Supporting someone with a life-limiting diagnosis or talking about death can be difficult for many people, but not for a hospice nurse.
What’s it like to care for patients and their families in the end-of-life process?
Maryette Williamson, RN, BSN, knows firsthand from working as a BAYADA Hospice Nurse in Fayetteville, North Carolina.
We asked her about her work. What follows is our interview, edited for length and clarity.
Maryette Williamson, RN, BSN, is a BAYADA Hospice Nurse in Fayetteville, North Carolina.
How did you get interested in working as a home hospice nurse? What drew you to it? How long have you been doing it?
I had a home hospice rotation in nursing school, and I loved it. Shortly after graduation, my mom passed, then my sister, then my dad. I was working through my grief at that point. Both my dad and my sister passed away in hospice. That was pivotal because it was such a beautiful experience. It was the best situation a bad situation could be, and I realized then that I wanted to provide that for other people. I’ve been doing it for a year and nine months.
Briefly explain what you do as a home hospice nurse. What types of patients do you serve? What ages are they, and how are they approved for the program? What do you provide for them?
I have several facility patients, but I also have patients in their homes. Building on what patients and their families already know, I provide a lot of education on what to expect near the end of life.
I provide nursing care to manage symptoms and prevent complications, such as positioning, skin care, respiratory, and hydration support. I may also identify and treat an infection. I provide both physical and emotional comfort care—anything from ordering a wheelchair to promote mobility to holding the phone up to a dying patient’s ear so they can hear their family member say, “I love you.”
If I have a relatively stable patient who hasn’t had many changes, I go in and talk with them. I reconcile their medications and make sure they’re still on the same medications we have listed. Then, I check their vital signs, do a head-to-toe assessment, and ask if they have any questions. I chart most of my visits, then go to my next visit. I see about five patients a day.
I’ve had a patient who was 57, and I’ve had a patient who was 106. Hospice can run the gamut in ages—younger patients typically have cancer.
Patients qualify for hospice if their doctor gives them a life expectancy of six months or less. Specific Hospice Local Coverage Determination (LCD) guidelines consider different disease processes, functional limits, and co-morbidities when referring someone to hospice care. We have recertification periods, so every six months, their doctor can recertify someone in decline to comfortably remain in hospice care for the remainder of their life.
Did you need to get additional education to become a hospice nurse?
No, I’ve done long-term care for most of my nursing career. I became familiar with many disease processes people face at the end of life. In long-term care, I did a lot of end-of-life care, even though patients weren’t necessarily in hospice.
However, there was a learning curve from long-term care to hospice. The most significant difference in hospice is our focus on quality of life rather than a cure. That was the most important change for me. Even in a facility, people look for ways to treat a progressive disease. But when a patient has chosen hospice, we prioritize making them comfortable. We treat anything to optimize their quality of life but don’t try to cure their life-limiting disease.
In hospice nursing, you have to meet people where they are.
What do you like most about working in your job?
I like the fact that I get to be with the whole family. It’s almost like you become part of their family; they trust you, and you comfort people through your presence. It’s rewarding to educate a family so they know what to expect and how to help, so they’re not scared and can make the most of their time together with someone they love.
What are your biggest challenges?
I have a great team, but at the end of the day, you’re out there on your own. You don’t have anybody standing next to you to chime in. You can’t draw a blank, so the biggest challenge is the autonomy of it. I’m grateful for the experience and clinical skills I learned in long-term care because they made me more confident in hospice nursing.
What are your greatest rewards in your work?
When the family wants and trusts you to be there and says, “We couldn’t have done this without you.” I want to be that calming presence and provide the knowledge so they can be present for their loved ones’ passing. That’s the biggest reward.
Is there anything else that is important for our readers to know?
Death is a part of life. We’re all going to die. I don’t find that depressing when I am in a place to make that as positive of an experience as possible.Don’t let the idea of hospice scare you away from becoming involved. People think it’s doom and gloom, but there’s so much more than that.
If you decide to become a hospice nurse, don’t think you’ll learn it all in a month. I’m still learning. It’s a different kind of nursing, and there’s a lot of room to grow your skills and experience. Getting your bearings and building your confidence takes time.
