When transplant cardiologists at the Debakey Heart and Vascular
Center at Houston Methodist Hospital, began to use percutaneously placed
axillary intra-aortic balloon pumps (PAxIABPs) in 2007, there was one problem.
Not with the procedure, which would act as a bridge to heart transplants. But
rather, with the nursing care that would take place after. When CICU nurses
searched for literature on the subject, there was one problem.
There wasn’t any.
The procedure was so new, so no patient care protocols existed. So they developed them. And now an article about the problems and solutions developed by the nurses is out.
Frederick R. Macapagal, BSN, RN, CCRN, RN, Cardiac Intensive Care Unit, Houston Methodist Hospital, was a part of that team and is a lead researcher on the article. What follows is an edited version of our interview with him
Q: Were you on the original team that discovered that no nursing literature existed on PAxIABPs in 2007?
I was part of the team at Houston Methodist Hospital that
searched the literature in 2007 and did not find any nursing articles about
caring for patients with PAxIABPs. Medical journals had a few articles about
similar procedures, but they focused on the surgical intervention with nothing
about nursing care.
Since this was a relatively new procedure, the lack of
nursing articles was not surprising. Our protocols were developed over time,
using evidence-based nursing care and lots of “learning by doing.” After about
10 years of developing, reevaluating, and taking care of more than 100 patients
with PAxIABPs who are awaiting heart transplant, our staff has become more
competent and comfortable taking care of these patients.
Q: Explain how the
nursing and medical teams collaborated to develop these protocols. Did you work
together to determine what to try and what not to? Please explain.
The cardiologists informed us about the new procedure and
what the change meant for the patients. They gave us parameters and guidelines
on what to do and not to do to take care of the balloon pump and the insertion site.
Overall, the doctors trusted the nursing staff to figure out how to walk these
patients safely and provide the care needed at the bedside. The
multidisciplinary team of nurses, doctors, physical therapists, and ancillary staff
collaborated to devise interventions to mitigate the problems that arose and
incorporate them into the standard of practice.
Q: How did you decide
how to develop and implement clinical practice guidelines if there was no
previous literature with evidence-based practice backing it?
We did not have a choice. Our patients with intra-aortic
balloon pumps needed us to find a way to get them moving. Our patients needed to
walk to keep up their strength while waiting for a transplant, and we had to
develop our own nursing care protocols based on existing evidence-based
practices in order to safely incorporate walking and mobilizing into their care.
Q: What are the
resulting clinical practice guidelines that reflect nursing care practice and
The mobility guidelines we developed address issues such as where
patients walk within the cardiac care unit, for how far, and how long. We
defined the number of staff who need to walk with the patient, based on each
one’s individual strength. The guidelines also cover how often laboratory tests
and x-rays need to be completed. For example, laboratory tests such as complete
blood count and basic metabolic panel are obtained every other day to minimize
blood loss and the need for blood transfusions. On the other hand, chest
radiographs are obtained every day to determine the PAxIABP position.
Our nursing team also developed a PAxIABP repositioning kit so
that transplant cardiologists can perform simple repositioning of the PAxIABP
at the bedside as needed. This kit
contains sterile gloves, masks, surgical cap, stabilization device adhesive,
CHG scrub stick, and a prepackaged central catheter dressing kit. The kit,
stored in a clear plastic bag, is hung on a pole attached to the IABP console
for easy access.
Q: The article lists
some really interesting morale boosters used. Why are these so important to patients
in these situations?
Our pre-heart transplant patients with IABPs wait anywhere
from a few days to months for a donor heart. Anyone would get depressed with waiting
for so long under such stress. So the nursing staff came up with different ways
of helping our patients cope.
We consider these patients part of the CCU family and treat
them as such. We call them by their first names, chat with them about anything
and everything whenever we pass by their rooms, and get to know their family
and other visitors. We celebrate birthdays, anniversaries, holidays, and other
special occasions. We’ve found ways for patients to enjoy the occasional
home-cooked meal, have their pets come for a visit, and more, in an effort to
keep their spirits lifted.
Our patients from 10 years ago regularly come to our unit
when they are in town, chat with us, and offer to visit with current patients
who might need a pep talk and some cheering up. Patients appreciate the extra
effort we put into making their stay with us enjoyable.
Q: What else is important
about the nursing protocols for patients with PAxIABPs?
We started with existing evidence-based practice, but our journey didn’t end there. Whenever a challenge arose, we found solutions to address the situation. We documented each lesson learned and worked through the unique challenges encountered with our patients. We gained confidence throughout this process in our ability to innovate and improve the care we provide to all of our patients. We hope that this article helps other nurses who are caring for patients with PAxIABPs or who may do so in the future. In addition, we hope it inspires nurses to trust in their abilities to be innovative and courageous as they strive to provide the best care for their patients.
