In the thick of the national opioid epidemic, hospitals are making a commitment to cut down on opioid prescriptions. Intermountain Healthcare, a Utah-based hospital chain, pledged to decrease opioid prescriptions by 40% in 2018.
Making a commitment to addressing the opioid crisis is a crucial first step. However, only addressing the patient-use side is not a holistic approach to the problem.
The mental health of the nurses and doctors who care for overdosed patients are not considered in the opioid equation. Yet every day they feel the magnitude of the epidemic, and they are left alone to manage their pain. Ultimately, they may leave the profession altogether without support in facing this problem.
Have You Asked How Your Nurses are Feeling?
Nurses are our frontline warriors in this epidemic. Several times each day, they’re responding to the screams of withdrawal, managing the inherent chaos of addiction, and dealing with family members who demand an immediate solution. For many patients, it’s the second, third, or tenth time to the emergency department for the same problem. So they’re desperate, angry, and looking for someone to blame, often defaulting to the nurse.
As the VP of Clinical Operations for a nurse staffing agency, I’ve had nurses from hospitals around the country explain that they feel that they’re enabling drug-addicted patients by administering pain medications. However, “managing pain” is an important aspect of HCAHPS. So, nurses are conflicted between caring for a patient and adding to the problem. This conflict can lead to anger, stress, and frustration among nurse staff, and in some cases, could drive nurses to quit.
The best thing hospital leadership can do is to mentally prepare nurses to care for these difficult patients. This will also help improve employee communication in often difficult situations.
Provide a Solution
Recognize the potential of this problem. I make personal visits to our nurses on assignment and always ask them how they are dealing with opioid-addicted patients. It is important to identify who is having issues on your team. Surveying your nurse team to ask if they feel respected at all levels and supported in their job challenges is a great strategy to begin with.
Build a plan to address those who are experiencing an emotional response. It should include a healthy dose of continuous learning intended to help build understanding and empathy for patients’ needs. Seeing how our nurses were affected, we now incorporate training on how to care for drug-addicted patients in our curriculum, as well as provide consistent follow up while nurses are on assignment. We want to pre-expose them for what they might face and be there for them when they face it.
There will likely be multiple tiers of support needed – varying from the occasional discussions about a particularly challenging patient to more intense, personalized support from your human resources department. Everyone has different experiences and belief systems about addiction, so allow for that. One of the hardest things to address is that opioid-addicted patients should not be discriminated against.
Following Up is a Must
Consistent follow up is necessary to support your nurse and also allows for positive patient experiences. If your nurses feel that you constantly empathize with them, they will feel the support they need when caring for such patients.
If your team has developed a great plan in addressing this issue, please share it with others. This will be a positive step for patients, and your nurses who are the backbone of the health care industry.
When you think about an infusion nurse, the first thing that pops into your mind is one who works with patients in everything from cancer treatment to skilled nursing care. But Kristopher Hunter, BSN, RN, CRNI, VA-BC, shows that there are so many other paths an IV nurse’s career can take. Hunter works as a Senior Technical Service Engineer for 3M.
“My current infusion therapy job is unusual in that I spend a significant amount of my time in meetings discussing infusion therapy needs and trends, on the phone answering clinical questions from nurses from around the world, in the lab tinkering, or in my office working on projects like educational modules,” Hunter explains. “I occasionally travel to speak from a podium to infusion therapy or vascular access professional organizations.”
Hunter took time to answer our questions to help us celebrate IV Nurse Day. What follows is an edited version of our interview.
What does your job entail? What do you do on a daily basis?
My expertise is in care and maintenance of vascular access devices in various care settings such as acute care, long-term care, and home infusion. In my role as a senior technical service engineer at 3M, I educate and consult on infusion therapy-related topics with both nurses working clinically as well as 3M scientists, to help develop innovative solutions that keep the patient and the nurse at the forefront. One of the particular tasks I am charged with is what is known as usability engineering, a fancy term for “Can someone use this?”
I love the challenge of identifying not just how we would want nurses to use something, but how the nurses in the real world actually use tools in their day to day jobs. Little things like how one peels the liner from the dressing, or whether the antimicrobial is attached to the dressing or a separate piece, makes a huge difference in how usable a product is and how easy it is for nurses to comply with best practices.
Why did you choose this field of nursing?
