Scoping Out the Surgical Intensive Care Nurse

Scoping Out the Surgical Intensive Care Nurse

An outgoing nature, a desire to act as a patient advocate, and a willingness to function outside your comfort zone are among the attributes you need to be a successful surgical intensive care nurse.

So says Kristina Massey, BSN, RN, CCRN-CSC, ECMO specialist and nursing unit director, cardiac surgery ICU/cardiac flex team at Carilion Roanoke Memorial Hospital Cardiovascular Institute in Roanoke, VA.

Nurses considering this role will find high demand, as surgical intensive care nurses joined the list of the 25 top roles growing in demand this year, according to LinkedIn Jobs on the Rise 2022. These nurses, according to the LinkedIn report, care for patients who are critically ill after surgery, usually following complex procedures such as open heart surgery.

The surgical intensive care unit can be a “very overwhelming environment,” says Massey, who has been the unit director since 2009, and an ECMO specialist since 2012. Nurses in the surgical ICU, she notes, need to be able to go out on a limb or outside their comfort zone to approach a surgeon or provider if something isn’t right.

Her unit also includes nurses who want to grow into more advanced roles, such as CRNA or NP. “I would rather have someone who is highly functional, who is always looking to increase their education and skill set, even if that only means having them for a few years,” she says.

Leading Staff

As the unit director, Massey leads 70 staff members, including RNs, LPNs, and nursing assistants. In her 11-bed unit, she focuses mainly on day-to-day operations, such as patient throughput and determining what patients can move to a step-down unit or who needs to do a lateral transfer to another ICU.

She also ensures that she has the right mix of nurses with the skills to care for the current acuity in her ICU. She can also be a bedside nurse, for instance, in an emergency.

Patients come to her unit only for cardiothoracic intensive care. Patients who had open heart surgery, she notes, come directly to her ICU, not a PACU or recovery unit. Her nurses work as a team with respiratory therapists to extubate the patients.

Experience a Plus

When Massey needs to hire a nurse for her unit, she prefers nurses with a BSN degree. If the nurse is a new grad, she wants to see healthcare experience, such as working as a nursing assistant in a hospital or having an EMS background. She will hire associate degree nurses based on their experience. For instance, in May, she hired an associate degree RN who had worked under her as a nursing assistant for three years. Another associate degree nurse she hired had worked as a paramedic before attending nursing school.

“Our ICU is a very high-acuity ICU, and we see a lot of incredibly sick patients,” says Massey. So having this prior medical experience “helps with their transition into the ICU.”

Massey’s interest in the surgical ICU started in nursing school during a rotation through the cardiac surgery operating room. There, she observed a patient undergoing open heart surgery and followed that patient through the ICU and the recovery process, including extubation. “I was very fascinated by what the ICU nurse was doing in the room that day. And I knew that I eventually wanted to end up in the ICU.”

Before joining the surgical ICU, she worked in the cardiac surgery step-down unit for about three and a half years. She joined the surgical ICU as a staff nurse in 2004, was promoted to preceptor, then clinical team lead, and ultimately became unit director in 2009.

Setting the Direction

For nurses interested in joining a surgical ICU, “if you know that’s what you want to do, you need to set yourself up in the right direction,” she notes. “Contact people who can help you get the position you want. If that means applying for a role as a patient care tech or a nursing assistant in the surgical ICU that you want to be in, do it while you’re in nursing school. It will help that staff get to know you and be your advocate when you graduate nursing school.”

“If you spend time on that unit, reach out to the unit director and let them know that this is something that you’re very interested in and ask what their recommendations are. Then, when they request the ICU, I’ve had many students make sure I know who they are. They seek out experiences, make themselves available to staff, and show interest.”

Learning Never Stops

Once you’re working in a surgical ICU, keep learning, Massey says. “Continue to expand your knowledge and grow yourself professionally,” perhaps through certification or becoming an ECMO specialist like her. “It helps with that validation of knowledge, and it will only elevate your profession and skill set if you continue to explore growth opportunities.”

Offering a Vision on Climate Change and Nursing

Offering a Vision on Climate Change and Nursing

From devastating hurricanes to prolonged droughts to scorching heat waves, climate change wreaks havoc on the planet, with more severe impacts to come. As a nurse, you can expect climate change to affect your work if it hasn’t already. “Climate change,” notes the National League for Nursing (NLN), “currently impacts or will impact every aspect of nursing care.”

