Nursing leadership is an essential feature of any successful health care administration. For many in the profession, the terms nursing administration and administration are used interchangeably because any nurse leadership role includes administrative–or managerial– and executive responsibilities.
The chief nursing officer (CNO) of any health care organization is considered the acme position of nursing leadership; however, there are as many nursing administrative roles as there are nurses to fill them. Every position is unique to the organization that creates it and the nurse that takes it on. The typical trajectory of a nurse leader goes in the order as follows:
As evidenced by the above, those who advance in nursing
leadership gradually move further away from direct bedside care. Regardless, at
every level of administration, having experience with direct patient care as a
nurse is essential for constructive oversight. As such, rarely do nurses
advance into administration without a foundation at the bedside,
and for good reason.
Charge nurses and nurse managers directly supervise nursing
within specific departments, such as the intensive care unit, or operating
room. Some of them even take on patient assignments of their own, whether to
fill gaps in staffing or as a fundamental part of their role. Nursing
department directors act as a liaison between their unit and the larger
organization or community, representing and speaking on behalf of their
nurses.
This might lead to them implementing evidence-based practice
or quality initiatives based on executive feedback and financial implications.
Nursing leaders, executives, and administrators direct and organize
systems-wide schema to better nursing and patient care, qualitatively, fiscally,
and systematically.
It seems the goal of nursing leadership and administration is a popular one for young nurses today. There are even resources for nursing students to establish themselves as nurse leaders while in nursing school, both through skill development and networking. For nurses who have the competence and resiliency to be nursing leaders, it is an opportunity to affect positively the quality of care patients receive, beyond the bedside.
Evidence-based practice is essentially a self-explanatory phenomenon. It’s the translation of the most current research insight into action. One commonly repeated definition of evidence-based practice is “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Evidence-based practice in nursing is not a matter of simply going from the lab to graphed data to the patient. As with any nursing principle, compassionate, individualized care is as important as the statistics that drive it. Thus, nurses who utilize evidence-based practice give the patient the dignity and respect to participate in their own care, guided by the expertise and resources of the nurse.
Nurses do not have the luxury of relying on what they learned in school throughout their career. As in any field driven by science and technology today, the onus is on the practitioner to stay current. In nursing and medicine, however, the patient’s well-being is at stake, rendering their obligation to stay current an urgent one. Whether it’s catering care to the needs of different patient populations or having the courage to ask questions that don’t yet have answers, the prudent nurse relies continuously on evidence-based practice as a guiding principle of his or her work.
From the Bedside to the Ballot
Although most nursing guidelines and institutional policies today are created based on current best practice research, many nurses are taking it upon themselves to up the ante and create nurse-driven initiatives. They are uniting in the spirit of staying current on best evidence for quality patient care in their respective specialties.
Beyond its relevance in caring for individual patients, evidence-based practice in nursing has made its way to the ballot. Today, health care legislation relies on evidence-based practice to enact laws that affect all members of the healthcare team, from the multidisciplinary team to the patient. One hot topic in nursing legislation today is nursing ratios and how they affect patient outcomes. Nurses are fighting throughout the United States to educate lawmakers and laypersons alike about the importance of quantity in healthcare quality, and with research to back them up, they are being heard.
A Certified Registered Nurse Anesthetist’s (CRNA) day begins with an inspection of the OR he or she is assigned to, with priority over the OR table and anesthesia equipment. Immediately before seeing the patient, a CRNA reviews the patient’s chart for any red flags, including information the patient may not willingly divulge. Examples of red flags include: a previous surgery, current medications (particularly cardiac medication and narcotics), and BMI. All of these factors can significantly impact how the patient will respond to anesthesia and surgery.
When meeting the patient, both a conversation and a physical exam ensue, as this is the final opportunity to determine what the CRNA can reasonably expect hemodynamically from the patient during the case. While inspecting the patient’s anatomy, a CRNA may ask how many stairs they can climb before getting winded, or how many pillows they use to sleep comfortably at night. All of this information combined will inform the American Society of Anesthesiology (ASA) score assigned the patient, which is a scale from one to five, one being a healthy patient and five being a moribund patient. This will be announced during the surgical time out.
In New York and Pennsylvania, CRNAs do not have APN status. In New York, this means that CRNAs work under the supervision of an anesthesiologist or the operating physician. This anesthesiologist is expected to be present for induction, intubation, emergence, and extubation, as well as frequent check-ins throughout the case. By contrast, CRNAs in Pennsylvania work in cooperation with a surgeon or dentist and the CRNA’s performance shall be under the overall direction of the chief or director of anesthesia services.
In all other states where CRNAs do have APN status, they perform collaborative care, which involves much less oversight. Nurse anesthetists practice under supervision of the surgeon with no physician anesthesiologist requirement in 49 states and completely independent of a physician in 17 states.
What every CRNA must carry over from days as a critical care nurse is nursing intuition, strong assessment skills, and a sense of resilience. It is not a position for shrinking violets; your voice as the patient’s advocate is more important than ever. A patient may be deemed unfit for general anesthesia based on assessment. The CRNA who cancels a surgery will find it is almost never received well by the patient, nor the surgical team or the nursing team who prepared for surgery. A significant portion of any CRNA’s day may be making decisions on the patient’s behalf that are unpopular.