Infusion therapy chose me. I started my career looking to work in cardiac critical care, but fell into a minor infusion therapy role in a skilled nursing facility when I first started out. From there I moved into acute care, and home infusion, vascular access, and outpatient infusion/oncology. I found the specialty to be extremely rewarding, as it offers a near perfect mix of technical procedural excellence—that other procedural nurses know such as in the cath lab or OR—but also retains that personal 1:1 patient care that I value. Some of my best memories from this role are the conversations with some amazing people.
What changes, if any, have occurred lately (last year or so) in being an infusion nurse?
I believe there has been an overall growing trend within infusion therapy surrounding the awareness of PIVs. As the research continues to mount we are finding that they play a much more significant role than we imagined. For many nurses the humble PIV is seen as disposable, but I have seen growing awareness around the country of changing the practice from scheduled PIV exchanges to maintaining functioning and healthy PIVs until clinically indicated.
What are the biggest challenges of your job?
Clinical practice varies greatly between hospitals, states, and regions of the country, not to mention internationally. It can be a challenge keeping on top of all the diverse needs of infusion nurses.
What are the greatest rewards?
I often hear stories from nurses, and our staff in the field, about solutions that I personally worked on that made a positive impact for patients. For example, I recently provided information about adhesives and skin-saving interventions to a nurse at a children’s hospital so she could make an educated decision on what products to use. I love how my very small contributions can help nurses improve patient’s lives.
What would you say to someone considering this type of nursing work?
Infusion therapy is a diverse specialty that affords any nurse many opportunities to explore and expand their career. If you are technically and procedurally inclined, you can focus more on vascular access. If you love the personal 1:1 connection with patients, then outpatient infusion is amazing. Infusion therapy touches nearly every other nursing specialty and offers a fantastic way to explore your nursing career.
Certification is so important—not just for your career, but the profession. It is important that we all take measures to study and improve our practice so that our patients are receiving the best possible care. I believe that certifications are a great way of showing that you are willing to go the next step. If you give IV medications or insert IVs, you are practicing infusion therapy, and I would urge nurses to look into the CRNI and VA-BC.
When correctional nurse author and educator Lorry Schoenly, PhD, RN, was writing a book about nursing in prison, her publisher asked her who would buy the book. “We were trying to figure out how many correctional nurses there are,” said Schoenly who scoured state boards of nursing for the numbers of those specializing in corrections. But, unlike cardiology or obstetrics, correctional nursing was rarely listed as a specialty and Schoenly was unable to get a reliable count. “It’s an invisible field,” she said.
But even though centralized data on staffing trends in corrections healthcare is elusive, the demand for NPs and PAs is expected to grow. According to UConn Health, which currently staffs Connecticut’s correctional institutions with “half MDs and half midlevels,” increasingly more “midlevels” are being utilized. “Future job growth will most likely continue to rise as incarcerated populations rise and the age of the population rises,” a UConn Health representative told MedPage Today in an email.
Although rising rates of overall incarceration leveled off in 2006 and reversed a bit after 2015, life sentences have increased almost five-fold since 1984.
This increase in life sentences, along with longer sentences and more incarceration late in life, has contributed to a trend, often referred to as the greying of the inmates. “People are growing old in prison,” said Owen Murray, DO, MBA, vice president of offender health services at the University of Texas Medical Branch in Galveston.
UConn Health noted that inmates 50 and older are the fastest growing demographic in federal prisons. With advancing age comes an increase in chronic disease, physical disability and cognitive decline. In Texas, there is pressure to either maintain current staffing or add more providers due to this shifting demographic. Spending per state is associated with, among other factors, the percentage of individuals 55 and older who are incarcerated, according to the Pew Charitable Trusts.
Greater use of NPs and PAs is one way prisons can provide legally required standards of care at lower cost. “The real impetus to use the lowest cost practitioner is not because there is less attention to quality, but to drive down healthcare costs,” said Kamala Mallik-Kane, MPH, a researcher at the Justice Policy Center at the Urban Institute.
Murray has noticed a rising presence of NPs and PAs over the past three decades. “Certainly as it relates to both jail and prison medicine, there has been a significant increase not just within the state of Texas but pretty much every other state that I’m familiar with in terms of the growth opportunities for midlevel providers.”
According to the American Academy of Physician Assistants, the absolute number of PAs working in prisons increased from 1995 to 2015. For NPs, a survey conducted by the American Association of Nurse Practitioners demonstrated that since 1999 the estimated NP population working in corrections has grown from 550, or 0.8%, of total NPs in 1999, to 2,400, or 1.1%, in 2016.