The NLN’s 15-page vision statement on climate change and health released in September 2022 “believes that the health consequences of climate change are among the most urgent public health and health equity crises of the 21st century. This statement addresses the importance of educating current and future nurses for climate change-informed practice and policy leadership.”

“Knowing that climate has so much to do with the health of the nation, and if we’re nurses who say we care about the nation’s health, then how can we not be about making sure that we understand climate, that our students are learning about the effects of climate,” says Beverly Malone, Ph.D., RN, FAAN, president and CEO of the NLN.

NLN Addresses the Education Gap

“The vision statement is essential because it addresses a gap in nursing education, where the adverse health effects of climate change are not well integrated into the nursing curricula at any educational level,” says Sandra Davis, Ph.D., DPM, ACNP-BC, FAANP, deputy director, NLN/Walden University College of Nursing Institute for Social Determinants of Health and Social Change.

Davis notes that in the climate change vision statement, the NLN wants to “address the importance of educating nurses on climate change-informed practice and educating them for policy leadership.” According to Malone, nursing schools are beginning to incorporate climate change into their curricula.

The vision statement is the most recent of 20 vision statements from the NLN. Each vision statement in the vision series, notes Davis, “is a living document that serves as a roadmap for navigating some of the most critical issues facing our world, facing healthcare and facing nursing education. Climate change in health is one of these critical issues.”

Five Focus Areas

The NLN vision statement discusses recommendations in five areas, with each providing strategic initiatives. They include strategic initiatives for:

  • National League for Nursing
  • Deans, directors, and chairs of nursing programs
  • Faculty
  • Policy and Advocacy
  • Nurses in practice

For instance, in the strategic initiative for faculty, “we want faculty to embed learning strategies related to climate change and planetary health into their didactic, clinical, and simulation experiences,” says Davis. Likewise, for practicing nurses, “we want every nurse in practice to become educated about the adverse health consequences of climate change and to be sure that they understand the concepts of mitigation, adaptation, and resilience.”

Aiding the Marginalized

“As with most other healthcare issues, the greatest burden rests on the marginalized communities, communities of color. The issues of diversity, equity, and inclusion raise their interesting head even in climate,” says Malone. “There are still those on the fringes that have worse experiences or a more intense experience than others. And that’s not anything new. But we’ve not talked about it in terms of climate.”

One School’s Start

At the Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, educators are just beginning work to integrate climate change into the curriculum, notes Mary T. Quinn Griffin, Ph.D., RN,  FAAN, ANEF, associate dean for global affairs, and May L. Wykle endowed professor. “We are interested in having our faculty learn more about climate change and the effects on health and how we can start integrating that into the curriculum,” she says.

In an article published in the September/October 2022 Journal of Professional Nursing, Quinn Griffin and coauthors offered ways to integrate climate change content into existing Doctor of Nursing Practice (DNP) programs. In addition, the article ties climate change content to the domains in The Essentials: Core Competencies for Professional Nursing Education from the American Association of Colleges of Nursing (AACN).

Recently, Quinn Griffin delivered a presentation on climate change during homecoming. In that presentation, she discussed how “nurses are really on the frontlines of working to mitigate the consequences of climate change every day. And that nurses comprise about 60% of health professionals globally, so their involvement in the education and the response to climate change is critical if we are to mitigate the impact of climate change on health.”

In addressing climate change, Quinn Griffin references the three strategies of adaptation, mitigation, and resilience. First, she notes that adaptation involves assessing the impact of climate change and planning for its effects.

In mitigation, “nurses could take leadership roles in helping and be on committees to create sustainable climate-smart hospitals and health systems,” says Quinn Griffin. In addition, resilience could involve the community and public health nurses helping to strengthen communities.

NLN Says Nursing Plays Unique Role 

“The nursing profession is uniquely positioned to offer critical leadership related to climate change and health and to address this complex challenge in partnership with other health professions and policymakers,” concludes the vision statement.

Climate change, notes the NLN’s Malone, is part of healthcare. “If you consider yourself a good practitioner, you need to build that into how you view the world and your responsibility as a nurse to that world.”

Peering into the Post-COVID Nursing Curriculum

Peering into the Post-COVID Nursing Curriculum

Nursing education after COVID will rely more on technology and digital tools than ever. Simulation and online learning will be part and parcel of the curriculum for nursing students. It will also be more competency-based as the new AACN Essentials further integrate into nursing curriculums.

But what about the content of the curriculum? 