We asked her about her work. What follows is our interview, edited for length and clarity.
How did you get interested in your particular field? What drew you to it?
Originally, I did not intend to become a rehabilitation nurse. In 2005, I graduated and obtained a Licensed Practical Nurse (LPN) certificate from the Community College of Baltimore County (CCBC).
While searching for a job, I encountered Kernan Hospital, about 15 minutes from my residence. I submitted an application to work in the Stroke Unit, but the position was already filled. The manager assigned there forwarded my application to the Spinal Cord Unit manager, who granted me an interview and accepted me on her team. That is how my journey started as a rehabilitation nurse, and I have since developed a strong passion and commitment to working with spinal cord patients and families.
Explain briefly what you do. What types of patients do you serve as a spinal cord/multi trauma unit nurse? What do you provide for them?
In general, a rehabilitation nurse provides care for and assists patients in their progress toward recovery, self-care, and independence. The rehabilitation nurse works as part of a multidisciplinary team in setting realistic goals and achieving a treatment plan.
Over the past two decades, I have worked in the spinal cord unit, providing care for patients suffering from injuries related to the spinal cord and teaching and advocating for patients and families.
Did you need to get additional education for this position?
When I first started working in the spinal cord unit at what was then Kernan Hospital, I was a licensed practical nurse. After that, I successfully completed my studies to become a registered nurse.
When the opportunity to do on-the-job studies became available, I took advantage and completed a BSN degree at Notre Dame University of Maryland. I have since risen through various assignments/positions to Senior Clinical Nurse I and am now working to obtain certification as a rehabilitation nurse.
What do you like most about working in your job?
What I like most about working as a rehabilitation nurse is recognizing that the care and teaching I provide to patients and their families–plus the voice and advocacy I add–all combine to work for the healing process of the patients and their families.
One cannot help but feel fulfilled upon realizing that what may otherwise seem like a minor help given and a voice added can help patients regain and maintain their optimal health.
What are your biggest challenges?
Being a rehabilitation nurse is admittedly hard work and can present some challenges in managing the expectations of patients and their families.
However, where a nurse has the passion to care for their patients with a sense of commitment to serve others and provide care for patients with deep or long-term care needs, a rehab nurse can still find his or her work rewarding and satisfactory.
What are your greatest rewards in your work?
My greatest reward is working as part of a multidisciplinary medical team with goals to plan and follow treatment plans for patients and their families with positive patient outcomes.
Of course, a plus is when patients and their families are satisfied with my care and make extra effort to highlight my acts of service and compassion.
While it is challenging, working as a rehabilitation nurse can be rewarding and satisfying, especially when my patients come back for visits, recognize the nurses they worked with, and smile in appreciation for the care and teaching provided to them.
In the setting of acute care, immediate intervention is essential when critically ill patients decompensate. These situations require highly trained experts who can do the job while remaining calm under pressure. Enter the rapid response nurse.
Rapid Response Nursing
“Contrary to common misconceptions, rapid response nursing isn’t solely about dashing from one Code Blue to another,” says Sarah Lorenzini, MSN-ED, RN, CCRN, CEN, a rapid response nurse, educator, and host of the Rapid Response RN podcast. “Much of our focus revolves around preemptive interventions aimed at averting emergencies before they escalate.”
According to Lorenzini, we don’t want things to get to a crisis point if we can avoid it. “While managing crises is undoubtedly exhilarating, there’s equal satisfaction in identifying at-risk patients and implementing interventions to prevent crises. Rapid response nurses like myself serve as specialized resources available throughout the hospital to support colleagues in handling emergent situations.”
When asked if all hospitals have rapid response teams, Lorenzini responds, “Yes, but each hospital’s team might look different. The roles and responsibilities of rapid response nurses may vary from one institution to another, but their primary objective is always to intervene swiftly and effectively to prevent patient deterioration.”
She continues, “Each hospital has a different structure for who responds to emergencies, but they all have the core goal of providing bedside nurses with access to a team skilled in managing emergencies and critically ill patients.”
How Did the Rapid Response Concept Gain Traction?
