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Registered Nurses are among the most in-demand, highly respected medical professionals in the country.
Registered nurses have numerous job duties that put them in the forefront of the medical field. Additionally, many RNs choose to specialize in particular areas of study in order to provide even deeper levels of care to patients. Training to become an RN requires at least an Associates of Nursing Degree, but in many cases nurses find that they have better opportunities by earning a Bachelor’s degree. The RN degree is often used as a stepping stone to an even more advanced degree, but in many cases it is more than enough for nursing professionals to achieve their goals. A dialysis registered nurse specializes in providing dialysis to patients with kidney issues. An oncology registered nurse is an RN that has specialized in providing care to cancer patients.
A Post Anesthetic Care Unit RN, or PACU RN, is responsible for providing care to patients following medical procedures that required anesthesia. These nurses work in neonatal ICU facilities providing round the clock care to sick or premature newborns. A travel RN doesn’t earn as much as some other RNs, but they enjoy the benefit of travel as a job perk. ICU RNs work in hospital ICUs to ensure that patients receive the kind of high level care that they need. Disclosure: We strive to provide information on this website that is accurate, complete and timely, but we make no guarantees about the information, the selection of schools, school accreditation status, the availability of or eligibility for financial aid, employment opportunities or education or salary outcomes.
Let’s take a look at Watson’s Caritas Process number five – Promote the expression of positive and negative feelings. Using ourselves as therapeutic agents we can work to promote healing of these negative feelings.
Hi Karen - we've shared this update from the VA board of Nursing for informational purposes only.
I held a LPN nursing license in VA and want to renew and transfer to the state of Maryland where I live. Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS).
Our experience shows that changes in ED processes using Lean thinking and available resources can improve efficiency.
Emergency department (ED) crowding is a major concern that affects both patients and providers. We performed a retrospective, observational study before and after implementation of a rapid triage and treatment (RTT) system within our ED. Our ED, located approximately ten miles from downtown Sacramento, California, sees approximately 67,000 patients annually. Prior to initiation of the RTT system, our patient flow process was similar to that of many EDs. Prior to the study period we employed different strategies to deal with lower acuity patients, including a “fast track” (urgent care). Following initiation of the RTT system, the flow process has been significantly altered for patients presenting to the ED. Higher acuity patients (ESI 1, 2, or 3) are immediately placed into examination rooms in the main patient care area and assigned to a physician.
All study data was extracted from the Kaiser Permanente Healthconnect system, which is the electronic medical record (EMR) order entry, and patient-tracking system used at our hospital. We report ambulance arrival rates, hospital admission rates, LWBS rates, ESI triage levels, LOS times, arrival to emergency physician start times and arrival to room times using simple descriptive statistics.
The ED census was 30,981 in the six months prior to RTT and 33,926 in the study period after RTT. Despite an increasing ED census, we found that the LWBS rates decreased between study periods. This study demonstrates that by decreasing inefficiencies associated with our triage process and creating a more efficient system for treating lower acuity patients in our ED, we were able to significantly decrease waiting times and LWBS rates.
We feel that the decreases in patient waiting times (ED presentation to room time and ED presentation to emergency physician start times) that we observed were the primary factors leading to improvement in LWBS rates. Referral of low acuity patients to outside clinics has been attempted 19,20 but with multiple drawbacks. Several studies have demonstrated that better use of existing ED resources can lead to improved metrics.14,21–23 In our department we sought to apply Lean principles to our ED processes to develop efficiency, thus improving patient wait times and LWBS numbers. The initial step in implementing any Lean system is actually watching the processes and mapping workflows, rather than describing them from memory.