To learn more about the protocols, visit https://www.aacn.org/newsroom/nurses-develop-protocols-for-patients-with-paxiabps.
A 2018 study by the American Enterprise Institute (AEI) called “Nurse Practitioners: A Solution to America’s Primary Care Crisis,” by Peter Buerhaus, suggested that NPs can help with the problems of not having enough primary care physicians in particular areas of the United States.
David Hebert, JD, Chief Executive Officer of the American Association of Nurse Practitioners (AANP), recently explained how NPs can make a difference and what can stand in their way.
What follows is an edited version of the interview.
How many states restrict NPs scope-of-practice? What are the limits—what are they not allowed to do in these states that other states allow them to do? If they are allowed their total scope-of-practice, are they able to do everything that a primary care doctor can do?
Currently, 28 states don’t allow NPs to practice to the fullest extent of their training and licensure. Twelve of these—including California, Texas, and Florida—are “restricted practice” states, where the law restricts NPs ability to provide care without a formal contract with a physician. Sixteen other states, including Pennsylvania, Ohio, and Kentucky, are “reduced practice” states, where state regulations limit NPs’ ability to treat patients in certain care settings.
In 22 states, the District of Columbia, and Guam, NPs have full practice authority. This means NPs evaluate patients, diagnose, order and interpret diagnostic tests, as well as initiate and manage treatments under the exclusive licensure authority of the state board of nursing.
NPs and physicians both have the skill set to provide the full range of primary care services to patients. It’s not really about the provider—it’s about giving patients a choice of provider and ensuring them access to high-quality health care. NPs are a critical component of care teams. We work with all kinds of providers in every care setting to make sure patients get the best possible care. When it comes to scope-of-practice laws, we want NPs to be allowed to practice to the fullest extent of their training and licensure.
With the lack of primary care physicians, especially in rural and medically underserved areas, what can the NP bring to the community?
NPs ensure patients in rural communities have greater health care access, especially in primary care. The AEI report confirmed that while the NP workforce is growing significantly, the physician workforce is growing at a much slower rate. The study also concluded what we’ve seen in our own work: primary care NPs (PCNPs) are more likely to practice in rural areas, where the need for primary care is greatest.
It’s important to remember that primary care can prevent additional health complications for patients, making NPs a vital resource for rural communities. People living in states with laws that reduce or restrict NPs’ scope-of-practice have significantly less access to PCNPs. This finding indicates that such state regulations have played a role in impeding access to primary care. This alone should be cause for concern among policymakers seeking to improve public health.
When NPs have moved into areas and had the complete ability to practice, what have been some of the results?
In U.S. News & World Report’s 2018 Best State Rankings, nine of the top ten states for best health care allow patients full and direct access to NP care. According to Buerhaus, author of AEI’s report, people living in states that do not restrict NP scope-of-practice have significantly greater geographic access to primary care. More and more people are choosing NPs because the quality is high and accessible as well as because NPs take into account the needs of the whole patient, which resonates with today’s families.
What would you say to patients who might be afraid that they are getting lesser care in being treated by an NP as opposed to a doctor? How can NPs and other health care providers help patients to understand the benefits?
It’s important for patients to feel comfortable in their selection of a health care provider. Research shows that NPs achieve health outcomes for their patients equal to—and in some cases—greater than their physician counterparts. We encourage patients to consider an NP, take time to learn more about the care NPs provide at www.WeChooseNPs.org, and if it’s the right choice for them, to visit NPfinder.org, where they can find an NP in their area.
We’ve launched a nationwide campaign called We Choose NPs that showcase patients who choose NPs as their primary care providers. We believe it’s important for patients to have access to high-quality primary care and to have the information available to make the right health care choice for their family.
NPs are strengthening health care in a variety of important ways. Recently, Congress passed comprehensive opioid legislation that makes permanent the temporary authorization granted nurse practitioners (NPs) and PAs to provide lifesaving medication assisted treatments (MATs) for patients battling addiction. After conducting a billion patient visits last year alone, we’re very excited about the future and the opportunity to help patients nationwide.
Barbara Stilwell, PhD, RN, FRCN, is on a mission. She wants nurses to be empowered. As the Executive Director of Nursing Now, a three-year global campaign run in collaboration with the International Council of Nurses and the World Health Organization, she and all those involved want nurses’ voices to be heard.
She took time to explain what Nursing Now is and what they hope to accomplish.
