In October 2012, Rebecca Lee, RN, was working at Bellevue Hospital in New York City. Hurricane Sandy hit, and it hit hard. Lee recalls that all the subways, highways, tunnels, and bridges were closed. Streetlights were out. Robberies and looting was rampant throughout the city. “We had to walk in the middle of the street to stay safe in the meager moonlight,” says Lee.
But she wasn’t outside much. She stayed at the hospital for five days and four nights, working, as she says, “24/7.”
To remember this stressful time, Lee, who runs natural health remedies resource RemediesForMe.com, wrote a memo to herself on October 31 of that year so that she would never forget. The following is what she wrote:
“While the storm worsened, staff secretly stole peeks out the darkened windows, trying hard not to let our fear show to the patients. Most of my patients were bedridden and kept asking how the conditions look outside. All I could say was, ‘it looks okay,’ as their concern wrinkles on their faces momentarily smoothed out.
They must’ve known the storm was getting bad because the rain was beating the windows hard, and their televisions now showed nothing but static. I tried to keep them as comfortable as possible as I saw the batteries on their machines running low, lights suddenly shutting off, and phone lines being disconnected.
After a few short hours, the FDR had completely disappeared under the east river, and the water was quickly reaching Bellevue doors. The scariest thing I saw that night was cars that had been parked next to the FDR were being swept away by the waves. We also lost contact with the outside world. We worked while wondering about the status of our families, friends, cars, and homes. The staff began to wonder how long they would be trapped for.
The next day, it became clear that we had lost all power, food, water, and each minute became more precious than the next. The coast guard, along with hospital staff, formed human assembly lines on the dark stairway, all the way up to the 21st floor. They helped transfer patients by hand, and gave out food and water. Manual machines were utilized, and critical patients were transferred to other hospitals that still had working power.
During the storm, some units pulled together and worked odd shifts to relieve one another from exhaustion and hunger, while other units fell apart and became fierce and chaotic. We had no food, no running water, and no running toilets. After a few days, we were running low on options. Thankfully we had an endless supply of gloves and masks.
Thank you for anyone who volunteered during this time to do all the heavy lifting and dirty work, to make sure everyone was fed, hydrated, and less stressed. I am re-thankful for family, friends, health, food, water, showers, music, clean beds, working toilets, and electricity. On Halloween 2012, I celebrated Thanksgiving.
What I’ve learned through all this: You give and take away.”
Thanks to Lee for sharing her experience.
Have you ever had to work during a natural disaster? Share your experience in the comments.
By the year 2030, it is estimated that one in five Americans will be over the age of 65, and approximately 60% of this population will need treatment for at least one chronic condition. As the U.S. health care system faces the aging of the baby boomer population and the rise of chronic disease, nurse practitioners (NPs) are leading the way by demonstrating positive results in managing care for older patients and the complexity of chronic conditions. This includes innovative practice solutions, research and training, and policy advances at the state and federal level to strengthen access to NP-provided health care.
Demand for nurse practitioners is at an all-time high, and NPs are now the fourth most sought after health care profession, as well as one of the fastest growing. Last year, primary care nurse practitioner graduates outnumbered primary care medical school graduates by more than three times. It’s no surprise U.S. News & World Report ranked the NP second on its list of the 100 best jobs – naming formidable salaries, job security, and increased practice rights as enticements for students considering health care professions. Factor in the Bureau of Labor Statistics’ projection of 31% job growth between now and 2024 (five times the national average for all professions) and the need for more than 50,000 new positions, and we have the right incentives to recruit the next generation of nurse practitioners who can continue strengthening our health care workforce.
But the rising tide of chronic disease is not the only factor revolutionizing the role of the nurse practitioner. Growing recognition of nurse practitioners as key players in the health care delivery system is driving legislative change. Today, 22 states plus the District of Columbia, have made the historic shift to grant NPs full practice authority, providing examples for similar legislation in statehouses across the country. Massachusetts, North Carolina, Pennsylvania and other states are considering comparable legislation, foreshadowing a time when all 50 states provide patients with full and direct access to NP care.
The abilities of NPs to lower costs, improve patient outcomes, and increase patient access have been noted in national studies. In 2017, more than 89% of NPs were trained in primary care, as compared to 14.5% of their physician counterparts. In addition to providing care in traditional settings within hospitals and rehab centers, many are now opening their own practices, working on the community front lines where they deliver comprehensive care, including managing chronic diseases from diabetes to COPD.
