When Jean Snyder, DNAP, CRNA, read a story about a vibrant boy who went in for routine surgery and instead of coming home, died during, she knew she had to do something. The cause of the child’s death was a medication error. “As a mother and as a nurse anesthetist, my heart grieved for this loss. I knew that if we had a safe means to keep our syringes and vials, the mistake may have been recognized earlier, and perhaps that child may have had a different outcome,” says Snyder, owner of Jean F. Snyder CRNA Inc. and co-owner of Goodwin and Snyder Anesthesia Associates, PLLC, who also works full-time for Bon Secours DePaul Medical Center. “I knew I had to invent ERMA [Error Recovery and Mitigation Aide].”
“I developed an ERMA prototype in 2008 but had no means to refine and market it. In 2016, as part of my doctoral program at Virginia Commonwealth University, I wrote a whitepaper discussing medication errors within the context of error critical systems. ERMA was a means to provide early recognition and, hopefully, mitigation of medication errors. I then submitted my whitepaper and prototype to Innovation Institute, a medical device incubator that is affiliated with my hospital system. Innovation Institute worked with me to refine ERMA and obtained a provisional patent. We are presently working to market ERMA,” states Snyder.
Snyder explains what ERMA is and what it does:
“ERMA is a clear reservoir inserted between the re-entry proof top and opaque terminal disposal portion of a traditional needle box. It allows a practitioner in any high-risk area (OR, ED, ICU) to have visualization of all the syringes and vials used during the course of a procedure, anesthetic or surgery. At the end of a single procedure, a trap door in the bottom of the reservoir is released to allow those sequestered vials and syringes to drop into the bottom of the needle box for terminal disposal. Providers now have a means to refer back to any medication delivered for an individual patient. ERMA allows us to recognize errors in a timely fashion and address the untoward events that may arise from the error in a timely fashion.
“Research has revealed that medication errors occur despite concentrated efforts to prevent them partly because medication administration has become increasingly complex. In addition, providers are distracted, tired, [and] face environmental barriers such as low lighting as well as production pressures. In anesthesia, the normal system of checks and balances in the administration of medication are eliminated as one person prescribes, prepares, administers, and charts the medication. A single anesthetic often administers several doses of up to 20 medications. Nanji et al determined that 1 in 20 perioperative medication administrations and every second operation resulted in a medication error and/or an adverse drug event. ERMA allows medical personnel a second chance—a method to make sure that the medication they thought they were giving is actually the medication they gave. If an error was made, it buys the practitioner precious time that would have been spent in trying to figure out the precipitating cause of the medical crisis.”
Some of the biggest rewards that Snyder has had in inventing the ERMA is that she has learned she has both the heart and mind of an inventor. In fact, she says that she’s already given two more ideas to the Innovation Institute and already has others “simmering on my backburner.”
Her biggest reward, though, hasn’t happened yet. But she hopes it does. “I would be extremely gratified to hear practitioners in high risk areas tell me that ERMA helped them recognize and mitigate a medication error. My biggest reward would be meeting the mother that lost her child to tell her that her loss was not in vain. I want to let her know that her story motivated me to change the way we recognize medication errors and that my product may prevent another family from suffering such a great loss,” says Snyder.
She also has advice for other nurses who have good ideas about improving something in health care. “I believe all nurses are inventors at heart. We develop workarounds every day at work. We innovate every day. We don’t have the power and means to move our ideas to reality. My advice is to find a mentor. I have some amazing mentors at Bon Secours, VCU, and Innovation Institute,” she says. “Read about other nurse inventors and reach out to them. By definition, nurses are nurturers and delight in the ideas and successes of our colleagues. Reach out to your hospital system to see if they are affiliated with a medical incubator. Google scholar and Google patent are amazing resources because sometimes your idea is so good, it has already been invented or patented! Read the research to look for inspiration.