Nursing education, according to Mary Dolansky, Ph.D., RN, FAAN, Sarah C. Hirsh Professor, Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school, may include instruction on telehealth, an emphasis on systems thinking, stress on leadership, and a focus on innovation and design thinking. 

Nursing education after COVID

Mary Dolansky, Ph.D., RN, FAAN, is a Sarah C. Hirsh Professor at the Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school

A Look at Nursing Education After COVID

Telehealth

Understanding how to use telehealth in nursing is key, according to Dolansky. The Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, developed a series of four modules on telehealth so that all students received a basic foundation in telehealth nursing, including telehealth presence. It included teaching using Zoom or the phone to assess and evaluate patients. She notes that interactive products that give students a feel for how such interactions occur and practice them can provide an excellent education.

Systems Thinking 

Another aspect of post-COVID nursing education involves systems thinking, says Dolansky. This involves “really getting students to think beyond one-to-one patient care delivery and about populations. We need to create more curricula for nurses out in primary care sites and nurses out in the community, and that has not been a strong emphasis in schools of nursing. Instead, we focus mainly on acute care.”

More specifically, students should learn, for instance, how to use data registries to look at areas of patient need. One COVID example, notes Dolansky, would be to use registries to identify long-term COVID patients. Another could be to use a registry or database to discover what patients have followed up on their chronic disease since, during COVID, many patients stopped visiting healthcare providers.

Emphasizing Leadership

In the post-COVID curriculum, developing leadership skills may become more critical. “What we observed in the COVID crisis,” says Dolansky, “was an opportunity for nurses to stand up and speak out more. We were the ones at the frontline and had the potential to be more innovative and responsive. Many great nurses did step up and speak up, but we need to ensure that every nurse can speak up for patients in future crises or even advocate for our patients now. Nurses can be the biggest advocates for patients.”

Every school of nursing probably has a leadership course, Dolansky notes. But ensuring that there are case studies from COVID as to how nurses did stand up and speak out and how that made a difference would be a fundamental curriculum change.

“We want to prepare our students that you will be a leader and you will be on TV talking about how you are innovating and adapting to the changing needs of the health of our population. And COVID was a great example for that.”

Innovation

Post-COVID, nursing education needs to help students with innovation and design thinking, notes Dolansky. Over the past 10 years with QSEN, “what we’re trying to advocate is shifting the lens of a nurse from direct patient care delivery, which has been the focus of nursing, to shifting a little bit to systems thinking.”

Critical thinking, notes Dolansky, focuses on making decisions for an individual patient. Design thinking and innovation are more about “looking at the system in which we work and empowering the nurses to fix the systems. This is key to quality and safety, but it’s also key to the need for our nurses to contribute strongly to the health of the future population. They have to be at the table to respond to these crises. We need them to have the skill set of being a leader, standing up, being at the table and when they’re at the table, having ideas, being creative, and knowing how to test them. And having the technical skills to use the technology is probably where most of the solutions will be for the future.”

QSEN and Competencies 

With the latest AACN Essentials, there is a drive for competencies in nursing education, notes Dolansky. The Essentials: Core Competencies for Professional Nursing Education, approved by the AACN in April 2021, calls for a transition to competency-based education focusing on entry-level and advanced nursing practice.  

While revising the Essentials began before the pandemic, the experiences and learnings from the pandemic greatly impacted the work, notes a recent article in Academic Medicine. As a result, the Essentials includes population health competencies that specifically address disaster and pandemic response and will better prepare the next generation of nurses to respond safely in future events, the article says.

Now, a crosswalk has developed between QSEN competency statements and the 2021 AACN Essential Statements, notes Dolansky. However, she notes that the AACN is taking the QSEN foundation and moving it forward, stating to the public that “the nursing profession has these competencies that are providing safe quality care to the public.” Since 2012, the QSEN effort has been based on the Frances Payne Bolton School of Nursing.

“Own Their Competency”

In the culture of nursing education, students now need to be educated to “own their competency,” says Dolansky. “Students will see that competency development is part of their lifelong professional development.

Expert on Nurse Medication Errors Places Vaught Case in Context

Expert on Nurse Medication Errors Places Vaught Case in Context

In May 2022, former nurse RaDonda Vaught was sentenced to three years’ probation for a fatal medication error, an unprecedented criminal conviction that echoed through the nursing community, and the implications of which are still to be fully determined. In an interview, Zane Robinson Wolf, PhD, RN, CNE, ANEF, FAAN, who has studied patient safety and medication errors for decades, expressed concern that this may have a chilling effect on reporting medication errors and thus harming patient safety.

