marine-related injuries that could have been the result of other factors, they did initiate a program with the potential to grow and make a more significant impact, especially since they took it to their ENA chapter for dissemination to a larger group (Pelton, 2012). Pelton (2012) makes a very compelling case for involvement in community outreach, which nicely sums up this aspect of professionalism in emergency nursing:

It takes time and energy to have an impact on a community. It takes passion and desire to effect change. All emergency departments are a reflection of the community they serve. It is our responsibility as emergency nurses to evaluate our communities to determine which risks are most prevalent. (p. 80)

In addition to the benefits for patients and communities, health promotion, injury prevention, and community outreach activities pose multiple opportunities for enhancing professional growth in emergency nurses. Presenting information to small or large groups builds public speaking skills. Interacting with event organizers and participants enables the development of new personal and professional connections and possible opportunities for a greater depth of involvement. Active community service may positively position you for a higher performance rating or for professional advancement. It may also help prepare you for a community education or outreach position within the healthcare facility. Community service is exceptionally rewarding because it offers the chance to help people avoid the situation that leads to an emergency department visit or a hospital admission. Ultimately, you can proactively prevent pain and suffering before it happens.

Summary
Nursing is a profession. That requires those in the practice of nursing to carry themselves as a professional. Yet asking individuals, even nurses, what the definition of professionalism is may conjure up responses as varied as the number of people asked. Understanding the concept of a profession and professionalism is challenging. This chapter provided a broad overview of the concept of professionalism. It’s essential that emergency nurses, as members of the nursing profession, understand the professional responsibilities that go along with the title of “Registered Nurse.”

Chapter author:
Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN, is vice president of emergency and trauma services at Christiana Care Health System in Wilmington, Delaware.

Book author:
Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN, is founder and executive director of Project Helping Hands and president of Solheim Enterprises.

Information on purchasing Emergency Nursing: The Profession, the Pathway, the Practice.

References
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