With the demand for quality, accessible health care growing, the supply of providers must keep pace. Nurse practitioner graduate education programs are expanding to accommodate increases in qualified applicants, and nurse practitioners are graduating at higher rates. Today, there are roughly 350 colleges and universities with nurse practitioner programs in the United States. In 2016 alone, more than 23,000 nurse practitioner graduates entered the workforce, with the majority prepared in primary care.
With the confluence of aging baby boomers, the rise of chronic disease, health care reform, and focus on prevention and patient-centered care, the next generation of nurse practitioners and the skills they bring to patients are poised to thrive. We are just a few years away from the historic shift when, for the first time in human history, the number of people over 65 will outnumber children under five, and by 2050, this gap will widen to a 2:1 ratio. With this shift comes tremendous opportunity and responsibility for nurse practitioners to practice at the top of their license, serving patients in innovative and rewarding ways. For the 234,000 nurse practitioners and counting, there’s never been a better time to be an NP.
When Teri Dreher, RN, CCRN, iRNPA, owner of NShore Patient Advocates, LLC in Chicago, Illinois, was still working as a nurse, she remembers when a patient kept having massive hemorrhagic episodes after a routine surgery. Despite this, the doctor wasn’t running tests to determine what was happening. When she questioned him, he yelled at her, became defensive, and threatened her. But that wasn’t the end of it.
“The next day, he transferred the patient out of ICU. She went into shock, and the family begged me to intercede. I told the daughter what I would do if it was my family member: insist she be transferred back to ICU and get a CT scan for an interventional study to find the cause of the bleeding,” recalls Dreher. Turns out that the patient had a bleeding splenic artery aneurysm that could not be accessed by the interventional radiologist to stop the bleeding.
Teri Dreher, RN, CCRN, iRNPA
“When the patient came back to ICU, she immediately started bleeding again, and we coded her for four hours, transfusing more than 30 units of blood. During the CODE, I had missed scanning out a narcotic, and 10 days later was charged with being a drug-abusing nurse,” says Dreher. Although her urine test was clean, she was put on 10-day suspension. This convinced her that she would never be happy again working as a bedside nurse. Her nurse manager had warned her not to tell the family member what to do to force the issue.
“I took a course in patient advocacy and started my own business. I vowed that no one would ever tell me not to advocate for a patient again,” says Dreher.
“Nurses today are taught to question, speak up, and challenge when they feel something is not right,” says Dreher. “Decades ago, the system was much more patriarchal, and nurses were frowned upon when questioning doctors. Doctors are human and make mistakes. Nurses spend more time with patients—we are the doctors’ eyes and ears.”
She says that good doctors generally listen to nurses, and nurses are free to speak with physicians as well as mid-level practitioners. If you don’t get a response from the doctor, she suggests speaking with the nurse manager, supervisor, and even the risk management department.
Dreher admits, though, that nurses who are “whistle blowers” can be at risk even with the nursing “bill of rights.” “Everything in hospitals is focused on data, stats, and money. If a nurse goes up against a physician, just do the math regarding who is more valuable to that hospital: a nurse who makes 80K annually or a doctor who makes millions per year for the hospital,” says Dreher. “I almost got fired for strongly advocating for a patient. Even though I was right, I was almost fired by a hospital that I had served well and faithfully for over 23 years.”
As a result, Dreher suggests that nurses still speak up, but tread carefully while doing so. “I think it is important to be humble and go up the chain of command carefully. Doctors have more training than nurses, and sometimes there are things we do not know,” she explains. “Communication is key—as well as respect. None of us knows everything, but if we have the courage to confront and work together collaboratively, everyone wins—especially the patient!”
When I tell people I’m a psychiatric and addictions advanced practice nurse, they are a bit surprised after I share with them my family origins. You see, I come from multiple generations of pharmacists, dating back to the turn of the 20th century when my great grandfather patented medicines around the world and maintained company with the founding fathers of Eli Lilly and Johnson & Johnson. My grandfathers, on both sides of my family, my parents, and numerous aunts and uncles also studied and practiced pharmacy.
Nevertheless, I ultimately decided my career path would include a deep understanding and respect for the role of the pharmacist, but I wanted to practice nursing and provide care to patients with psychiatric and substance use disorders. As an advanced practice nurse, I was able to incorporate prescribing into my practice as a master clinician in psychopharmacology.
My extensive connection to pharmacy and pharmaceutical agents, and psychotropic medications in particular, is why I have embraced pharmacogenetic testing for patients who present with complex diagnostic issues and for whom various trials of medications have failed to provide symptom relief and emotional stability.
