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.

‘Find a Niche that You Love’

‘Find a Niche that You Love’

Vanderbilt’s dean of nursing on her career path and advice to others

“The field has grown tremendously in terms of academic advancements, but also in terms of nurses being viewed as key players in healthcare decision-making,” explained Linda Norman, DSN, RN, Valere Potter Menefee Professor in nursing and dean of Vanderbilt University’s School of Nursing in Nashville.

I recently had the privilege of sitting down with her to ask her questions about her personal career, and about the field of nursing in general.

She says she knew from a young age that she wanted to go into nursing education. She completed both her Bachelor’s and Master’s Degrees at the University of Virginia. She gained experience between completing the two degrees by teaching at a Hospital-based program, and simultaneously working as a staff-nurse on the weekends, and in the summer.

After finishing up her Master’s, Norman became a part of a National Heart, Lung and Blood grant. She helped establish hypertension detection and adherence clinics in southwest Virginia and northwest Tennessee.

When the project ended, she took on a new role, teaching at East Tennessee State University (ETSU). After only a brief time at ETSU, she was promoted to serve as chair of her department.

Norman moved to Nashville a few years later, and began working as the director of Aquinas College’s Nursing program, while also earning her doctorate from the University of Alabama. After completing the degree, she was offered a position as the Associate Dean of Academics at Vanderbilt’s nursing school. In 2012, Norman was given the endowed chair, and in the following year, became dean.

While she earned her degrees and landed job offers, Norman had other responsibilities as well. She was already a wife and mother to two children. She always managed to strike a balance between work and family.

How has the field of nursing changed for the better and for the worse since your career began?

“I think the role that nurses play has grown exponentially. Today, we do not have to convince people of the value that nurses bring. Both healthcare professionals and the public understand that nurses play an important role, and that advanced practice nurses are vital to our industry. People have also realized that we need nurse scientists and Doctorally prepared nurses as clinicians and administrators. I think that the field has grown tremendously in terms of academic advancements, but also in terms of nurses being viewed as key players in healthcare decision-making. In my opinion, the most significant growth has occurred over the past ten or fifteen years.

“I feel that some change still needs to be made regarding entry into practice. It can be confusing because right now someone could become a nurse through an Associate’s program, a hospital-based diploma program, or a Bachelor’s program. I would like to think that changing the laws to make the bachelor degree the only route would decrease confusion so people would understand that a nurse is a nurse is a nurse.”

Why did you decide to get your Doctorate of Science in Nursing?

“I needed my doctoral degree to stay in academics. When I went for my master’s that was the terminal degree in nursing. Shortly after graduating, I knew that in order for me to do what I wanted to do – be a leader in the academic arena- I needed to get my doctorate.

“During the time when I was getting my education, it was typical to take years between degrees in order to gain experience. We have learned a lot now, and that mindset is not longer true … You do not need years of experience anymore. Whether you want to do a research doctorate or a practice doctorate I would recommend going straight through. There are a few advantages: one of which is that you’re in study mode, which makes for an easier transition; another one is that if you get your master’s and start your DNP as a part time student while you’re working as a licensed NP, you can start applying the learning from your coursework immediately.”

How do you effectively balance your personal life with your work life?

“When I started my master’s I had a 15-month-old and a three-year-old. Even though they were active little people, they fell asleep at 7 pm. So I could study from 8 pm until midnight.

“When I started my doctorate, I had a sixth-grader and an eighth-grader, and they did not fall asleep at 7 pm. At this point, in addition to school I was working full-time as director of a nursing program. I had to figure out when I was a student, when I was director, and when I was a wife and a mom.

“I found out that I could not study when everyone else in the house was awake. I also realized that going to the library was unrealistic. I determined that I could accomplish more between two and four in the morning than I could at any other time of the day. No one was up, and even the dog was asleep! I started waking up at about 2 AM naturally. I would get up, and do my reading, or start my paper. Then, around 4 am, I would start to get sleepy, and I would go back to sleep. I would wake up again around 6 am and fool myself into feeling as though I had gotten a full night of sleep. I still wake up in the middle of the night to this day, especially during budget season. Being able to compartmentalize your various roles in life in order to give attention to whatever is needed at a given moment is the key.”

What advice do you have for nursing students of today?