According to UConn Health, staffing depends on the medical acuity of the inmates, the inmate population and the level of onsite infirmary services.
Predicting future workforce demand for NPs and PAs depends on many conditions beyond sentencing, policy, and crime rates, according to National Institute of Corrections, and incarceration rates could change again depending on policy of the Trump administration. Whether that means releasing low-level offenders, potentially increasing the number of immigrant detainees, diverting offenders from the criminal justice system, or rollbacks in sentencing reform is unclear.
As people enter prison with high health needs – from a lack of preventive healthcare, substance abuse, or homelessness — for some, incarceration provides stability. “There’s an expression,” said Mallik-Kane, “three hots and a cot,” meaning regular meals and shelter. “A person with medical needs might now have access to healthcare. On the other hand, there’s criticism of the quality of prisoner health services.”
In an Urban Institute study of a group of people returning to a major city from prison, 80% of men and 90% of women had chronic health conditions requiring treatment or management; 15% of men and more than one-third of women reported a diagnosis of depression or mental illness.
In Texas, as the complexity of care has grown, the demand for PAs and NPs has grown. “The midlevel provider group has really become the backbone of our delivery system augmented with our physician group,” said Murray.
Yet as prisoners’ medical acuity has increased, healthcare spending in corrections has decreased from a peak in 2009. In some states, the downturn stems in part from a reduced prison population. But states with relatively larger shares of older inmates have higher per-inmate spending for these more complex patients continues to pose a fiscal challenge.
According to Maria Schiff of The Pew Charitable Trusts, outsourcing the employment of clinicians has become increasingly appealing for states to overcome the challenges of recruiting healthcare workers to remote prisons. Private entities can offer hiring incentives, student loan repayments, and bonuses where state agencies are prohibited from doing so.
Schiff said there are 50 different programs in the U.S. since each state raises its own tax money and allocates to corrections. “There’s no nurse to patient ratio that is standard among hospitals, and [corrections departments] are no different, but states do track the age, the gender and certainly the average daily census of who they’re incarcerating,” she said. Anecdotally, several states noted that their staffing ratio of NPs or PAs to physicians is about two to 2.5 to one.
Two issues that remain for any provider considering a job in corrections is their personal safety and litigation exposure.
Unlike outpatient settings, providing continuity, rapport and safety in correctional healthcare can sometimes prove impractical. Inmates are moved often and even in secured settings, the risk of violence and danger is ever present. “A big theme is always personal safety,” said Schoenly. “And the expectation is that you’re doing evidence based standard of care because it’s very litigious. We have a saying that if you haven’t been named in a lawsuit, you haven’t been in correctional healthcare very long.”
The Joint Commission’s presence is limited in correctional healthcare. Unless a health care organization is in a state that requires its accreditation or is in part of an agency such as Veteran’s Affairs or the Department of Defense, which also require accreditation, its process is voluntary. The Joint Commission doesn’t require specific staffing levels, but it does require a sufficient number and mix individuals to support safe care. The American Correctional Association (which declined to comment for this article) and National Commission on Correctional Healthcare operate in corrections and can be consulted to review their policies and procedures. Accreditation can sometimes offer a layer of protection against malpractice, but does not ensure immunity.
These risks do come with rewards, said Schoenly, who views correctional healthcare as a mission to serve the most underserved population in healthcare, and one with broad public health implications, since most inmates do return to society. “You realize that this is really a part of our society who is marginalized and who desperately needs healthcare,” said Schoenly. “And the idea that it’s a vulnerable population with great need can draw in individuals who want to possibly help and improve society.”
Prior to starting my first nursing job, I hadn’t heard of a nursing portfolio. As far as I was concerned, all the important documents representing my nursing career were a mumbo jumbo pile somewhere in between my nursing school books and my long lost social security card on my black hole of a bookshelf. Every time someone asked me for my CPR card it was a five-day task that got moved to the bottom of my to-do list each day. When I started my nursing residency at my new job, I was told i was going to have to create a portfolio. I dreaded this, too. I continued to put everything in a pile on my bookshelf until the week before it was due. While that wasn’t the best idea, the outcome was fantastic. I now have a large binder that is my go-to for anything nursing related.
So what is it, and how do you make one?