In terms of how rapid response became prevalent, Lorenzini points to the 100,000 Lives Campaign launched by the Institute for Healthcare Improvement (IHI) several decades ago. The campaign highlighted six critical interventions:
Rapid Response Teams
Improved Care for Acute Myocardial Infarction
Medication Reconciliation
Preventing Central Line Infections
Preventing Surgical Site Infections
Preventing Ventilator-Associated Pneumonia
IHI reported in 2016 that the first ten years saw 75% of U.S. hospitals join the campaign, which is encouraging, even though their data shows that far too many patients still needlessly die.
Lorenzini states, “Hospitals were encouraged to implement these teams to convene at the bedside of declining patients, bringing ICU-level care to any unit.”
“Some hospitals have a system where staff are dispatched from different areas in emergencies (e.g., the ICU charge nurse might leave the ICU and meet up with the respiratory therapy supervisor in the patient’s room). Some hospitals have dedicated interdisciplinary teams whose only responsibility is emergency response.”
How do Nurses Become Adept at Rapid Response?
“While every hospital has different standards, having either ED or critical care experience is needed,” Lorenzini states. “Rapid response nurses need to be able to lead a team in a coordinated effort in emergency response. They need experience administering vasopressors and other high-risk medications, assisting with intubation or other resuscitation skills, and managing a critical patient independently (sometimes for hours) while waiting for an ICU bed to become available.”
While not all institutions require it, having CCRN (Critical Care Registered Nurse) or CEN (Certified Emergency Nurse) certification is one way a nurse can be prepared for the role.
“My best advice is to get really good in your specialty (e.g., ED or ICU),” advises Lorenzini. “Become a preceptor or a super user and be seen as a resource on your unit. If you’d like to be a resource for the entire hospital, start by being the person people call on when they have questions.”
When asked if this is a viable career path, Lorenzini responds, “Absolutely! It’s the perfect mix of ER, ICU, and nursing education rolled into one.”
A Rapid Response Story
Rapid response nurses have many stories about their work, and Lorenzini is no exception; that’s the purpose of her podcast, Rapid Response RN.
She relates this story.
“A nurse once called me for a consult. She was concerned that a patient was breathing faster than normal, and she ‘had a bad feeling’.
“The patient was several days post-op from a bowel resection and had so far recovered well. Their vitals were stable, but the BP had been trending down and was 90/50 with respirations of 28. The nurse had expressed her concern to the doctor and been told that the patient was just ‘the anxious type.’ She called me for a second opinion saying, ‘Should I be concerned, or is this normal?’”
Lorenzini intervened.
“I assessed the patient and felt that same bad feeling. Not only was she tachypneic, she was more lethargic than her baseline, and her tachypnea didn’t seem like anxiety. Her color wasn’t right, and her abdomen was tender and firm. I supported the nurse in advocating for the patient, calling the doctor, and pushing for further diagnostics.”
“We got the patient to CT and discovered a perforated bowel leaking into her peritoneum, causing septic shock. Within an hour, she declined rapidly, required vasopressors and intubation, and ultimately returned to the OR. As a rapid response nurse, I supported the bedside nurse in her assessment, taught her how to advocate for the patient with the provider, and facilitated getting the patient stabilized in ICU.”
Response and Proactive Vigilance
“Rapid response nursing isn’t just about reacting swiftly to emergencies,” says Lorenzini. “It’s about proactive vigilance, expert coordination, and unwavering patient advocacy. It’s a dynamic field that demands clinical acumen, leadership, and passion for making a difference in every patient encounter.”
She adds, “At my facility, we’re tasked with responding to a variety of alerts, from cardiac arrests to sepsis, STEMI, stroke alerts, and even unexpected births outside of L&D. But beyond mere response, we prioritize proactive measures. We utilize tools like the Modified Early Warning Score (MEWS) to identify at-risk patients and provide timely interventions. Our ‘nurse consults’ allow healthcare professionals to reach out for assistance even if vital signs don’t raise immediate concerns. This fosters a culture of early intervention and collaboration.”
“In summary,” Lorenzini concludes, “rapid response nurses exist both to respond to and prevent emergencies throughout the hospital.”