“Look broadly for opportunities that you are truly interested in. I look at people who really flourish, and they find that one area that they are particularly passionate about. Try to land your first job in an area of healthcare that you love. This way, you will be energized to learn a lot. Whether it’s chronic disease, prevention, or anything else, find a niche that you love, and then what you do will not be your job … it will be your career.”

This story was originally published by MedPage Today, a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals and provider of free CME.

A Year of Questioning Authority

A Year of Questioning Authority

Creative Nursing: A Journal of Values, Issues, Experience, and Collaboration is a peer-reviewed professional journal, with an overarching theme for each year and a related theme for each of our quarterly issues. Creative Nursing 2017 has been a year of Questioning Authority.

Questioning Authority: What Does It Mean?

Our mission for the year was to examine, evaluate, and criticize the body of knowledge that informs our care. The principles that guided our journey were:

Humanize patient care. Let the people we care for decide how they want to be cared for. The unit of experience is the intervention with the individual. Use common sense – no matter what authority says, do what is right for the patient. Think like a nurse.

Know who and what constitutes authority: Self (conscience, judgment, critical thinking); peers; patients, families, and other caregivers; nurse educators and theorists; physicians and other health care professionals; health care organizations and their policies; regulators; third party payers; national and community leaders; social conventions; the media; evidence-based practice. The list goes on.

Standardization values compliance over creativity. At specific times, standardization and compliance are paramount, but of all the actions nurses take in their professional practice, those times are very few. The rest of the time, we need creative nursing: wide eyes, open ears, open minds, and a healthy skepticism, in order to reimagine the next health care system. Topics in this issue included deferring to expertise before authority, Dorothea Orem and self-care, teaching millennials and Generation Z, and whether virtual simulation and pre-op teaching actually work.

Questioning Authority: What Does It Take?

“It is at the intersection of the self and the other that true reflective practice occurs,” says guest editor and Curry College nursing professor Susan A. LaRocco. In this issue, we talk about what it takes—the attributes (personal and system) required—to challenge assumptions.

It takes courage: Facing fears of retaliation or marginalization; finding strength in trial and error and in failing forward; having confidence in our Ways of Knowing.

How do we process what we dare? Through reflection: debriefing for meaningful learning.

What else does it take? Humility, authenticity, tolerance for disruption, leadership that creates a safe environment for questioning.

Other topics included helping teammates work together through “virtues in common;” healthier work environments for academics and certified nursing assistants; helping new nursing professors become excellent teachers; unintended consequences of some JCAHO mandates; how understanding triggers could help nurses influence health behaviors; and how the movement to establish nursing as a profession distinct from medicine succeeded in the face of paternalism and misogyny.

Questioning Authority: What Does It Look Like?

It crosses boundaries. It is interprofessional, interdisciplinary, and respectful of individuals’ unique personal resources and contributions.

It advocates courageously for patients and families.

It uses science and art to humanize care.

For this issue of Creative Nursing, we found role models, exemplars, and stories of responses to educational and societal silos, inspired uses of simulation and art to humanize care, creative ways to recruit and retain valuable individuals in the nursing profession, and the application of nursing expertise to correct a scientific and cultural wrong number. The most moving story is by Joanne Dunn, from a health care skills simulation lab at the University of Worcester in England. Her depiction of a simulation of a typical busy unit on a typical morning moves us to reject the assumption that simulation lab exercises can never truly replicate what it means to be a nurse.

Questioning Authority: What is the Impact?

In this issue of Creative Nursing we explored the impact on both process and outcomes, for both patients and those who care for them, in all arenas. We highlight a nurse theorist (Margaret Newman) who went against prevailing views of what constitutes health and illness; a biomedical scientist who questions currently accepted treatment for patients with breast carcinoma in situ; and a nurse and former Minnesota state senator who found the legislature to be a practice setting in which challenging assumptions and demanding reliable, authoritative, scientific justification for existing or new law is the major function of the role.

We invite you to experience the wisdom of our thought leaders, and to consider making your own contributions to Creative Nursing. To learn more about the journal, visit www.springerpub.com/cn.

My Experience as a CNA

My Experience as a CNA

My name is LaShayah (call me Shay), and I have been a Certified Nursing Assistant (CNA) for six years. I honestly love what I do! Although some people may look at me as the poop cleaner or waitress, I see myself as an important part of the health care team. With pride I assist the nurse with wound care, collecting blood, and performing EKGs among other tasks. With pride, I lend an ear for concerns, fears, and uncertainties to my patients. With pride, I help with urinals, bedpans, baths, and changing linen. These are important things to be done and if I am on your team, believe that it will be done well and with a smile. Most people do not look at those “little things” as being significant, but imagine having to do my tasks on top of educating, medicating, and nursing your patient back to health.