What is the Nursing Now campaign? Why did you
start it? Why do you think it’s important?
The purpose of the campaign is as follows: Nursing Now aims to improve health and health care globally by raising the status and profile of nursing, demonstrating what more can be achieved by enabling nurses to maximize their contribution to achieving universal health coverage.
Strengthening nursing will have the additional benefits of promoting gender equity, contributing to economic development, and supporting other Sustainable Development Goals. This “Triple Impact” was identified by a British All Party Parliamentary Group in 2016 which reviewed the contribution of nursing to global health and identified the triple impact—improving health, promoting gender equality, and contributing to economic growth.
specific outcomes of the campaign are:
investment in nursing
in global policy
nurse leadership and influence
evidence of impact
ways of sharing effective practice
The strategy for achieving these outcomes has two interconnected elements—influencing policy globally and supporting action locally. The first involves adopting a high-level influencing approach working with partner organizations and the campaign champions to influence decision makers and organizations at global and regional level to include nurses at every level of decision making.
The second involves providing support to partners
locally, including professional associations and national Nursing Now groups,
to influence policy nationally, and support the development of nursing and
midwifery in their countries. We
want the local groups to create a social movement among nurses and midwives
that will support the aims of Nursing Now and result in changes being locally
The campaign is important because all countries face
enormous challenges in improving health and providing health care due to growth
in non-communicable diseases, changing demography, and the impact of emerging
factors such as climate change and migration, all coupled with rising demand
for health care with its associated costs. Achieving this will require massive
increases in health workers.
Nursing can make an even greater contribution to health
in the future. This is partly because nurses and midwives between them make up
almost half the professional health workforce globally. As importantly,
however, that nurses are particularly well-suited to contribute even more in
the future because of the way in which the whole health environment is
changing. The core arguments are:
- The burden of diseases is changing with increases in long term non-communicable or chronic diseases and—as populations age—more people with multiple morbidities who are living longer (often at home) and dying at home too. There is an increasing concern to care for those with mental health problems too, especially young people. Nurses are already central to much of this home care, and their role will continue to expand.
- These changes require new, more community-based
and holistic models of care as well as greater focus on health promotion and
disease prevention. Implementing new
models of care will require teams that, at times, should most appropriately be
led by nurses because they may be best suited to plan and manage care pathways.
- Nursing philosophy, values, and practice mean
that nurses are particularly well-suited to planning, implementing, and
managing patient centered, community-based care with a view to the full bio-psycho-social-environmental aspects
of health. Moreover,
nurses often work closely with their local
communities and constitute the majority of most health teams; they are ready to step up to the challenge.
To learn more about Dr. Stilwell and the global campaign, visit www.nursingnow.org or check out the radical advocacy special issue of Creative Nursing.
In honor of Certified Nurses Day, we reached out to nurses who have earned certification to find out why they love being certified.
As you’ll see their answers are varied: some are glad to have the additional knowledge, some are proud of the accomplishment, and some like being able to have varied skills to help support patients and the nursing field as a whole.
What follow are just some of the quotes that we received. Some were edited, but only for length and/or clarity—we didn’t change the ideas expressed.
“Being certified in rehabilitation nursing benefits our patients and families with a documented level of knowledge and shows our commitment to patient care. It also benefits our coworkers as they have a mentor who can advise and support them with their patients and families.”
—Barbara Hennigan, BSN, RN, CRRN; Nurse Manager, Comprehensive Medical Rehabilitation Unit; University of Maryland Rehabilitation & Orthopaedic Institute
“Certification opened doors for me by allowing my supervisors to trust me enough to teach competencies and mentor new nurses. My supervisors trusted my nursing and clinical judgment enough for me to become a valued resource on our cardiac unit. Certification allowed me the opportunity to climb our clinical nurse ladder, which also provided an additional monetary component.”
—Kendra Armstrong, MSN, RN, ACNPC-AG, PCCN; acute care nurse practitioner; Phoebe Putney Memorial Hospital; Albany, Georgia (Provided by AACN.)
“Nursing certification helps me provide the highest level of care to patients during some of the most vulnerable moments of their lives. Knowing that my certification provided me the skill set and knowledge to have meaningful effects on people’s lives is both rewarding and humbling.”
—Shentelle Parker, RN, BSN, TNCC; ICU Nurse; Southeast Louisiana Veterans Care System
“Certification offers me a sense of personal accomplishment and validates my knowledge, skills, and clinical judgment in my specialty area.”