Deep expertise Zane Robinson Wolf, PhD, RN, CNE, ANEF, FAAN.

Wolf, the editor-in-chief of the International Journal for Human Caring, is dean emerita and professor of nursing at the School of Nursing and Health Sciences at La Salle University, Philadelphia, PA. She has been researching issues around patient safety since her 1986 dissertation “Nursing rituals in an adult acute care hospital: An ethnography.

She directly observed nurses preparing and administering medications, and nurses began to tell her their medication error stories. Wolf was a member of the board of the Institute for Safe Medication Practices (ISMP), a highly respected organization that distributed alerts, information and analysis about medication errors. In 2020, ISMP affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world.

Three phases

Wolf says she has lived through three phases or ways of thinking about medication and other healthcare errors. In the first phase, perfectionism, “providers are supposed to be perfect, but since we’re human, we’re not,” she says. In this “blame the provider” phase, the clinician was often blamed for the error.

In phase two, the “no blame” phase, the focus was put on the systems in place that may have led to the error. This has been followed by the “just culture” phase, where there is acknowledgment that systems and their cultures can contribute to risk and clinicians could be reckless and need to be counseled or perhaps fired.

Understanding context

In analyzing the Vaught error, Wolf points to the importance of the error’s context. Vaught admitted to investigators that she had been “distracted with something,” according to a New York Times report. Vaught administered the neuromuscular blocking agent vecuronium instead of the sedative Versed.

The ISMP, commenting on the case in a press release, noted that the trial ignored existing science about confirmation bias, inattentional blindness, alert fatigue, and normalization of automated dispensing cabinet overrides.

“The context is important in terms of the patient load she was carrying at the time,” notes Wolf. “How many patients were basically under her care at that point?”

In committing the error, Vaught was said to have overridden a system when she couldn’t find Versed, typed in “VE,” and chose the first medication on the list, vecuronium, notes the Times quoting a Tennessee Bureau of Investigations report. Wolf says that confirmation bias could have played a role, where Vaught read the VE for what she was expecting, Versed, instead of the actual drug she selected, vecuronium.

The ISMP, commenting on the case in a press release, noted that the trial ignored existing science about confirmation bias, inattentional blindness, alert fatigue, and normalization of automated dispensing cabinet overrides. If healthcare providers fear harsh penalties such as imprisonment, they’ll be less likely to disclose errors or be willing to describe workarounds that set them up to make errors, the ISMP notes.

Quadruple Aim

In helping healthcare providers cope with medication errors, as well as other traumatic events, Wolf points to the Quadruple Aim. Building on the Triple Aim of the Institute for Healthcare Improvement, the Quadruple aim adds the idea that providers should work in a supportive workplace, notes Wolf.

Wolf points to a report of a support structure for the “second victims” of adverse clinical events. This structure was designed to increase awareness of the second-victim phenomenon, normalize psychological and physical impacts, provide real-time surveillance for potential second victims in clinical settings, and provide immediate peer-to-peer emotional support.

A mistake versus a crime

According to Wolf, Vaught “did violate safety, but I think the intentionality is not there. And that to me is what breaks down the difference between a crime and a mistake. And it is a glaring mistake. There is no doubt about it. But it’s very alarming to all kinds of healthcare providers, not just nurses, but anybody who’s administering a medication.”

“I think the intentionality is not there. And that to me is what breaks down the difference between a crime and a mistake. And it is a glaring mistake.”

“I think that people need to know that as healthcare providers care for patients, their actions have high consequences with important impacts for patients,” says Wolf.  “And that safety is a persistent concern of providers and leaders of healthcare systems. This work of caring is a weighty responsibility. But if we want to do this activity in life, we live with it and go forward. It’s a choice. But reporting near misses and errors is always the best avenue and we should never be dissuaded from that.”

 

New Grad Residency Program Takes Nurses From Books to Bedside

New Grad Residency Program Takes Nurses From Books to Bedside

Few, if any, new nurse graduates walk onto a hospital unit on their first day brimming with confidence, much less clinical expertise. Thus, new grad residency programs help transition nurses from the world of textbooks to the realities of the bedside.

At UMass Memorial Health , new grads can find a wealth of support in the organization’s graduate residency program, which accepted its first cohort in 2007.  Two campuses, University and Memorial, host the program.