I often see or hear nurses say they are “glad they are not the CNA” because we have to clean poop. Yet, there are so many other things that we do! So many times patients have expressed their dislike for the nurse or the care they are receiving to me. I then need to inform the nurse so hopefully the matter can be cleared up. Many times I have encouraged a patient to take medication, because they gave the nurse a hard time. (Just to be clear, I have never administered medication.) I always encourage my patients to ask questions because they do not understand certain things and are afraid to bother the nurse or doctor. While wound care is being done, I remind the patient to hang in there and remain strong. Do you know how good it feels to have someone say they are glad you worked the shift with them because they do not know what they would have done without you? The nurse cannot do everything, and I just love being the support that they desperately need some nights. Key word: support; not servant or personal runner.

These days, I work on a heart failure and thoracic unit at a hospital. This was one of the best decisions I could have ever made. Cardiology is one of my passions. It can definitely be hard seeing people so sick, but learning how to interpret EKGs, and seeing positive changes in patients after they come back from procedures such as cardiac catheterizations and pacemaker placements is amazing. I work the night shift, which in itself can be hard, but I really love it. When I come on shift at 19:00, I receive report and begin rounds. Vital signs are done every four hours on this unit at 20:00, 00:00, and 04:00. Every morning, heart failure patients are weighed and EKGs are done for those who had procedures done the day before. I often care for patients with LVADs (left ventricular assist devices) and chest tubes. With LVAD patients, blood pressures are not obtained with the automatic cuff of a blood pressure machine. A MAP must be obtained with a sphygmomanometer and Doppler. This is a skill that I am proud to have. Around 21:00, I check blood sugars. By 23:00, I prepare to recheck vital signs and say goodnight to my patients. Throughout the night, I answer call bells, pick up blood for transfusions, assist with turning patients to offload pressure, and encourage my team that we can make it through to 07:00. From 04:00 to end of shift, I am checking vital signs again, giving baths, performing EKGs, and checking weights.

Being the support that the nurses (and sometimes doctors) need is rewarding to me because some nights can be truly hard. Although not very often, we have rapid responses and code calls. Patients have incontinence accidents because they are not used to taking diuretics. Sometimes patients go into funky dysrhythmias in the middle of the night and need one or two EKGs per the nurse’s or doctor’s instruction. Often, a nurse is in one patient’s room for literally the whole night because he or she is in really bad shape. I enjoy being there for my nurses providing them with encouragement and support.

Currently, I am finishing prerequisites for nursing. I can now apply for a program next fall. I am so excited and look forward to learning the skills that RNs possess. I am grateful for the great nurses that have answered my questions, and encouraged me to continue into nursing. I am also grateful for the good and bad examples of nursing that I have seen because although everyone has a unique style of care, they have shown me what to do and what not to do. I am grateful to be a CNA because I see things from this point of view, and this experience will keep me humble when I become a registered nurse.

On a final note, please appreciate your CNAs! Do not over delegate and remember that it is okay to help us out sometimes, too! We are supposed to be a team and when everyone is on the same page for the patient, the shift moves along smoothly. Some of us may be rough around the edges, but remember that we have quite a bit to complete throughout our shift. Oftentimes, the CNA-to-patient ratio is greater than that of the nurse-to-patient ratio and each patient has different needs. The different color of our scrubs should not change the fact that the patient is the number one person in the room. Not the nurse or CNA. Do not look down upon CNAs because at any given moment, it could be you that has to help a patient get cleaned up if the CNA is tied up in another room or not there at all. No matter what your view is of the CNA, we are an important asset to the health care team and the patient. After all, who else is going to lift a butt cheek up for you to place a dressing?

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.

Get More of What You Need from Your CNE—Your Association Can Help

Get More of What You Need from Your CNE—Your Association Can Help

Continuing nursing education (CNE) is both a blessing and a curse for the working nurse. You recognize that keeping fresh and up to date on new procedures, equipment, and protocols will improve the care you give patients. Yet carving out time to take classes (even virtual ones) is challenging.

That’s why nurses are coming together in their nursing associations to ensure that their CNE is exactly what they need to maintain certifications, stay current on health care issues, and keep their peer-reviewed classes efficient and effective.