On any given day, depending on what type of surgeries are being done in a given OR, a CRNA may see one patient or twelve during a twelve-hour shift. While doing a series of quick hysteroscopies on young women may mean your patients are healthier, the challenge is to keep pace and to do so without sacrificing thoroughness. Having every patient’s life essentially in your hands is nothing to take lightly, no matter how clean their health record may be. After each case, the CRNA has to make sure every patient is stable in recovery before leaving them with the PACU team. It’s then on to the next patient to do it all over again.
In order to become a Certified Registered Nurse Anesthetist, you must graduate with a minimum of a master’s degree from an accredited nurse anesthesia program and pass the national certification exam, which is administered by the National Board of Certification and Recertification for Nurse Anesthetists.
The term “midwife” literally means “with woman.” Although nurse-midwives are best known for their work during pregnancy and specifically labor and delivery, nurse midwives care for women’s health in a comprehensive way. Certified nurse midwives (CNM) are advanced practice nurses specializing in prenatal care, labor and delivery, postpartum care, gynecology, well women’s health care, and family planning. They work anywhere other advanced practitioners do: in the hospital, at the clinic, and at home.
In the past, many people thought of midwives as only assisting women in home births, water births, and labor without anesthesia. Although some women may choose to deliver their babies in this way, midwives actually oversee all types of births, including those that are more conventional in the hospital. Nurse midwives have the credentials and authority to empower patients, so the kind of care given is according to their preferences and in their best interest.
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Despite common misunderstandings, nurse midwives are qualified
to care for women during various stages of life. Furthermore, as prescribers
and independent providers, they are able to manage all types of pregnancies,
whether straightforward or complicated. Like other advanced practice nurses,
many midwives have years of experiences as registered nurses in labor and
delivery and other areas of women’s health. Many contend that the unique
experience of working as a registered nurse before advancing is what sets nurse
practitioners, including midwives, apart from their physician counterparts.
Within midwifery, there are stratified scopes of practice and levels of education; this is both location and training-dependent. Just like other advanced practice nurses, midwives work with varying degrees of independence from physician oversight in an ever-changing climate of advanced practice patient care. The majority of midwives hold a master’s or doctorate nursing degree (CNM); there are also certified midwives (CM) who have passed their advanced practice boards while maintaining a bachelor-level degree of education. For those who don’t have a bachelor’s, master’s, or doctorate degree can qualify to be a certified professional midwife (CPM). They are either trained through apprenticeship and/or formal education, and their scope of practice is narrower than CNMs.
As standards of health care providers evolve, the accreditation process for nurse midwives has increasing standards. The good news is that nurse midwives are learning through rigorous training and experience to provide high-quality patient care independently. Nurse midwives are more than the overseers of alternative birthing methods. They are fully licensed and independent women’s health providers.
I am a cardiac acute care nurse in a large Northeast suburban trauma hospital. I arrive at work twenty minutes early so that I can get to know my patients. I then check the chart for admitting diagnosis, pending labs, exams, point-of-care testing needs, etc. I do this because no matter how much I trust the nurse giving me the report, I recognize that any human is more liable to make mistakes and oversights after working at this level of intensity for thirteen hours.
After receiving the report, I introduce myself to my patients. The nursing ratio on my unit is 3:1 and at times up to 5:1. If the patient is awake, I assess them right away after introductions. I bring a computer-on-wheels (COW) in the room with me to document everything. The COW minimizes distractions and allows me to assess anything I forgot if needed. Next, I administer scheduled medications.
I find it most effective to complete tasks while in the room with the patient. The hallway is an obstacle course of distractions. For example, it may seem reasonable to step out while your patient is on a nebulizer treatment knowing the treatment takes five to eight minutes to complete. In a high-acuity unit, eight minutes is an eternity. Therefore, no matter how much I plan, I can almost guarantee I will be sidetracked by a new task in that short time. On good days, my charting is done by 10 a.m., which happens about 60% of the time. This allows me to have my afternoons free to address anything that comes up. Afternoons are less predictable because usually the night shift has set up and stabilized the patient for the mornings.
The hospital I work in is not unionized, so taking breaks is not enforced. We are entitled to one 30-minute and one one-hour break during a twelve-hour shift. Some nurses follow that timing fastidiously on each shift, while some nurses don’t take a break at all. I strongly discourage that. I perform better when I take a few 15-20 minute breaks throughout the day when my patients are settled. Otherwise, I use the extra time to prepare for later tasks, such as setting up and labeling IV medications. This ensures I leave on time, and I always do.
I have the opportunity today to precept new nurses and I always encourage them to find their own rhythm. In the beginning, I used to follow my preceptor and make an index card with a table of all the medications and point-of-care testing for each patient. Once I found my stride, I realized this card was actually wasting more time than it was saving, and I relied on the EMR instead anyway. Who knows? That may change again.
Evolving and learning are constant features of acute care nursing. A day in the life of an acute care nurse may be a misnomer as, lucky for me, no two patients are the same and no two days are the same.
To learn more about a career in acute care nursing, visit here.