Year-long program

The one-year program has various components. During the first 13 weeks of the program,  new grads are establishing their foundational practice, notes Karen Uttaro, MS, RN, NPD-BC, NEA-BC, senior director, professional practice, quality and regulatory readiness, UMass Memorial Medical Center. Nurses are placed in a unit, based on their skill set and where a position may be vacant, and assigned a preceptor.

Working with the preceptor, they refine the skills learned in nursing school. What’s more, the new grads meet weekly with fellow new grads and members of the nursing leadership team. The 13 weeks are an average time, which can be tailored to individual needs until a nurse can practice independently.

Besides working with a preceptor, the new grads attend class weekly, where “we have a chance to emphasize key components around clinical skills,” says Uttaro. “It’s that sense of community and support. And that’s the undercurrent and the foundation of our program, to really make sure that they feel supported,” she says.

After that first 13-week component, new grads have a monthly three-hour check-in. Instructors review a topic, such as mock resuscitation, or bring in a subject matter expert, notes Uttaro.  “It’s really building on their knowledge and skills throughout that whole first year,” she says. Finally, at the end of the year, the new grads have conversations about their professional goals to foster life-long learning.

Learning from each other

Not only do the new grads learn from the seasoned nurses, but the reverse also is true, notes Uttaro. “Our seasoned nurses know the new grads will teach them just as much as the seasoned nurses are going to teach our novices because they have strengths in both generations.” For instance, baby boomers and Gen Xers may not be as strong in evidence-based practice and where you find those resources, Uttaro notes, whereas Gen Z’s and millennials are very savvy with that information. “It’s establishing that common ground that they’re going to get something from each.”

One new grad who went through the program, Brittany Garlisi, BSN, RN, says that she was under the misconception of the old axiom that “Nurses eat their young.” But when she was paired with one of the oldest nurses on her unit, “I was pleasantly surprised to find that they were one of the most kind and nurturing teachers I could have had.”

Striking gold

As a new grad, Danyel Stone, BSN, RN, CCRN found support in the program. Having graduated from nursing school in December 2020, she started in the new grad program in March 2021.

“It’s a lot to start off as a new RN, especially because I feel like 80-90% of the job you will learn in person while you’re working,” she says.  “Starting off as a new nurse, I was very, very nervous going into it. And I think that being part of the residency program really helped me stay grounded.”

Coming from a previous career as a securities broker, Garlisi felt anxious about working as a new nurse. “I felt that even though I had the book knowledge, I did not have much of the practical knowledge. So it made me very nervous to be doing a lot of things for the first time as a registered nurse as opposed to being oriented and having a support network to really teach me.”

“I thought I was just signing up for some kind of mentorship but I really felt that I struck gold. It really was way better than I could have anticipated.”

Growing program

Typically, notes Uttaro, each cohort has 50 new grads. Each year, the hospital supports three cohorts, one starting in March, then August, then December.  This year, Uttaro expects to have as many as 150 new grads, with a target of 200 to 250 new grads in 2023.

Impact of COVID

As with virtually every aspect of healthcare, COVID threw a wrench into the residency program.

The cohort that was to start the program in March 2020 couldn’t go onto the units. Instead, the new grads worked as a prone team. “We found a different role for them to leverage their nursing knowledge,” says Uttaro. “And we were able to foster skills like leadership and teamwork and communication.”

Because many new grads lost out on clinical time during COVID, notes Uttaro, the program re-emphasized skills the grads didn’t get.

Measuring success

The program can measure success in two ways, notes Uttaro. First, in November 2021, the program achieved accreditation from the ANCC Practice Transition Accreditation Program (PTAP). “So we have the external validation that our program is evidence-based and meets the rigorous criteria of that organization,” Uttaro says.

Second, retention of new grads pre-pandemic was 100% at the one-year mark, 92% at the two-year mark, and 88% at the three-year mark, according to Uttaro. “We retained our novice nurses for the long haul,” she notes.  “I think it’s really planting the seed and being that coach for them that keeps them in our village,” she says.

Fostering respectful communication is one hallmark of the program. “Most of the bad things that happen in healthcare are a result of communication breakdown,” Uttaro says. “In this program, and throughout the organization, we emphasize asking questions in a respectful way. If it doesn’t feel right in your gut, you don’t need to know why, you just need to know whom to talk to. Being able to say, ‘I think something isn’t right,’ really reinforces that communication is essential to all aspects of your practice.”

Healthcare is a very complex environment right now, notes Uttaro, “and making sure that the new grads are positioned for success is our top priority.”