A nursing portfolio is a compilation of anything and everything nursing related. The idea is to have everything in one place so that when you apply for a new position, apply for certification, or are asked for a copy of your CPR card, you’ve got it in a second! Some items that I included in my portfolio are:
- Nursing license
- College diplomas
- BLS Card, ACLS Card, PALS Card
- Letters of recommendation
- Copy of resume & CV
- Copy of Daisy nominations
- Copy of recognitions from coworkers
- Copy of all certificates for training, classes, etc.
- A collegiate writing sample
- Evidence of committee/hospital involvement
- Thank you notes from coworkers and families of patients
- CEU certificates
- Transcripts from nursing school
- Evidence of community involvement
- Copies of evaluations
- Copy of professional presentation posters
Start by gathering items like these. Place them all in a box if you need to, or spread them out over your entire dining room table and drive your family crazy (like I did). Then, start organizing them into sections like professional development, community involvement, education, recognition, CEUs, etc. I strongly recommend organizing your portfolio using labeled tabs so you can easily find something or easily open up to a specific document if asked to do so in an interview. I stuck to six sections total so I wasn’t overwhelmed.
Other hints from my residency director (also known as the lady who knows this stuff inside and out!) include remembering that nursing portfolios are professional—they are not a scrapbook! As tempting as it is to add decorative pages, pretty colors, etc., do keep in mind that this portfolio is to be used as a collection of all of your professional accomplishments. As such, a handy dandy tool for your portfolio are page protectors. I went ahead and invested in a 500 count box and placed several extra at the end when I was finished. When i get a certificate now, instead of throwing it on my bookshelf, I at least put it in a page protector in the back so I can organize it the next time I sit down to refresh my portfolio.
Feel free to add anything relevant to your career, whether it be work-related or not. For instance, if you work on a neuro unit and volunteer with children with spinal cord injuries, you would definitely want to include something about your experience. You can type a simple word document outlining your duties, role, hours spent, etc. and have it in your portfolio. This would be a place that would be acceptable to place a picture or two of your volunteering experience.
Finally, get creative! Think: if everyone else had a portfolio, what would make mine stand out? While your nursing license and college degrees are essential, everyone has these items. Don’t forget the little things that make your career special—notes from families and patients, pictures and articles of you in your hospital newsletter, and so on. These not only make your portfolio more appealing and personal if you utilize it in an interview or professional setting, but also will make it that much more memorable in 20 years when you can look back on everything you have accomplished.
I hope these tips will help you get started. Feel free to comment any other suggestions you have or questions you have for me. Good luck and happy organizing! I guarantee you’ll thank me next time you have to provide your CPR card.
Life as a Neonatal Nurse Practitioner (NNP) is like an ocean tide on a gray day! The only certainty is the start and end to the day. We deal with patients and families experiencing the shattering of the hopes, dreams, and plans they imagined when becoming pregnant. In an instant, their life is turned upside down and they enter a foreign world of new terminology, high technology, and their most vulnerable possession… their son or daughter at the hands of strangers. In some cases, there may have been some introduction and preparation of what to expect. However, for the majority, families are just trying to grasp the reality that their infant was born. After all, the birth of an infant is typically a joyous event enveloped with laughter, celebration, and family. Typically, our role is delivering the news of not only how we need to “take your baby to the NICU,” but also rattling off the list of what we did, what they can do, allowing them to see the infant (in some cases through a peephole), and then leaving with a door probably bellowing as it closes behind us.
There are many things to love and hate about being a NNP. There is the black and white task of the position, which may not be the favorite part, yet it is an essential piece to assist in making optimal and safe management decisions. Our day traditionally starts with getting sign-out from the on-call team, dividing up our patient load based on acuity, obtaining pertinent stats from the medical record, and reviewing notes. Next, we join the multidisciplinary team for daily rounds. Since we are part of a teaching institution, this can be an overstimulating feat even as a neurologically intact adult. However, the benefits of daily rounds on each patient certainly outweigh the challenges of parading with what seems like a million people for an eternity. Rounds provide us with critical firsthand observations, vital feedback from nursing staff, and inclusion of the family if present. It is a way for all disciplines to hear the infant’s story, plans, challenges, and successes. Rounds allow us to be facilitators of the medical plan, advocates for the patients, and to mentor/teach other disciplines. After rounds, we pursue the downhill trajectory of our concrete tasks of entering orders, connecting with consults, writing notes, and updating the problem list. This is not the most glamorous part of our role, but vital for consistency and progression of care.