Genomind’s Genecept Assay is a simple, in-office, cheek swab-based test that I offer to patients to assist with personalizing their psychopharmacological regimen; it’s painless and easy to perform. The assay explores key pharmacokinetic and pharmacodynamic genes, which affect how the patient’s body may metabolize medications and the potential impact the medication may have on the body. This information provides an understanding of whether a drug is likely to either work properly or produce adverse effects for a patient before he or she even tries it. The details provided by the assay also offer insights into the dosing of medications and potential drug-to-drug interactions based on their metabolism by the various CYP450 system enzymes located in the liver.
With this information, along with the patient’s symptom presentation; medical, psychiatric, and substance use histories; family history; and medication (including over-the-counter and supplemental medications) history, I am able to narrow down the pharmacological treatment options so patients can feel better, faster.
In 93% of patient cases, the Genecept Assay influenced clinicians’ decisions about medications. It helps reduce the trial-and-error approach, time, expense and struggle of finding the right treatment options. I think the results of the assay are especially helpful for patients who are frustrated after multiple medication failures when trying to find a medicine to alleviate their symptoms. As a clinician, the more information I have in my toolbox when working with a patient, the better.
An example of the beneficial results received as a result of using genetic testing occurred when I treated a woman who was in her early 60s and who said she had suffered from a lifetime of depression, dating back to her early childhood. The genetic testing helped me realize she was suffering from low dopamine levels, our pleasure enhancing and energizing neurochemical located in the prefrontal cortex of the brain, the area responsible for executive functioning, including motivation, attention, concentration and organization. This was an ah-ha moment for both my patient and me, as it explained why so many past trials of medications were either ineffective or contributed to adverse side effects.
Based on the results of the Genecept Assay and my patient’s history, I prescribed a psychostimulant, typically reserved for the treatment of Attention Deficit Hyperactivity Disorder. Once dosed to the appropriate level with guidance from the pharmacokinetic results of the assay, it revolutionized her life; the depression lifted and her quality of life improved dramatically for the first time she could recall. Now, at the age of 70, she remains free of depression and is catching up on the life that depression stole from her for so many years.
An important point to emphasize is that the test is neither directive nor diagnostic. For those prescribing advanced practice nurses and other clinicians who may feel challenged by interpreting the results of genetic testing, I can assure you it’s well within your ability to do so and that the companies who offer the testing have extensive clinical support teams to guide you through the results and pharmacological decision-making process. I will also point out that genetic testing to personalize medication decisions is not a new science, as oncology clinicians have been utilizing such reports for years to personalize chemotherapy regimens for their patients.
As health care and the disciplines of psychiatry and addictions continue to evolve, personalized medicine will become more and more the norm. Advanced practice nurses have an opportunity to serve in a critical and leading role during this emerging period by adding pharmacogenetic testing to assist in streamlining psychotropic medication options for their patients. Genetic testing is one of the keys to unlock the mysteries of prescribing psychotropic medications and should be added to the clinician’s arsenal of clinical tools in order to to maximize improvement in symptom relief and quality of life for our patients.
For the last 12 years, Camille Prevost, RN, has worked as a travel nurse. This means that she works for a company via contract which then is contracted with a health care facility. Travel nurses work as temp staff nurses, and they can work for one company or move around as needed.
“There are about 500 companies in the United States, and they vary in terms and benefits,” explains Prevost. “I have worked for five or more, and once as a freelance worker.”
Travel nurses can be contracted for anywhere from 8 to 26 weeks, depending on the facility’s staffing needs. But, she points out, most contracts last for about 13 weeks.
Prevost became a travel nurse “for the adventure aspect, traveling to different parts of the country. I like the challenge of adjusting to a new environment, including working with new people and experiencing different cultures.” As of press time, she’s working at the Northern Navajo Medical Center in Shiprock, New Mexico.
“The greatest challenge being a travel nurse is being ‘the new kid on the block,’ with the facility’s staff. There is the ‘proving ground’ that is always part of a new job. Of course, working in health care is serious business, and you have to develop relationships that include a level of trust and your competency as a nurse,” says Prevost.
The best part of her job? Her patients. “I’m a labor/delivery nurse, so I play a very important role in supporting women during their labor and childbirth,” she says. “My greatest reward is that you are an integral part of a woman’s labor/birth experience—not to mention those magical newborns!”
If you are interested in possibly becoming a travel nurse, Prevost says that you should check the top ten travel companies in the country listed online. “Talk to other travel nurses about their experiences with the companies out there. Pay attention to housing, and make a list of priorities that will work for you. Get all the details—as far as health insurance and when it kicks in, car rental, how far of a commute to the facility etc.,” explains Prevost. “Most facilities require at least 1-2 years of experience in your current specialty. In your telephone interview, ask questions about staffing and the on-call policy for providers. Always know the facility’s protocols and policies specific to them.”
