Integrating New NPs into the ICU

Integrating New NPs into the ICU

When Nurse Practitioners (NPs) begin to work at the R. Adams Crowley Shock Trauma Center in the University of Maryland Medical Center, they are given training that helps integrate them into the ICU. Brooke Andersen, ACGNP-BC, Clinical Program Manager for Shock Trauma and Advanced Practice Provider for the Critical Care group, wrote about this topic for Critical Care Nurse. She took the time to answer our questions about how this process works and why it is important.

What follows is an edited version of the interview.

As opposed to having them begin working directly in the ICU, what kind of preparation is done beforehand? Why is this necessary?

All newly hired NPs attend a 2-day hospital orientation and a 1-day Advanced Practice Provider orientation that includes content on regulatory requirements, computer training, access to systems, and supplies needed for the job. Each NP receives a structured orientation manual and details regarding the orientation plan.

This standardized onboarding phase assists the NPs in completing the necessary requirements to begin work in the ICU and has minimized delays in credentialing and other regulatory requirements while streamlining the process.

What kind of training do they receive before starting in ICU? Why?

We do not provide training before starting in the ICU. The new NPs receive education in conjunction with their clinical training. They participate in weekly 1-day standardized didactic education and bimonthly procedural workshops or simulation sessions throughout the orientation. The weekly sessions provide time off the unit and opportunities for the NPs to obtain knowledge and technical skills while gaining confidence and competency in the critical care setting.

Education sessions include over 30 critical care core topics. The procedural skills lab provides the necessary training for NPs to become credentialed in ICU advanced skills. High-fidelity clinical simulations are failure-to-rescue and rapid-response scenarios that provide training in critical high-stress situations with debriefing.

How has this helped them be better at their jobs when they begin in the ICU? Why? How does this training and integration help the patients?

The weekly education allows the NPs time to network with other critical care providers and develop a support system. Our program evaluation has shown that novice NPs do not feel adequately prepared to work in an ICU immediately after graduation, but at the completion of orientation, they are confident and competent.

This training helps the patients by ensuring that the NPs have had standardized training that promotes success in achieving competency in necessary critical care knowledge and technical skills.

Is this just done for the ICU or other departments as well? Why?

A structured orientation is provided for newly NPs throughout the organization, but is tailored to the specialty areas. The critical care orientation that we have described is specific to the critical care units and has been shown to meet the necessary NP competencies needed in all the ICUs. These competencies are based on the AACN Scope and Standards for adult and pediatric ACNPs.

What else do you think is important for nurses to know about how new NPs are integrated into the ICU?

Newly hired NPs require a depth of knowledge and skills to successfully transition into their new roles. A comprehensive training program that includes standardized educational activities, clinical training, and thoughtful matching of preceptors with new NPs are key elements. Mentorship is especially critical during the orientation period to ensure new NPs receive support and guidance in their learning while fostering independence and autonomy as competencies are achieved—and ultimately builds confidence.

Careers in Nursing: An Interview with Nurse-Midwife Addie Graham

Careers in Nursing: An Interview with Nurse-Midwife Addie Graham

When you think of a nurse-midwife, you may think that they just help delivery babies (not that this isn’t a crucial and exceptionally important part of their jobs). But they really do so much more.

Adelicia (Addie) Graham, MSN, FNP, CNM, works as a certified nurse-midwife with Connectus Health in Nashville, Tennessee. With the other midwives in her group, Graham sees patients for prenatal care and GYN care at Vine Hill Community Clinic and Priest Lake Family & Women’s Health Center, and they all are privileged to attend births at St. Thomas Midtown Hospital.

What follows is an edited version of the interview with Graham.

Addie GrahamAs a nurse-midwife, what does your job entail? What do you do on a daily basis?

My schedule varies each week as I work a mixture of day and night shifts, as well as clinic days.

My hospital shifts are mostly 12-hour call shifts with an occasional 24-hour call shift thrown in. On a clinic day, I will see patients for prenatal care visits, birth control consults, well-woman exams, and IUD placements, etc. On a hospital call shift, I take calls from my patients and triage them at the hospital. If they are in labor, I admit them and provide support as they labor and give birth. Some of our patients get epidurals and others choose to go natural.

From the moment my patients enter the hospital, I like to make sure they are provided with the information needed for them to make informed decisions about their labor/birth experiences. I want to make sure that they always feel empowered, and that we work as a team to give them a beautiful birth and a healthy baby. Midwives specialize in vaginal birth, but sometimes a C-section is needed. In those cases, we have some wonderful back-up OB/GYNs who perform surgery when needed. I will stay at the patient’s side through the procedure and continue to provide support and encouragement.

Why did you choose to work as a nurse-midwife? How long have you worked as one?