Then we enter the world of LOVE it! There is so much to love about being a nurse practitioner, especially in a tertiary center NICU such as ours. No patient is easy or straightforward. Our patient population comes from mothers typically of higher risk—medical, social, mental health, or a combination which accompanies challenges and obstacles separate from the infant. Infants born to these mothers often have multiple medical issues that lead to chronic issues and prolonged hospitalization. The diversity of illness and complications these infants possess challenge us as nurse practitioners to have a high level of knowledge specific to the neonatal population. This fosters our learning on a daily basis to continually be more proficient and knowledgeable; there is constant intellectual stimulation.
Due to the complexities of our infants and families, we are fortunate to collaborate with nurses, social workers, case management, child life, physical/occupation/respiratory therapists, medical staff, and multiple consults. In our facility, we truly have a village participating in the care of our most vulnerable patients and families. As a nurse practitioner we are able to build close relationships with these disciplines, respect their roles, and promote the best patient experience for our families with the hope of optimal outcomes.
A much respected neonatologist used to say “listen to the baby.” As NNPs, we use our knowledge and experience to listen to our babies. However, we also extend that skill to communication with the parents of our infants. We need to establish a sense of rapport with the families. We have the privilege of delivering good news, such as “your baby is going home.” However, sometimes we need to deliver difficult news or be physically present as parents receive difficult news. Typically, we remain present with the family afterwards to provide empathy, clarity, and support.
The role of a NNP extends beyond the NICU. At any time, the ringing of phones signal to us that our presence is needed in Labor and Delivery. We attend all deliveries of preterm infants, infants with identified anomalies, or any delivery where there is a potential risk to the infant whether it is preterm or term. We can be called to General Care Nursery to assess a well infant with an evolving issue or need for further assessment. Further, our role is not limited to our hospital. The NNPs in our facility go on both air and ground transport to pick up critically ill infants requiring escalation of care. Here we use all of our skills to not only stabilize an infant for transport, but also make an initial contact with the family and provide reassurance as we prepare to separate them from their infant.
As a NNP, our days are unpredictable like the tide of the ocean. The knowledge and resources we need to provide the care to our patients and families are vast. The path we take with each infant and family is unpredictable, ranging from a calm rippling stream to a raging tide feeling like a tsunami. But the rewards of seeing infants make progress and parents evolving from being hopeless to feeling empowered and connected makes every day worth it!
If you ask any nurse what their favorite thing is about wearing scrubs (besides the fact that they are basically PJs), they will most likely say “pockets!” Scrub pockets hold all of the essential tools that a nurse needs to survive a shift. If you’re a student or a new nurse, you might not know yet exactly what you should keep in your pockets. So here is a list of 14 pocket nursing essentials:
1. Pens and highlighters
You can never have enough pens! Highlighters are also a great tool to use if you want to mark important information about a patient on his or her chart.
Nurses get up close and personal with lots of people, so fresh breath is a must.
3. A snack
Maintain your blood sugar and be prepared for those busy days when you may not be able to get a break!
While a paper towel or scrub pants will work for jotting down vital signs, sometimes it is nice to have paper.
Whether you choose to keep your stethoscope around your neck or in your pocket, a stethoscope is an absolute must for a nurse.
6. Lip balm
Hospitals are cold and dry. Coat your lips in lip balm to prevent the inevitable chapping.
Between taping up IVs and blood draw sites, you’ll certainly use a lot of tape throughout the day.
8. Alcohol swabs
Chances are, regardless of your nursing field, you will deliver at least one IV push med each shift. Make patient safety easy by keeping alcohol swabs handy.
There may not always be a clock in your patient’s room. A watch is essential for taking vital signs as well as knowing how many hours before your shift ends.
Be the hero on your unit by having scissors. Put your name on them to prevent other nurses from holding onto them.
11. Pen light
Pen lights are not only good for neuro assessments; they also make great lights for charting at night in a patient room or finding a pill you dropped on the floor.
12. IV flushes
Save yourself time when giving medications or maintaining a line by having your IV flushes always at your side.
13. Hair ties or bobby pins
Avoid getting your hair in body fluids by having a hair tie or bobby pins in your pocket.
14. Hand lotion
After the 100th time washing your hands, your hands will be screaming for moisture. Keep your hands soft and happy with a small tube of lotion.
What do you like to keep in your scrub pockets? Comment below!