Members of the throughput committee then dissected each portion of the value-stream map and classified activities as “value-added” or “non-value added.” In our process, we first identified that certain triage questions could be considered non-value added and eliminated them. Fostering a culture of continuous process improvement among ED staff ensures that gains aren’t lost and allows for rapid adaptation to future changes. The primary limitations of this study are those associated with retrospectively collected data. Ideally we would have studied longer pre-and post-intervention intervals in order to adjust for any seasonal variation in ED patient patterns. Unfortunately, for this study we did not collect data regarding patient satisfaction, ED return visits, insurance co-pay collection, physician relative value unit (RVU) productivity or physician satisfaction. We found a slight decrease in hospital admission rates in the post-intervention period when compared to the pre-intervention period.
In our ED we found that redesign of ED processes, using Lean principles and existing department resources, improved important metrics.
Address for Correspondence: Karen Murrell, MD, MBA, Department of Emergency Medicine, Kaiser Permanente, South Sacramento Medical Center, Sacramento, CA. They enjoy one of the highest average salaries, rock-solid job stability, and great employee benefits. They not only provide patient care but also help educate patients and their families about health care, specific situations, and more. There are numerous high-paying RN nursing jobs and careers available, and finding one that matches your interests and goals is important.
Travel RNs often work for cruise lines and other similar companies, providing medical care during cruises and travels to other countries. This can include a wide range of things ranging from medication administration to monitoring vitals to controlling the risk of infection.
I received my bachelor’s degree, then my license as a Registered Nurse, then my Masters degree, and later my certification in my specialty area. We bring it with us into our patient rooms, and into discussions with our peers and managers. Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital.
Using this system, patients undergo a rapid triage with low-acuity patients seen and treated by a physician in the triage area.


Ambulance arrivals, ED patient acuity and hospital admission rates were unchanged throughout the study periods. In this community hospital ED, use of an RTT system decreased patient wait times and LWBS rates.
EDs today provide a safety net for patients without medical insurance and are used by patients who need evening and weekend service.
The goals of this paper were to evaluate and discuss the application of Lean principles to our ED processes. Upon arrival, an ED technician “greeter” met patients and determined whether there was need for immediate placement into the patient care area. This system of care entailed an extensive patient triage, then redirection of lower acuity cases to the “fast-track” area. In the ED, a value stream map is simply a diagram showing the progression of patients through the system as services are provided (Figures 1 and ?and2).2). The re-arranged triage area places a triage nurse and registration clerk close by, so that the initial triage and registration processes may be performed simultaneously. Treating nurses and physicians document all patient activity prospectively into the system at the time of the patient’s ED visit. We provide 95% confidence intervals where appropriate and made comparison of proportions using Chi-squared test for ambulance arrival rates, hospital admission rates, LWBS rates and ESI triage levels.
We evaluated the six-month period prior to implementation (August 2006 – January 2007) and the six-month period following implementation (March 2007 – August 2007). Emergency department (ED) data before and after initiation of the rapid triage and treatment (RTT) system. It has been shown previously that ED LWBS rates (and patient satisfaction) are directly associated with patient waiting times to see a physician.14–18 The largest decreases we observed occurred in lower acuity patients (ESI triage category four and five). Partial resource enhancement tends to simply move the resource “bottleneck” to another area of the ED. Use of a “triage out” system does require dedication of some ED resources for MSE and clinic transport. Additionally, in the era of nursing ratios, a single critical patient can close three ED beds. Lean is a business concept that has previously been applied to ED systems to improve patient care processes.6,7,8,9,10 Because the ED is comprised of multiple different work flows making up the patient care experience it is both an ideal and difficult setting for creation of Lean process changes. For the process improvement described in this paper, we made a value-stream map of the entire ED experience for low acuity patients prior to any discussion of improvements (Figure 2). We further evaluated the value-stream map and developed a shortened workflow for lower acuity patients to improve throughput times (Figure 3). We have accomplished this in our department by continuing our multidisciplinary throughput committee, which focuses on ED processes and application of Lean to solve problems. However, the use of the computerized EMR in our facility leads to fairly standardized and reliable data collection similar to that of prospective studies. However, this was difficult as we also needed to pick a study period that didn’t include any significant changes in department staffing, processes, or external factors that may have confounded our results. It is important to note that our results may be unique to this single physician group within a single hospital system.