I decided I wanted to go into the medical field as a child, and I have always been drawn toward caring for people with few resources or options. When I researched organizations like Doctors Without Borders and other service organizations, midwives came up again and again as the most needed practitioners. As soon as I entered the Master’s program at Vanderbilt University School of Nursing, I knew that I was meant to be a midwife.

I love the rich history of midwives empowering women and helping them through the most difficult—and the most beautiful—times in their lives. Birth still amazes me, and the strength that I see in every woman who goes through this transformative process is so inspiring. I have been a midwife for eight years, and I am blessed to have worked in non-profit organizations for that entire time. I love the diversity of culture, language, and birth practices/preferences that I get to see every day.

What are the biggest challenges of your job?

The biggest challenge that I run into on a daily basis really is fatigue and lack of sleep. Every practice is different, and I have worked a large range of hours from 24/7 on-call to the more reasonable schedule of defined shifts that I work now.

On a more overreaching note, there is also the stress that comes with being responsible for two lives—mom and baby—and dealing with difficult births and emergencies. Fortunately, the normal births outnumber the emergencies, but I always need to have all of the possible outcomes in mind and be prepared for anything.

What are the greatest rewards?

Women’s health is an incredibly rewarding area of nursing. I love providing detailed teaching in my visits and equipping women with knowledge that will help them to live healthier lives. Providing physical exams and birth control options is just as needed as attending births and supporting women through labor. My patient population is absolutely amazing and inspiring. I love seeing how women labor, birth, and bond with their babies in such similar ways, despite cultural and language differences. I get to take care of patients who were born and grew up in the U.S. as well as patients here as New Americans from countries like Somalia, Iraq, and Mexico. Birth is a beautiful and powerful event in any language.

What would you say to someone considering this type of nursing work? What kind of training or background should he or she get?

I would say that you are in for an intense, tiring, amazing, and beautiful journey… pretty much what I tell all my pregnant moms as they prepare for birth! Be prepared to give a lot of yourself, but also make sure that you take time to recharge and nurture yourself and your family.

As for training, if you are already an RN, you will need a Master’s degree in nursing with a certification in midwifery to become a certified nurse-midwife (CNM). If you don’t have a school near you that offers this specialty, don’t be discouraged, as there are some great distance programs out there as well. If you have a degree in something else and need a bridge program, those exist too. I would recommend asking a midwife—homebirth, birth center or hospital—if you can shadow him or her. I shadowed a homebirth midwife prior to entering school, and it really confirmed that I was headed in the right direction. You might also consider being trained as a doula and attending births as labor support to show nursing schools that you are a part of the birth community, and also to gain valuable experience.

Where can midwives work? They can work at clinics, hospitals, birth centers, and even at home. Most CNMs attend hospital births, but there are a lot of options out there for midwives who want to attend out-of-hospital births as well.

Working with Patients Who Have Alzheimer’s Disease

Working with Patients Who Have Alzheimer’s Disease

While some nurses may find it difficult to work with patients who have Alzheimer’s disease, others find it to be a calling.

Take Christine E. Crouch, RN, BSN, for example. As a Licensed Nursing Home Administrator and the Vice President and Senior Administrator at Bethesda Health Group, specifically working with Charles Village and Southgate, she loves what she does. “It is extremely rewarding, hard work, and the families become part of your life,” says Crouch. “And they are so appreciative of the care you provide their loved one.”

In honor of National Alzheimer’s Disease Awareness Month, Crouch took some time to answer our questions about what it’s like to work with Alzheimer’s patients. What follows is an edited version of the interaction.

As a nurse working with patients with Alzheimer’s disease, what does your job entail? What do you do on a daily basis?

As a nurse working with Alzheimer residents, my goal is to provide a safe environment while promoting self-worth and dignity for the resident. I want each resident to be able to do as much for him/herself as possible while having a meaningful life.

Why did you choose to work with this type of patient? How long have you worked in this particular area of the nursing field?

I have chosen the geriatric field of nursing because I love working with seniors and have cared for residents with Alzheimer’s disease since the 1970’s. I have always enjoyed talking and interacting with older people because they are so interesting and have had so many life experiences.

What are the biggest challenges of your job?

The different stages of Alzheimer’s disease affect residents in different manifestations of behaviors and daily life skills. So when you are caring for 27-30 Alzheimer residents on your neighborhood in different stages of the disease process, it is a huge challenge to meet every person’s needs (person-centered care) and wants.

What are the greatest rewards?

When someone who has not spoken, smiled, or engaged with staff or family all of a sudden talks, sings, or smiles.

What would you say to someone considering this type of nursing work? What kind of training or background should he or she get?

This type of nursing is actually a calling. You have to want to care for this special group of individuals. Most of the time a nurse assistant or medication tech who worked with this population makes the best nurse.

They would definitely need geriatric nursing training and specialized skills and competency in dementia care. The Alzheimer’s Association offers some training, and also, there are other special programs like the Teepa Snow training and Landmarks for living program, just to mention a few.