Say the word “travel” to many nurses. They’ll likely think of travel nursing, which gained a high level of attention during the height of the COVID-19 pandemic when nurses were needed in large numbers at hundreds of facilities nationwide. However, if you mention “travel medicine,” some nurses might stare at you blankly.
Travel medicine is a specialty focused on travelers’ health, often those bound for international destinations. From tourists and businesspeople to students and missionaries, being appropriately protected against travel health risks is no small feat, and many people don’t know where to begin when planning for their health on the road.
Since it’s so common for people to turn to nurses they know for advice, it’s a good idea for nurses to be familiar with some of the basics of travel medicine so that they can provide the guidance that their loved ones, friends, colleagues, and neighbors are seeking, and also to protect themselves when abroad.
Travel Medicine Offers Protection in a Hyper-Connected World
In a hyper-connected world where diseases can be spread through the movements of people around the globe, considering the risks of particular destinations is a smart strategy. And with the recent coronavirus pandemic sweeping the world still fresh in many of our memories, we might also be concerned about other potential travel-related diseases.
Despite the relatively high cost of many vaccines not commonly covered by health plans, not being protected and getting sick while away from home can result in significantly more costs, including unexpected but necessary emergency medical evacuation. In light of this, fee-for-service travel medicine clinics often fill the gaps and provide travelers with the advice and protection they need for their upcoming time away from home.
Not only do illnesses spread through travel, but several diseases (e.g., malaria, yellow fever, Japanese encephalitis, etc.) are endemic in certain countries, and some of these can pose significant short- and long-term risks to your health.
All travelers should be up-to-date on tetanus (the CDC recommends every 5 years for international travel), as well as pneumococcus (as age-appropriate); influenza; COVID-19; hepatitis A and B; varicella; measles, mumps, and rubella; and polio (some countries with wild-type or endemic polio may require proof of vaccination for entry).
Malaria: A mosquito-borne illness, malaria infects almost 300 million people per year and causes over 400,000 deaths. Sub-Saharan Africa, South and Southeast Asia, the Pacific Islands, Central America, and northern South America are all target areas for malaria prophylaxis. Protective clothing, insecticides, and medications to prevent infection are the go-to strategies for this deadly disease.
Zika, Dengue, and Chikungunya: This trio of tropical and sub-tropical mosquito-borne illnesses can be severe. Since travelers can take no medications to prevent infection, protection against bites is crucial.
Japanese encephalitis (JE): Mosquito-borne with a 25% fatality rate, travelers to Asia must rely on bite prevention and the additional option of the Japanese encephalitis vaccine.
Yellow Fever: Yet another disease spread by mosquitos, the yellow fever virus is a tropical and subtropical disease found in Africa and South America. There is no known treatment or cure, so the yellow fever vaccine and bite prevention are paramount. Some countries require proof of yellow fever vaccination for entry.
Rabies: Although the multi-dose rabies vaccine is costly, rabies is 100% fatal if not treated within 24 hours of exposure (bite, scratch, or lick on open skin). Most developing countries lack access to the blood product that must be injected directly into the wound or have poor asepsis practices that can expose international travelers to diseases like hepatitis C and HIV during medical intervention.
Traveler’s diarrhea can become quite dire. Thus, carrying medical-grade bovine colostrum and antibiotics for severe cases is essential. (Most physicians are unaware that certain countries have E. coli strains resistant to ciprofloxacin, and azithromycin is needed in those areas).
Public Health Ambassadors
Due to how the general public leans on nurses for health advice, all nurses are, in essence, public health ambassadors. Understanding the risks posed by international travel — especially travel to the developing world — is an important knowledge base for nurses who want to be well informed.
Although not comprehensive, this article provides a grounding in the due diligence recommended for international travelers in a world filled with fantastic destinations and consequential health risks. The importance of good travel insurance — including emergency medical evacuation — cannot be overstated.
Find your comfort level with knowledge about travel medicine and share freely with friends, family, colleagues, and community members who are avid travelers needing sound advice, safety, and good health abroad.