“I encourage all nurses to innovate. Through nursing innovation, we will improve patient safety. Innovation is a positive feedback loop; as we innovate and take our places as experts in the medical field, administration will reach out to us as the experts.”
Tina M. Baxter, APRN, GNP-BC, has worked in both acute care and long-term care. A board certified gerontological nurse practitioner, she now teaches through HIS Solutions Health Care and works as a legal nurse consultant for Baxter Professional Services, assisting attorneys in nursing home litigation cases. Baxter took time to tell us what nurses can expect when working in long-term care.
Describe a typical day in the life of a long-term care nurse.
A typical day depends on your background. As an RN, you are responsible for the assessment and care plan for the resident. You may be responsible for staffing the unit and completing assessments in the hospital to determine if the resident is appropriate for admission to the facility. You may also function in the capacity below as is described for the LPN. As the director of nursing, you will be responsible for the day-to-day operations of the nursing unit by supervising other nurses, nursing assistants, and volunteers. You are responsible for making sure you stay within budget for care, approving the allocation of resources, and providing guidance to the staff.
As an LPN, you will begin with shift report, round on your residents, and morning med pass. After med pass, you usually begin your wound care treatments, breathing treatments, or other treatments needed. You also will begin your documentation of your assessment of the resident, field phone calls from the MD/NP for orders, review labs, fax pharmacy new orders or requests for refill medications. You then get ready for noon med pass, help monitor the dining room, and repeat the above. Afternoon med pass is anywhere between 2 p.m. and 5 p.m. You will document your assessments of the residents, attend to any resident urgent needs such as injuries, sick complaints like a headache or pain, and make additional phone calls as needed. Also, you will answer any family or resident question or concern that may come up during your shift.
As an advanced practice nurse and nurse practitioner, the NP will round on the residents similar to rounds in the hospital or for a primary care visit. The NP will assess the residents, address any medical or psychosocial concerns, document the findings, recommend treatment, and write orders for medications and treatments. The NP may meet with the staff, residents, and/or family to discuss the overall course of treatment, review any proposed changes to the plan of care, and discuss the best therapeutic options. The NP will also review and interpret laboratory and radiological testing and sign off on recommendations from other disciplines, such as dietary and physical therapy.
What kinds of nurses would do well in this role?
Nurses who love a challenge, can practice autonomously, and have a solid background in nursing across the lifespan. You have to be a generalist, as you will use your medical-surgical nursing, mental health nursing, community nursing, and nurse educator skills on a daily basis. You have to be comfortable with knowing that your resident may not ever become discharged from your facility until death.
What are the biggest challenges?
One of the biggest challenges is managing family and resident expectations. Often, residents come from the hospital and the ratio of patient to nurse is very different. Also, the expectation of the length of stay at the hospital is temporary. Residents come to long-term care (LTC) to live and therefore, they are in their “home.” The resident and family need to understand those changes in the dynamics. Sometimes, you have to have the difficult conversation of discussing curative versus palliative care. The goals of being in LTC is to keep the resident safe, provide for the best quality of life as possible, and to provide an enjoyable living environment.
What do you love most about what you do?
I love working with the residents and knowing that I can make someone’s day by just giving a listening ear, giving a cup of water, or explaining to a resident’s family a complicated procedure and having them appreciate the care that we give to the resident.
What do you wish more people knew about the job?
I wish more people knew that, while maybe not as glamorous as working in the critical care unit of a major hospital, LTC nurses are required to utilize a lot of the same skills as those in critical care. LTC facilities have come a long way and they are not the “sad prisons” for the elderly as they are portrayed in the movies and on television. There are many nurses and nursing assistants who work hard to care for the residents and do so with grace and dignity.
If a nurse is thinking about working in a long-term care facility, what kind of training should s/he have?
They should have some training in medical-surgical nursing and/or rehabilitation nursing.
Whether you’re caring for patients, assisting physicians, or talking with families, you love what you do. No day is ever the same. We asked nurses why they love being a nurse in 2018. They gave us many different reasons, but they all agree on one thing: being a nurse rocks!