No organization is more aware of continuing education’s critical role than the Society of Pediatric Nurses (SPN), the premier pediatric nursing society representing over 3,300 pediatric nurses dispersed over 28 specializations.

“The practice of pediatric nursing is constantly evolving, and pediatric nurses need current, relevant information to be effective in their jobs, especially in an ever-changing health care environment,” says Kim Eskew, MBA, CAE, executive director of SPN.

Rather than guessing what pediatric nurses wanted or needed from an education program, SPN – with the assistance of its association management partner, SmithBucklin – conducted an education needs survey of its membership. The purpose was to identify the desired educational topics and delivery modes.

“Overwhelmingly, our members responded that they wanted specific clinical content in a variety of areas such as behavioral and mental health as well as the care of children with chronic conditions,” Eskew says.

The results fueled SPN’s plan for creating and implementing new education opportunities for pediatric nurses to earn CNE contact hours. SPN developed an online education center, which provides easy access to online classes and helps members track their progress. SPN also offers six free webinars annually for members, and is publishing specialty books on mental and behavioral health. Overall, SPN increased its accredited contact hour offerings from 19.75 contact hours in 2014 to an anticipated 83 contact hours in 2017.

SPN’s new education programs led to improved clinical performance. Last year, 62% of SPN education participants reported actual changes in on-the-job practices due to the education provided. SPN also created pre-licensure and residency competencies that outline the professional guidelines and standards expected in programs for pediatric nurses. These professional competencies help ensure that pediatrics remains in the forefront of the general nursing curriculum, and they guide development of hospital-based residency programs.

“The survey helped us to better understand our nurses’ educational needs,” Eskew says. “The findings have been incorporated into our organization’s three-year strategic plan, which calls for the implementation of evidence-based education that will help our members provide high-quality care to their patients.”

Another nursing organization, the Association for Nursing Professional Development (ANPD), has been tailoring education offerings to the wishes of its members since 2013. ANPD is a 4,000-member organization that advances the specialty practice of nursing professional development for the enhancement of health care outcomes. One of the primary goals of its enhanced education program was to increase the relevance to nurse professional development leaders, such as charge nurses.

“Rather than relying on speculation or hearsay, ANPD asked its members: Does the education program meet your needs?” says Kaye Englebrecht, executive director of ANPD.

Additionally, ANPD framed its education by consulting with an accrediting body, which takes into account the standards of excellence governing a profession’s continuing education programs. This is especially important for nurses because accredited continuing education is required in order to maintain their certifications, licenses, or other job requirements.

After assessing its members’ educational needs, ANPD worked with its association management partner, SmithBucklin, to enhance its education programs by implementing new technologies, such as online programs and on-demand webinars. From 2014 to 2016, ANPD quadrupled its offerings for members to earn CNE contact hours. The association created online programs, offered 10 free webinars annually for members, and developed the Nursing Professional Development Quick Guide Series (a go-to guide for executing educational activities).

ANPD also developed the Frontline Nurse Leader curriculum, an online program that provides the bedside registered nurse with leadership knowledge to function effectively in a charge nurse position.

“We wanted to offer our members education that they couldn’t find elsewhere,” Englebrecht says. “Our board of directors was awesome. They were open to every new idea we presented them.”

As a result, conference attendance increased by 12% from 2012 to 2017, and membership increased more than 30%.

Additionally, a quality CNE program has impact beyond a professional’s credentials. From a public health perspective, an educated health care workforce improves patient care in hospitals, clinics, and medical offices.

“Better education means better patient outcomes and a higher quality of care,” Eskew says. “For hospitals or health systems that seek accreditation based on clinical benchmarks, highly educated nurses are an asset, and a better-educated nursing staff means a healthier community.”

Because they are peer-led, nursing associations are better able to adapt and respond to issues affecting their profession. They can provide webinars and on-site education programs that are timely and relevant. These programs often lead to changes in best practice guidelines and sometimes industry standards.

“Unlike other purveyors of education, nursing associations are wholly focused on helping their members succeed,” says David Schmahl, executive vice president and chief executive of the Healthcare + Scientific Industry Practice at SmithBucklin. “Each nursing association maintains its own body of knowledge that defines core domains and competencies required for the profession, and it ensures its members’ professional development is moving forward.”

“What’s really great about fulfilling your members’ education needs is seeing them grow and develop in their careers and knowing that you played a significant role in helping them achieve their goals,” Englebrecht says.