February 4th to 10th is National Burn Awareness Week, and Daily Nurse is recognizing the specialized work of burn nurses. Burn nurses are known for their exceptional skills, commitment, and unwavering dedication to patient care. They work tirelessly to treat individuals who have been affected by burn injuries and to advocate for burn injury prevention within their communities.
Meet Emily Werthman, PhD (c), MSN, RN, CBRN, the Burn Program Manager at The Johns Hopkins Burn Center. She is also a member of the Board of Certification for Emergency Nursing (BCEN) board of directors for the 2024-2025 term and shares her insights on burn nursing as a specialized nursing practice.
-What are your title and credentials at The Johns Hopkins Burn Center?
Burn Program Manager
PhD (c), MSN, RN, CBRN
-How long have you worked there?
13 years
-What do you enjoy most about your role as burn program manager?
I love the detective aspect of my job: finding a problem, discovering its root cause, and then developing a plan to fix it. I also work with an amazing interdisciplinary team that makes it exciting to come to work every day.
-Talk about how you ascended to that role.
I started as a BICU nurse and loved our burn program’s research and quality aspects. I knew that burn nursing was where I wanted to practice, but I also wanted to further my career options by pursuing an advanced degree. After about 10 years at the bedside, the burn program manager position became available while I was obtaining my MSN in nursing education. I was so happy to be able to combine my love of research, quality, and bedside burn nursing knowledge into this role. I am also incredibly fortunate to work for a health system that encourages and supports its nurses’ continuing education so I can continue with my PhD.
-What inspired you to become a burn nurse?
My mother died in a house fire shortly after my college graduation. Knowing that her nurses were with her, providing the best possible care, inspired me to do the same for all the families and patients we care for here at the Johns Hopkins Burn Center.
–What associations are you a member of, and how have they helped your career?
I am an American Burn Association (ABA) member, serving as the lead nurse planner. I volunteer with the Board of Certification for Emergency Nursing (BCEN), serving as a CBRN Exam Construction Review Committee member, and have just been appointed to BCEN’s board of directors.
These roles have allowed me to work outside of my hospital system to impact the work of burn nurses nationally and internationally. My work with the ABA has allowed me to progress from member to committee member to lead nurse planner. Similarly, at BCEN, I started as an item writer and have continued to work within the organization to support its mission. Both organizations have provided opportunities for professional growth through networking and continuing education.
-What does a burn nurse do?
There is not a typical day in burn. We see patients at their worst on the first day they are injured, their best on the day they are discharged, and everything in between. Burn is unique because we know our patients and their families through one-on-one interactions during daily wound care sessions. A shift in the BICU or BWU will usually involve all your standard nursing interventions but with a healthy dose of specialized wound care, wound vac placement, dressing takedowns, and lots of psychosocial support for our patients and their families.
–Burn nurses are more than trauma care. Can you talk about the other types of care they provide patients?
Burn nurses genuinely care for the patient across the entire continuum from admission to discharge and then reconstruction procedures in the years following an injury. In addition to critical care, they provide outstanding psychosocial support to families and patients. Many burn nurses participate in prevention activities like outreach at local schools and partnerships with local firefighters.
-How do you become a burn nurse?
After graduating with a history degree, I returned to school to get my AS in nursing, eventually earning a BSN and MSN. I am currently preparing to defend my PhD dissertation, as well. I knew when I entered nursing school that burn nursing was my calling. I contacted the burn center for my senior honors project to arrange a guest lecture at my nursing school. I kept in touch with them after graduation so that they were aware of my interest in the burn center and to let them know when I applied for an open position there.
–Talk about the need for burn nursing and BCEN specialty certification.
I seek to effect change in the field of burn nursing as a subject matter expert, test question writer, and exam content review committee member for the CBRN exam. Specialty certification is an essential part of recognizing burn nurses’ unique work. As more hospitals move toward Magnet certification, standing with other certified nurses offers burn nurses the ability to demonstrate our commitment to quality care.
-What are the benefits of being a burn nurse?
Burn nursing is a challenging field. But it is just as rewarding as it is difficult. We see patients progress through their recovery, and through our work with the Burn Therapy Program, we continue to see them for years as they return to their lives.