Thanks to all who contacted us. Here’s what some of your fellow nurses had to say.
“I get to help celebrate new life with mothers/fathers and family members by working in the Mother/Baby unit. Where else can you celebrate a new beginning, literally every day?”
—Teresa Kilkenny, DNP, APRN, CPNP-PC
“Being a nurse is great because I can focus on the holistic care of the patient—taking care of their physical, emotional, social, and spiritual needs.”
—Kim Hinck, BSN, RN
“I’m excited to be a nurse in 2018 because as health care evolves and improves, our ability to make a difference in our patients’ lives improves as well. Every day that nurses go to work, they have an opportunity to make a difference. That difference can be with lifesaving interventions or it may be providing explanations to our patients and their families in their times of need. Every day as a nurse is different and exciting, but also incredibly rewarding knowing your actions matter.”
—Megan Meagher, RN, CFRN, Care Fight Flight Nurse Truckee Base Supervisor
“With all the changes in health care over the past few years, I look forward to nursing in 2018 to bring innovative partnerships with community members, focusing on enhancing healthy lifestyles and preventive patient care through REMSA’s outreach programs in community and rural health.”
—Kristine Strand RN, BSN, REMSA-Care Flight Clinical Services and Quality Manager
“As more and more evidence confirms the high-quality care that nurse practitioners provide patients, 2018 is a great time to be a nurse practitioner (NP)! NPs are recognized for delivering patient-centered, comprehensive care, and meeting the health care needs of patients in more than 1 billion visits annually. NPs are improving access to primary care nationwide and consistently demonstrating excellent patient outcomes.
With CARA, NPs have stepped up to the plate to help combat the opioid crisis. Beyond primary care and our work to provide care to the nation’s most vulnerable populations, NPs working in acute and specialty care are also meeting the growing the needs of health care systems and the demand for mental health services as mental health NPs. The opportunities to make a difference for patients, families, and communities have never been greater—making 2018 a great year to be an NP—and a great year for states to enact full practice authority so that all patients can directly access NP care.”
—Joyce M. Knestrick, PhD, CRNP, FAANP, President, American Association of Nurse Practitioners
“I think it is great to be a nurse in 2018 because the different ways in which you are able to help patients is endless. From floor nursing to rare disease education, from a cruise ship to an elementary school, from the beginning of life to the end, and every phase in between, there is a nurse who is willing to listen and do all they can to make your day a bit brighter.”
—Shannon Ambrose, RN-BSN, Clinical Nurse Educator at Horizon Pharma
“As I look back on my career, I realize my practice has spanned four decades! It has been great to watch our practice change from routine to evidence-based (EBP) and the application of technology to both diagnostics and patient teaching. As an OB nurse, one of the most gratifying moments is when a new life is delivered into a mother’s waiting arms. Being able to help families identify their baby’s signals can give a new parent the confidence they need to get through the first night at home. As a nurse, I have so many tools to utilize for parent teaching, and we can customize them to our families’ needs and language—such as teaching them comfortable breastfeeding positions or practicing mindful diapering to promote bonding and protect sleep (something every new family cherishes!).
I remember my first months as an OB nurse in the 1980’s and feeling conflicted when some of my colleagues taught patients based on their opinions that babies could be held ‘too much.’ Fortunately, science has proved hugging your baby improves brain development, so nurses can encourage bonding. I can hardly wait to see what the future of nursing holds and will get to watch it unfold through the eyes of my daughter-in-law, Becky Faifer, who chose the NICU as her nursing home.”