—Robin Colchagoff, MSN, RNC-OB, C-EFM; Director, Clinical Nursing Practice; University of Maryland Capital Region Health
“Becoming a certified nurse affirmed my nursing knowledge within my specialty of practice, Critical Care. Since becoming certified, I have joined my professional organization and have an easier time staying up to date with new evidenced-based practices by reading publications distributed by AACN. I have also encouraged many of my peers to pursue certifications in their specialties, too. I proudly wear my “Nationally Certified RN” badge as a reminder of my dedication to provide the best possible care I can to Every Patient, Every Encounter, Every day!”
—Tracy Kline, MSN, RN, PCCN; Direct Care Nurse, Intermediate Care Unit; University of Maryland Upper Chesapeake Health
“Being certified is a validation of my commitment, experience, and clinical expertise. I am proud to work along with my fellow certified nurses every day. It is a constant reminder and reassurance to our patients and family members that they are receiving the highest quality care. Certified nurses are determined professionals who invest in their professional and personal growth – they inspire me to be the best.”
—Sherley John, MSN, RN, CCRN; Clinical Nurse, Neurosurgical ICU; North Shore University Hospital, Manhasset, New York (Provided by AACN.)
“Having a certification, NE-BC, has given me confidence in my role and supported growth in my career! I would encourage everyone to consider certification in their specialty areas.”
—Danielle M. Wilson MSN, RN, NE-BC; Director Nursing Innovation and Evidence Based Practice; University of Maryland Capital Region Health
“As a certified nurse, I have even more confidence when conferring with my clinical colleagues, because they understand that I have specialized knowledge about my field of nursing. Because of this, I can advocate even more strongly for my patients, consistently improving the standard of care—and the reputation of our nursing staff and hospital. My certification shows that I am a mentor, a leader in my field, committed to growth, accountability, and superior care.”
—Kristen Wolfe, RN, RNC-MNN; Nurse Manager, Mother-Baby Unit; University of Maryland St Joseph Medical Center
“Becoming a certified nurse validates competence and knowledge within a specialty area, and it could increase job opportunities and potentially an increase in earnings. Some areas, such as case management, nursing administration, or being promoted within levels of practice for staff nurses, require certification.”
—Marilyn Wideman, RN, DNP, FAAN, Academic Dean and Vice President; the School of Nursing at Purdue University Global
“I am very proud to have been a certified rehabilitation nurse since 2007. This certification elevates our expertise in the way that we understand and take care of our rehabilitation patients after a disabling event or chronic illness. Maintaining the certification keeps me current with evidence-based practice specific to the needs of our rehab patients.”
—Holny Santana, BSN, RN, CRRN; Nurse Manager, Spinal Cord Unit; University of Maryland Rehabilitation & Orthopaedic Institute
“What I value most about my certification is the opportunities it’s opened up for me – the respect that I receive from my nursing and non-nursing peers, and the changes I’ve been able to make to the nursing practice at my current and previous organizations. I am a better practitioner because of my certifications.”
—Sam Merchant, MBA, BSN, RN, CCRN, PCCN, NE-BC, RN-BC; Progressive Care Unit; University Health System, San Antonio, Texas (Provided by AACN.)
“Earning my Medical Surgical Board Certification provided more professional credibility as a nurse. It helped me with my professional growth as well because it made me more confident in providing quality care to my patients. Patients I have taken care of expressed ‘feeling safe under my care’ just by them knowing that I have an RN-BC title in my badge.”
—Lina DeCastro, MAN, RN-BC; Clinical Nurse 4; Post-Surgical and Orthopedic Unit; University of Maryland Charles Regional Medical Center
“Besides personal satisfaction and a sense of accomplishment, certification validated all of the knowledge and experience I’ve gained working in the ICU for almost 10 years. My certification has made me a more confident nurse, knowing what I’ve been doing for my patients is aligned with national guidelines and standards for excellence in patient care.”
—Erica McCartney, BSN, RN, CCRN-CMC, ICU/IMCU; resource RN; Swedish Medical Center, Edmonds, Washington (Provided by AACN.)
“It is important for myself and my colleagues to become certified because it demonstrates that nurses have the knowledge, skills, and passion to provide high quality care to patients and their families. Certification shows that you are a lifelong learner who cares about the quality of care you deliver based on the most up-to-date evidence. Certified nurses are role models for other nurses and other health care professionals. It enhances their credibility among colleagues, patients and other members of the health care team. Certification shows that nursing is a profession that cares about safety, quality, and excellence.”
—Kathy M Reisig, RN-BC, BSN; Nurse Manager, NICU, Pediatric Unit, and Pediatrics After Hours; University of Maryland St Joseph Medical Center
“Certification provides validation and it indicates pride, dedication, self-direction and professional development for nurses. It also provides assurance to patients and families for quality patient care. I am proud to hold two certifications!”