The Bureau of Labor Statistics lists the average pay for registered nurses at around $64,690 per year or about $31.00 per hour – both of which are well above national salary averages. And in many cases, they provide a kind of emotional support to patients and family members that other medical professionals won’t provide. In some cases positions are available at resorts and even on cruise ships that have dialysis centers set up for patrons. Job duties will include helping monitor a patient, administering chemotherapy or other treatments, helping an oncologist provide care to patients, and more.
They will monitor patient vital signs and ensure that the anesthesia’s residual effects wear off properly. They’re also in very high demand, and take part in very specialized medical care processes.
We actually get quite good at problem identification in the world of nursing, but it is how we manage these problems, that defines and shapes our nursing practice.
We can best do this by taking a deep breath, slowing down, and assuming good intent in the person we are trying to help.
Are we emanating positive energy as we identify and address problems and the negative feelings they bring about? No changes in staffing, physical space or hospital resources occurred during the study period. In particular we were interested in how the redesign of ED systems to develop a Rapid Triage and Treatment (RTT) system, using existing resources, affected certain important ED metrics (left without being seen [LWBS] rates, waiting times, ED length of stay [LOS]).
These patients waited in a separate waiting room before being seen by the “fast-track” emergency physician. Upon arrival patients undergo a “quick registration,” including name and medical record number entry into the computer system, armband placement and consent signature.
An ED technician may also be assigned to the area depending on availability and time of day. We used student’s T-test for comparison of mean LOS times, arrival to emergency physician start times and arrival to room times. Prior to implementation of the RTT system, LWBS rates were steadily climbing reaching a high of 7.7% in the month just prior to RTT. It is not clear whether this change represents a difference in baseline characteristics of the two study groups or is a result of implementation of the RTT system.
However, waiting times for category two and three patients also appeared to improve (Tables 2 and ?and33). Flexible resource expansion (at times of high volumes) would be ideal, but is frequently impractical.
Unfortunately, these activities do not add value for the patient and, in the end, are completely wasted steps. While we cannot control the patients who present to our departments, ambulance diversion might be used as a method to control ED patient acuity.
The application of Lean principles requires: evaluation of systems, identification of waste, elimination of waste, improvement of flow, and constant adaptation to change (Figure 1). The use of frontline workers to develop process improvements is another key Lean principle.
We also used 5-S principles to standardize equipment in the triage and RTT areas.24 In our experience, the most difficult Lean process adaptation is standardization of workflows.
Gray bars denote monthly ED census (left axis) and black bars denote LWBS rates (right axis). Recall bias is not an issue as the data points of interest were recorded during the course of the patient’s ED visit.
A decrease in admission rates might represent a decrease in patient acuities presenting to the ED between periods; however, this is not reflected in the rates of ambulance arrivals or ESI triage categories.
We, however, feel that our ED is similar to many other departments in the United States and our findings will be of interest to other EDs.


The job is so highly thought of that US News named it the Best Job in the Country for 2012. Additional responsibilities could include things like monitoring vital signs and ensuring that the patient is following good care guidelines after they leave the dialysis center. In many instances, oncology RNs will find themselves providing some measure of moral, emotional, and mental support to patients who are fighting cancer.
There are times when negative feelings arise among our patients and their families, our co-workers, or yes, even within ourselves. If we enter a situation bringing judgment, condescension, and anger, the conversation will not go well.
We then performed a retrospective, observational study comparing hospital electronic medical record data six months before and six months after implementation of the RTT system. Residents of all levels from the University of California Davis Emergency Medicine Residency Program rotate through our department. Full registration processes are then completed after patients have been seen by a physician.
The RTT physician treats and releases patients placed in the RTT area, apart from the main patient care area. The RTT physician and nurse are encouraged to communicate and work closely as a team, and the triage nurses are encouraged to communicate freely with the RTT physician to resolve any triage questions or issues as they arise. A one-month start-up phase was excluded from data analysis as we considered this a transitional period during which staff and physicians were learning new ED processes.