—Felicia Fitzgerald BSN, RN, RNC-OB, C-EFM, CLNC, Perinatal Outreach Educator and Huggies Nursing Advisory Council member
“It’s not every day you hear that someone loves what they do after doing it for 35 years. I can say that I have the opportunity to live my passion every day and have for 35 years in the NICU. I get to observe and listen to the language of babies and even sometimes speak for them. Many medical technologies have changed the course of premature infant lives over the past 10 to 15 years, but one of the most powerful is simply listening and observing the language of their movement, cues, and cries. I love teaching parents and the health care team about the uniqueness and language of the premature infant and how every touch and relational experience we have with the premature infant can have impact on who they will become.”
—Liz Drake, RN-NIC, MN, NNP, CNS, NICU Clinical Nurse Specialist at CHOC Children’s and Huggies Nursing Advisory Council member
When a patient is undergoing organ transplant surgery, there are teams of people involved in everything before, during, and after the procedure. Jenna Vinje, RN, CNOR, a circulating and scrub nurse on the Peripheral Vascular and Liver Transplant team at University Hospital for the University of Wisconsin Hospitals and Clinics in Madison, WI, took time to give us a glimpse into what it’s like working as a transplant surgical nurse.
Jenna Vinje, RN, CNOR
As a transplant surgical nurse, what does your job entail? What do you do on a daily basis?
As a transplant surgical nurse, my job entails a variety of tasks that differ based on if I am circulating or scrubbing the surgery. As a circulator, my day starts by setting up my operating room with the supplies, equipment, medications, and instrumentation needed for the day. I count with the surgical technologist or scrub nurse. Then I get to meet my patient. I only get a chance to speak with them for a short time before I bring them back to the operating room. I facilitate the surgery by assisting anesthesia with intubation and any lines they may need to place. I then complete my patient preparation by inserting a Foley catheter, positioning, clipping, and prepping the patient.
Throughout the procedure I am continually assessing the room including patient position, supplies, and equipment needed by the surgical team, as well as, blood products and medications needed by anesthesia. I document all assessments and interventions completed in the patient’s electronic medical record. I keep the family updated throughout the surgery. As a scrub nurse, I set up the instrumentation and supplies. I am at the field with the surgeons, handing them instruments and assisting as needed.
Why did you choose this field of nursing?
The operating room has always intrigued me. I was able to observe a surgery during my clinical rotation for nursing school and thought this would be a good fit for my career. When I went through the interview process for the nurse residency program, I was offered the opportunity to interview for surgical services. Everything worked out from there.
What are the biggest challenges of your job?
Transplant surgeries can be very challenging. Patients tend to be extremely sick by the time they are able to get a transplant—especially with liver transplants. This can provide different challenges throughout the surgery. Transplants can be high-stress surgeries so it is important to stay calm and use your critical thinking skills to get through tense situations.
What are the greatest rewards?
The greatest reward is to hear how well my patients are doing after they receive their transplants. I get to help people every day try to overcome serious illnesses that impact their lives on a daily basis. Knowing that our goal in transplant is to give our patients a better quality of life is really rewarding to me.
What would you say to someone considering this type of nursing work?
Being a surgical nurse on a transplant team is challenging, however, it is also rewarding. The operating room is a fast-paced environment, where teamwork and critical thinking skills are extremely important. No two days are alike.
As a surgical nurse, you may not get to see the outcome of your patients in their daily lives; however, it is wonderful to think you are helping to give the gift of life to someone or at least improving their quality of life.
Andrew J. Johnson, APRN, CRNA, grew up in a rural area and always knew that it was the exact type of setting where he wanted to work. As the sole anesthesia provider for a critical access hospital in Olivia, Minnesota, Johnson loves what he does. But he does face quite a lot of challenges.
He took some time to tell us about his work. What follows is an edited version of our interview.
What kind of work do you do?
I am the sole anesthesia provider for our critical access hospital. I opened a pain clinic at our facility because access to care for those suffering with chronic pain was lacking. Fortunately, I was able to find an incredible mentor, Keith Barnhill, to teach me chronic pain management. I was then accepted into the post master’s advanced pain certificate program through Hamline University. The pain clinic has definitely benefitted our community.