—Katie Boston-Leary, PhD(c) MBA MHA BSN CNOR NEA-BC; Chief Nursing Officer; University of Maryland Prince George’s Hospital Center
Take a moment to celebrate Certified Nurses Day and tell us what you love about being certified in the comments below.
Ever thought about becoming a nurse in one of the armed forces? Alicia Murray did.
For six years, Murray, MSN, RN, CHPN, now an Assistant Professor at Husson University, served as an LPN in the Army. Having been recruited while in school, Murray spent eight weeks in basic training at Fort Dix in New Jersey and then had four weeks of AIT, which is individual training. She entered the military as an E-3—private first class—and was promoted to E-5 sergeant after completion of the aforementioned 12-week training. This allowed her to be a non-commissioned officer, as nurses without bachelor’s degrees or more are not eligible to be officers.
“The military offered the GI bill, student loan repayment, and a monthly income,” says Murray. But it also gave her so much more. “It provided me with leadership experience, organizational skills, structure, and the confidence to continue my education and team building.”
Murray answered other questions about how civilians can become nurse in the military.
What are the first things that people must do to become nurses for any of the branches of the military? Do they need to become RNs first? What type of degree do they need to have? Is this the same throughout the branches of the military? If not, how are the requirements different?
All military RNs are commissioned officers, and so unfortunately, RNs with an associate degree are disqualified. Any civilian who earned a bachelor’s degree in nursing and received an RN license in their state can apply for a direct commission. RNs, doctors, lawyers, and other licensed professionals in this pipeline receive a somewhat abridged version of officer candidate training to orient them to the military culture and their role in it as officers.
There are also programs that help civilians offset the cost of nursing education in exchange for serving once they graduate. The Navy, for example, offers a full tuition ride (unless you can find a school that charges over $180,000) to high school students going into a nursing program, or up to $34,000 to current student nurses through their Nurse Candidate Program. The Air Force also has a scholarship program for health professionals and each branch may offer college loan repayment incentives.
Scholarship programs are generally only for civilians aiming for a military career as RNs, but what about those already serving in the military? As with other college degrees, those who serve can receive tuition assistance or use their GI Bill benefits to pay for off-duty courses in an accredited nursing program.
Completing a bachelor’s degree while serving as a full-time enlistee is no breeze, but depending on your level of experience in an enlisted health care specialty and the number of credits your college is willing to grant for military experience, you may be able to make your journey that much easier.
After civilians become nurses, how do they go about entering the military? Do they have to go through what any other civilian does? Or are they automatically on a different level because they are specifically joining to serve as health care providers? Please explain.
Upon passing the NCLEX and becoming a registered nurse with a BSN, a nurse should speak with a recruiter of the branch they wish to serve. They enter as an officer, complete an officer candidate training, and enter into practice. You can work with the recruiter to help secure a specific location or desired base station. As above, if you have an associate degree or diploma education as an RN, you would have to enter the military in a different capacity and take advantage of the tuition reimbursement options available. Nurses want to designate if they want to be active duty or reserves depending on the commitment.
Active duty commitment usually begins with a two- or three-year commitment. The reserve option is usually eight years with six years being active at one weekend a month and two weeks of active duty a year for the first six years. The last two of the eight years are considered inactive reserves. You do not have to attend drill weekends, but can be called back to duty at any point in those two years if needed. With 20 years of active duty status, one is eligible to retire with full military benefits. If one has 20 years of reserves, they are also eligible for pro-rated military retirement benefits.
What else is important for people to know about how to become a nurse in the military?
Military nursing allows one to travel as well as support our troops in the field and in stateside hospitals. It is an admirable career that allows for career and promotional developments. Nursing positions can vary from bedside nursing, to leadership/managerial roles and field nursing. It allows you to reach you own potential for autonomy, leadership, and team building. It gives a different perspective to troops returning home, families, and caring for retired veterans and their families.
The career paths and specialties are endless. It is an experience that may push you to realize that you can do things you never thought you could do. It teaches respect and the importance understanding what the military culture is in the U.S. The skill set brought after finishing the enlistment will carry into the civilian world. It is rewarding, fulfilling, heartbreaking, and life changing.
I would encourage others to enter the military first and foremost to serve their country—to be there for the troops for medical support and to provide competent care. I learned confidence and a skill set that I was able to carry over into my civilian practice and promoted autonomy. I was able to obtain my associate degree RN through the assistance and went on to obtain my bachelor’s degree in nursing.