Talking Turkey: What Nurses Do When Working on Thanksgiving

Talking Turkey: What Nurses Do When Working on Thanksgiving

Working on Thanksgiving can be great—extra pay and often a quiet day. But it can also make nurses wish they were home with their families.

We decided to ask nurses what they do to celebrate Thanksgiving when they do have to work. They told us what they do with their “work” families.

When Doria Musaga, RN, was working as a nurse, she said that the hospital would provide them with a free meal. But since it was, as she calls it, “the pressed turkey thing,” she adds that “it was dinner all the same and free.” She and her coworkers would often bring in more homemade foods to add to it.

“I have worked on the OB unit at two hospitals since I became a nurse. Usually, the hospital provides turkey for each nursing unit, and each staff member prepares a side dish to enjoy. Patients can choose to order a turkey dinner for their meal from food service. We give thanks for our healthy moms and babies. For the families being dismissed that day, we try to expedite the process so they can enjoy celebrating with extended family.”

—Lois Williams, RN, MN, RDMS

“I don’t work holidays any longer but my staff usually plan a feast with each one bringing some home-cooked part of the meal. The hospital usually provides a holiday meal, but rarely on the actual holiday–usually several days before.”

Lisa Fiorello RN, BSN, CCRN, RN-BC

“We would bring in pot luck snacks for Thanksgiving but we also scheduled shorter shifts to be home part of the day and rotated it year to year.”

—Janine McCowan, RN

“Everybody brings a dish in. We have a unit thanksgiving dinner during the shift.”

—Barbara Benzing Smith, RN

“You celebrate and give thanks with your work family as you would at home. Always be Thankful! Everyone brings a dish!”

—Cheryl Murad, RN

“At some places I worked, we would all bring a dish of food and have an open buffet so everyone to could get something on their break.”

—Theresa Zubrowski Woodson, RN

“I always had my own ‘Kristie’s (Christmas/Thanksgiving/Easter/etc.)’ with my family. At work, we always did a pot luck–usually it’s not quite as busy, and we could enjoy ourselves.”

—Kristie Davalli, CRNP

“We have pot lucks, and every one brings a dish to share.”

—Kristen Corkran, RN

“When I had to work Thanksgiving, my family would take sympathy on me, I never had to cook nor clean and had dinner waiting for me when I got home.”

—Estelle Schwarz, RN

Nonprofit “Nurses of Pennsylvania” Vows to Make Changes in Health Care

Nonprofit “Nurses of Pennsylvania” Vows to Make Changes in Health Care

This past summer, a group of nurses in Pennsylvania created the nonprofit Nurses of Pennsylvania with the main goal to be to focus on the safety and care of patients in health care.

According to a statement issued in September, Nurses of Pennsylvania is a group “of, by, and for nurses focused on improving the bedside care nurses provide. PA nurses work in cities and small towns, at large hospitals, in nursing homes, and more—tied together by our commitment to our patients, our families, and our communities. United for quality care, Nurses of Pennsylvania is focused on leading the state to a healthcare system that gives nurses a seat at the decision-making table and puts patients first.”

As stated on their website, more than 10,000 nurses have joined—either online or in-person—since the group launched. Initially funded by union nurses in SEIU HCPA, the Nurses of Pennsylvania is managed by a volunteer board of nurses and advocates in the health care field.

Under the heading “Why Nurses,” the group states: “Nurses are the single biggest group of people in the healthcare system. We spend the most time with our patients, and are the people who they see and interact with the most. We provide most of the care that patients receive, and our priority is always our patients’ well-being first, money second. We are the most respected profession in American for the last 15 years in a row, and we live in every county in the state. If anyone has the power and the motivation to fix healthcare in this country, it is nurses together, and if we can do it in Pennsylvania then we can do it anywhere.”

The nonprofit has already released a report, “Breaking Point: Pennsylvania’s Patient Care Crisis,” the results of which are based on a survey of 1,000 nurses located throughout the state of Pennsylvania. The results found that while Pennsylvania is not currently experiencing a nursing shortage, staffing decisions made by individual facilities and the ability to retain qualified nurses have fueled a crisis in patient care. An overwhelming 94% of nurses reported that their facility does not have enough nursing staff and 87% reported that staffing levels affecting patient care are getting worse.

“We spend the most time with patients, and we’re the people patients and their families rely on the most,” Jake Reese, a nurse in Scranton, PA as well as a Nurses of Pennsylvania board member, said in a statement. “As nurses, we take pride in buckling down and figuring out solutions at warp speed, but there is only so far any one of us can stretch. Giant corporations and multi-billion-dollar hospital systems are making decisions about care and care delivery farther and farther away from the bedside. This has to stop. We’re playing with first and we cannot stand by any longer. As Nurses of Pennsylvania, we’re speaking out and sharing our stories like never before.”

For more information about the Nurses of Pennsylvania, visit