She adds that your certifications must be current. For example, basic life support, advanced care life support, neonatal resuscitation program, pediatric advanced life support must all be up-to-date, depending on the area in which you work.
Prevost gives one final suggestion: know the different computer programs for charting because you will most likely only receive a short orientation to each unit—about 3 days, and then you’ll be considered ready to work.
While people in the United States still use Western medicine, many are also doing so in conjunction with Eastern treatments used for centuries. Jennifer Bjork, MSN, RN, Clinical Educator and Interdisciplinary Partnership Council Site Coordinator at Sutter Maternity and Surgery Center, implements aromatherapy and healing arts with patients. The center began using aromatherapy with patients in October 2016, and added additional techniques in December 2016.
Bjork, who has earned certifications in Clinical Aromatherapy in Obstetrics and Level 1 Integrated Healing Arts, took time to answer some questions about these for us.
Regarding Aromatherapy and Healing Arts: Please explain what these are to those who may not be familiar with them.
Integrated Healing Arts, which includes gentle touch techniques, simple breathing techniques, presence, imagery, and use of essential oils—or aromatherapy—are used to help hospital patients undergoing some sort of stress. We know that hospitals can be stressful places, and we integrate these techniques with traditional medical treatments to help our patients heal by decreasing their stress. We also teach these techniques to our staff, because we know that we are best at helping others when we first help ourselves. Here is a breakdown of our Aromatherapy and Healing Arts program components:
- Aromatherapy is the use of essential oils—liquids taken from plants, flowers, and trees that have been used for centuries to reduce symptoms, such as pain and emotional distress. They are also disinfectants and used to promote a sense of peace and well-being.
- Gentle touch techniques—such as a gentle massage—are simple techniques from many healing traditions used to help a person relax.
- Simple breathing techniques help the body release tension and slows the brain activity.
- Imagery is using your mind to imagine an image that brings a patient relaxation, decreases anxiety, and promotes overall healing. Our bodies do not know the difference between “imagining” an experience and actually experiencing it. We get the same benefit from both.
When do you use these procedures?
We use these therapies any time a hospital patient is feeling pain, fear, anxiety, depression, nausea, or any other form of stress. Any patient, actually, any person—including staff—can benefit from the Integrated Healing Arts.
Why do you use them for the patients?
Being sick, having a baby, and having a surgery or procedure can be very stressful. This stress can cause fear, pain, anxiety, depression, poor sleep, etc. Stress activates hormones and chemical reactions in our bodies that can decrease immunity and not allow us to heal.
How does it help?
We use them to reduce the human stress response by promoting relaxation and stimulating the release of chemicals in our brain that improves immunity, allowing hospital patients to heal. The work with our bodies’ neuro-hormonal-endocrine system helps promote consciousness and relationships.
What are these processes bringing to patients that other methods don’t?
These techniques, or treatments, are used together with traditional medical interventions to treat the human response to illness (i.e., reduce stress, reduce pain, increase well-being, enhance immune function, diminish emotional distress, promote rest, or sleep, etc.). For instance, if a pain medication is not working for our patient, we use one of our techniques to help our patient relax, and thus, allow the medication to work fully and, hopefully, with the least amount necessary to alleviate her pain.
Is there research that it benefits patients or are you going based on anecdotal evidence?
There is a multitude of evidence-based literature to support our use of the Integrated Healing Arts. In our electronic medical record at Sutter Maternity and Surgery Center, our care plans have these methods as interventions for the human response to illness based upon evidence-based practice. These plans are reviewed every year with updated evidence. There is strong evidence that the use of the Integrated Healing Arts can improve traditional medical care by assisting the mind, body, and spirit.
What would other facilities or nurses need to do to implement this into their own situations?
You need support from the leadership team, experiential training in these techniques, a policy that supports the use of these Integrated Healing Arts, rounding to support the staff in using these techniques, and sharing of successful stories to assist the culture in believing that these techniques actually work.
What else haven’t I asked you about regarding your use of Aromatherapy and Healing Arts that you think is important to know?
We know the biological impact of stress or negative emotions can decrease immunity and increase our chances of becoming ill, and once we are ill, not allow us to heal. These Integrated Healing Arts all help ourselves as caregivers, allowing us to be present and get our nurses back to the bedside, where they can do what they do best: provide compassionate care for our patients and assist them in their healing process. We also know these techniques can improve our hospital patients’ overall satisfaction with their care.