Determination of whether the RTT actually caused a decrease in hospital admission rates would require more study. Generalized resource expansion ensures periods of low resource utilization at a substantial cost. Also, mis-triage to a lower level of care is a potentially harmful error both from the standpoint of patient care and potential regulatory violation of the Emergency Medical Treatment and Active Labor Act.
Unfortunately, ambulance diversion has adverse effects on the emergency medical services system and is a frequently applied measure of ED quality. The core concept of Lean is that the only important steps in any process are those that add value for the customer (or patient in this case). In our department we formed a “throughput committee” comprised of all levels of ED workers. It is critical that all members of the healthcare team identify task sequence, and then perform them in a standard way and time. We felt that this time period adequately represented the different seasons but, to our knowledge, did not include any confounding changes. It is also possible that institution of the RTT system somehow decreased hospital admission rates. Specializations could bring further levels of training with them and also come with further clinical training. However, it was not until I immersed myself into Jean Watson’s Human Caring Theory, that I really saw that I had a nursing practice. If however, we bring trust, compassion, and a desire to help, we are setting ourselves up for success. This MSE consisted of 18 questions, including chief complaint, brief history, vital signs, allergies, medications, domestic violence regulatory question and focused physical examination. In the worst-case scenario, a patient was mis-triaged from the ED to “fast-track” then returned to the main ED after evaluation by the fast-track physician.
Waste is defined as any work, time or supplies that add no value in the eyes of the customer (or patient).3 We then streamlined our triage and admitting processes to remove waste. Concurrently a nurse obtains vital signs, collects the chief complaint, records allergies, and assigns Emergency Severity Index (ESI) triage category. Simple imaging tests may be ordered by the triage nurse prior to RTT placement in anticipation of patient needs. This improvement in LWBS occurred despite a slight increase in ED census and similar numbers reflecting ED acuity (ESI acuity, ambulance arrivals) [Table 1]. Value is any operation or process step that contributes directly to providing service to the patient. All staff members were coached in the Lean principle of “continuous process improvement” and were invited to give input on the process throughout the timeline. This required a cultural shift and constant vigilance by members of the committee for the first month of the implementation and beyond. It was my very own nursing practice; certainly defined by regulatory standards, behaviors and policies, but now shaped by something so much more important and influential.
An “RTT” physician was placed in an area immediately adjacent to the triage nurses (formerly triage bays), which decreased unnecessary movement and allowed that physician to immediately address triage questions, thus decreasing mistriages. Under the RTT system, lower acuity patients may also be evaluated and treated while seated in ED hallway chairs.
This “bottom up” approach tends to yield the best ideas for process improvements and better implementation of those improvements. Not only did I have to use evidence based care to provide what is best to my clients, I had to do so using the art and science of caring to bring about the best results. After this triage process, which took an average 12–18 minutes, patients returned to the waiting room. Additionally, our hospital administration had regulatory concerns related to triaging of patients out of the ED to a lower level of care.
We also partnered the RTT physician with one nurse to increase efficiency through improved communication and teamwork. RTT patients who are uncomfortable with being treated from a chair have the option of waiting for an open bed in the main patient care area. As stated above, investment by front-line staff members in the flow improvement process is crucial to its eventual success.
When an ED bed became available, the patient was placed in an exam room and evaluated by a second nurse.
Following these process improvements, we have maintained a system of constant re-evaluation to identify problems and make further modifications as needed.
Most of this work of re-evaluation is done at weekly process meetings involving ED technicians, nurses and physicians. In the event that the RTT area is full, lower acuity patients (ESI level 4, 5) may be placed in the waiting room until space becomes available. The theoretical effect of this system is to maintain space in the main patient care area for rapid rooming of higher acuity patients (ESI 1,2,3), while lower acuity patients (ESI 4,5) are triaged and treated as efficiently as possible from the RTT area. Nursing staffing consisted of 14–18 nurses and four to six ED technicians, also depending on time of day.




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