I also provide anesthesia for obstetrics, emergency room, and surgical cases including general, podiatry, gynecological, ENT, orthopedics, and urology. In 2017, we became the first critical access hospital in Minnesota to get a Da Vinci surgical robot. This has definitely increased the number and complexity of general surgical cases we are able to do at our facility. We have been performing total hip and knee replacements the last 2 years, which was a much-needed service in our community.
Working in a rural area is quite different from what most nurses do. Have you worked in a more urban or suburban area before this? If so, how does working in a rural area differ from those places? If the facility you work in large or small?
Rural anesthesia is much different from that in urban and suburban facilities. Although the anesthesia doesn’t change, the number of resources available to trouble shoot and help in difficult situations is severely limited. I have always found that the toughest decision I make is what cases I shouldn’t perform at my facility.
What kinds of patients do you tend to see? How are they different from those you saw in a more urban setting?
I feel like the patients and staff have closer relationships in small communities. We all know each other, and many times are related to each other. I hear weekly from patients that they feel so comfortable knowing I will be doing their anesthesia because of our relationships in the community.
What have you learned from working as a nurse in a rural area?
There are many individuals and organizations that want to limit scope of practice for advanced practice nurses, especially nurse anesthetists, and thereby limit access to care for rural comminutes. It is easy to get busy with work and family and lose track of the politics of anesthesia, but it is vitally important to stay vigilant about what is going on in the medical and political arena.
Because it’s a rural setting, do you tend to know more of the patients or their families, as in a small-town? Do you get a lot of patients who have to travel a long way to get to you? How many miles might some patients travel? Are people ever helicoptered in? Brought by ambulance? How far?
I know most of the patients that I see for anesthesia and pain injections. In a town with a population of about 2,500, it is no surprise to run into people I have seen in the community. Most patients do not need to travel more than 45 miles to see us. There are about six hospitals in a 45-mile radius of Olivia. Some of these facilities provide a higher level of care, so we are able to transport to these facilities if we are unable to provide the level of care needed. For bad traumas, often the flight crews will land at the scene of the accident and evacuate the patient from the scene instead of delaying high-level care by coming through our emergency room. Certainly, there are times when these patients need to come to our emergency room for stabilization prior to transport.
What are the biggest challenges of working in a rural setting?
Call is always tough in rural settings. If can be tough to achieve a work/life balance because of the need to be available and within call range of the hospital. Because of this, my family has several hobbies that we can do together on our acreage including gardening, yard work, blacksmithing, exercising, hunting, and sports.
What are the greatest rewards?
It’s fun to be recognized in the community by patients that have been through the surgery department or pain clinic. They are appreciative of being able to be cared for in their hometown where they have friends and family to help with their recovery. I feel that community recognition makes it easier for my family to accept me not being home. My wife and kids can become frustrated with me getting called to work, but when they find out later I was helping one of their friends, they understand the importance of my job and are happy that I do what I do.
What would you say to someone considering moving to work in a rural area? What do they need to be willing to do or deal with?
Deciding to work in a rural facility is not a decision that can be made lightly. It is not just a job, but a lifestyle. My family has to take two vehicles to the movies, dinner, church, etc. Calling in sick to work is not an option. There is no additional help when emergencies arise.
Personally, I think there is no better place to raise a family that in a rural community, but I may be a little biased. To work in the setting, confidence is an absolute requirement. Someone will always try to challenge your decisions. As long as you can always make decisions with the patient’s best interest in mind, you will have the respect of your medical staff, and this will make for a satisfying career.
Also, you can’t decide not to see particular patients because there are no other options. As an example, I had to do the anesthesia for my wife’s caesarian section. I had someone hired to do her case, but her water broke a week before her schedule C-section. Another example of an interesting rural experience is when the locum I had hired to do my colonoscopy got the schedule confused and didn’t show up for the day. I had to do anesthesia for 6 procedures and was finally able to get someone to do my anesthesia in the afternoon.