–Talk about the reward of being a burn nurse.
The payoff is the outcome. When we see a patient with substantial burn injuries overcome their injuries and go on to live happy, successful lives, it makes all the long, hot days in a tub room worth it.
–Talk about being 1 of 12 expert nurses selected by BCEN to serve on the Burn Nursing Role Delineation Study Advisory Committee.
No other specialty provides you with a level of interaction with patients and their families, all while providing life-saving critical care. The burn nurse is truly the best representation of a holistic nurse that I know—integrating critical care with psychosocial care, wound care, focused systems assessments/interventions, and all that comes with the care of surgical patients. Being selected to help define what a burn nurse does was an honor. And to be able to work with some of my role models in burn care (Gretchen Carrougher and Katie Hollowed, in particular) was so exciting. To think that we could work together with burn experts from all over the country to help on our path to certification was life-changing.
–How does the committee’s work serve as a roadmap for nurses who sit for the CBRN exam?
In our work, we helped define what the burn nurse does, which helped define the parameters of the CBRN exam.
-Do you have anything else to add for Burn Awareness Week?
This year’s theme is preventing flammable liquid injuries, so I encourage people to check out the resources available at ameriburn.org to ensure they are following all appropriate safety measures!
Have you ever wondered what it’s like to work with psychiatric patients?
Surely, it’s not like many movies and television shows have portrayed. Not even close.
To get more information about becoming a psychiatric nurse, we interviewed Jessica Martinez, RN, a Behavioral Health Registered Nurse working on CareRev’s platform at Bergen New Bridge Medical Center in Paramus, New Jersey.
What follows is our interview, edited for length and clarity.
Jessica Martinez, RN, is a Behavioral Health Registered Nurse at Bergen New Bridge Medical Center in Paramus, New Jersey
How did you get interested in working as a psychiatric nurse? What drew you to it? How long have you been doing it?
My mentor from nursing school was a psychiatric nurse instructor, and she told me she thought I should try it. She helped me get my first job.
I fell in love with it after working as a psychiatric nurse. That was in 2019, and I still really love this area of medicine.
Briefly explain what you do as a psychiatric nurse. What types of patients do you serve—what ages and how are they approved to be in the program? What do you provide for them?
As a psychiatric nurse, I assist patients from ages five to 105 with a mental health diagnosis who have been admitted to the hospital.
I ensure patients and staff stay safe, and a big part of the job is administering medications so patients can return to their daily lives. I work with patients to help reduce the stigma of their mental health challenges and help them understand it is a chronic condition that can be treated.
Some of my patients–once they start their medication and begin to feel better–think they don’t need their meds anymore. As a result, I work with patients in a group therapy setting to help them understand they have a diagnosis and that the best way to deal with it is to follow the doctor’s orders.
Did you need to get additional education to become a psychiatric nurse?
I earned an associate degree in 2018 and a bachelor’s degree in 2022, and I’m currently pursuing a master’s degree.
You can do this job with an associate degree, but a bachelor’s is preferred.
What do you like most about working in your job?
My favorite part is seeing patients get better and feel more like themselves. I work with patients to help them develop new routines for improved health and wellness. When a patient is ready to go home, that is the best feeling in the world.
I work in the hospital through CareRev, a technology platform that allows me to maintain my schedule based on what is going on in my life. I can build my work schedule around my life, not the other way around. This has helped balance my work and personal lives, pays well enough for me to travel, and allows me time to schedule a break when needed.
What are your biggest challenges?
Sometimes, patients are frustrated, but we work hard to ensure everyone navigates to a healthy outcome.
What are your greatest rewards in your work?
The biggest reward is working directly with patients and knowing that every day is different. I’m constantly learning and growing in my role.
Is there anything else that is important for our readers to know?
Nursing has changed a lot. I work through CareRev’s platform, where I work side-by-side with hospital professionals daily. However, I have the flexibility to control my schedule so I can pursue further education, accommodate my family’s needs, and pick up shifts close to home.
We need more nurses going into psychiatry. It’s a field that has changed so much, and so has society’s understanding of mental health challenges.
