On May 5th each year, Frontier Nursing University recognizes International Day of the Midwife by focusing on the outcomes of midwifery-led care. While we celebrate the role of nurse-midwives, one of our main goals as a leading educator is to reach others who may be thinking about a career in nurse-midwifery. We strongly advocate for integrating midwifery into the health care system to improve access to care because the nurse-midwife plays an important role in maternity and primary care for women, as well as the health of the family.
Rising Maternal Mortality in the United States
Frontier educates nurse-midwives to seek opportunities to lead positive change. One of the biggest concerns facing our society is the rising maternal mortality rate in the United States. We have the most expensive health care system in the world, yet American women are more likely to die during childbirth than women in any other developed country. The U.S. has experienced a continued increase in the maternal mortality ratio, which was 7.8 per 100,000 live births in 1987 and climbed to 22 per 100,000 live births in 2014 (2).
Rising maternal mortality is a complex issue, and contributing factors extend beyond medical complications. There are financial, bureaucratic, transportation, and language barriers, as well as social concerns and a shortage of maternity care facilities and providers. The obstetrician to patient ratio is much less than it was 20 years ago, and the number of family physicians providing maternity care has decreased from 25% in 2000 to 10% as of 2010, according to a 2013 study published in the Maternal and Child Health Journal.
Health Disparities and Inequality
Rural areas are some of the most affected as community hospitals shut their doors. According to the American College of Obstetricians and Gynecologists, 49% of all U.S. counties do not have an ob-gyn. And while 23% of women live in rural areas, only 7% of ob-gyns practice in rural areas. Additionally, health care insurance coverage is not a guarantee in the U.S., which leads to difficulties accessing care and worsening health outcomes.
Health equity is another priority for nurse-midwives. A 2007 National Center for Health Statistics study showed that non-Hispanic black women are three times more likely to die than non-Hispanic white women during childbirth. While that study is 10 years old, we are not seeing any improvement. Racial disparity is highly evident in Washington, D.C., where the maternal mortality ratio is the highest in the country. If you separate white women living in Washington D.C., however, they have the lowest maternal mortality ratio in the country.
Improving Access to Quality Care
Accessibility to quality health care should be a social goal and a human right. Effective access includes convenient locations and hours; an adequate number and choice of providers; economic and informational resources; and appropriateness of services provided. Social determinants, such as confidentiality, perceptions of quality, and cultural sensitivity, are also key to patients seeking care.
Frontier Nursing University is working to increase not only the number of certified nurse-midwives, but also diversity among those who provide maternity care in rural and underserved areas. Through our distance education model, we educate nurse-midwives in their home communities. We were delighted when the American Midwifery Certification Board recently reported a record number 11,600 certified nurse-midwives. But there’s more work to be done as we need to dramatically increase the number of nurse-midwives needed in the U.S. in order to meet the health care needs of women and families.
According to a recent Cochrane Review, midwifery-led care can result in better outcomes. For example, there is more continuity of care, fewer pre-term and instrumental births, higher maternal satisfaction, and a cost-savings compared to medical-led care.
As educators and providers, we must have a larger focus on primary and preventative care and collaborative health care environments. We need to continue to collect more data to better understand the factors that lead to maternal mortality and poor health outcomes, and then develop programs to address those issues. And finally, we must diversify the health provider workforce so that patients are more likely and willing to participate in care.
We invite you to learn more about nurse-midwifery led care at Frontier.edu.
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.
Victims of any kind of sexual assault are traumatized—they’re anxious, vulnerable, and, not surprisingly, scared to trust. They need help.
In 1994, Dr. Christine Jackson noticed that when victims of sexual assault were brought into area hospitals in Baltimore City, neither physicians nor the nurses had been trained in how to collect evidence or detect injuries for these patients. Police, though, expected that the staff was trained. As a result, the outcomes of the kit collections were terrible.
Dr. Jackson wanted the hospitals to do better for these patients. So she founded the Mercy Medical Center Forensic Nursing Program. Back then, says Debra S. Holbrook, MSN, RN, SANE A, FNE A/P, specially trained nurses, which were called Sexual Assault Nurse Examiners (SANE) or Sexual Assault Forensic Examiners (SAFE), were trained and educated in comprehensive care of victims of sexual assault. Mercy Medical Center, in Baltimore City, was designated the point center for this kind of medical forensic care.
“The Mercy Medical Center Forensic Nursing Program now cares for almost 1,000 patients each year, and sees all forms of interpersonal violence including sexual assault; domestic, dating, and stalking violence; elder and vulnerable populations abuse, neglect, and maltreatment; human trafficking; strangulation; trauma; chronic abuse of foreign nationals seeking asylum and T/U Visas; and suspects of all person’s crimes,” explains Holbrook, the Director of Forensic Nursing at Mercy Medical Center. Holbrook says that the program is also one of the only mobile ones in the United States—meaning that the nurses involved are able to travel to various hospitals, etc., throughout the area. “For 25 years, the Mercy Forensic Nurse Examiner (FNE) Program has been the only mobile program of its kind in Maryland, seeing patients in all surrounding hospitals including Johns Hopkins Hospital, the University of Maryland Medical System, Shock Trauma, and all emergency departments, nursing homes, and prison systems. The Program has also created Memorandum of Understandings with all branches of the military, seeing victims from the U.S. Naval Academy, Ft. Meade, Ft. McHenry and Reserves, and Kimbrough Army Hospital.”
Currently, the program has 32 FNE who provide coverage every hour of every day of the year. Holbrook explains that these nurses must first participate in a mandatory curriculum, which includes 40 hours of didactic training, a preceptorship including partnering with stakeholders to gain a working understanding of the criminal justice system in the Baltimore City jurisdiction, and a rigorous preceptorship by skilled FNE until the trainee is competent and comfortable enough with practicing independently.
All the cases they are involved with are peer reviewed by leadership as well as peers to make sure that they are accurate and complete. Holbrook says that nurses are prepared to testify in court in either a fact or expert capacity as needed. Most nurses in the program work at hospitals other than Mercy, but they are on a per diem status with the Mercy FNE program.
When nurses are finished with their training, Holbrook signs off on them, and they are certified by the Maryland Board of Nursing as FNE. “This assures competency, uniformity in practice, and accountability under the license of Registered Nurses in Advanced Practice,” she says.
As expected, there are challenges for FNEs who work with this program. “The challenge of working with victims of crime is that we never see a happy case,” says Holbrook. “Never. Day in and day out, we see patients victimized by unimaginable violence and cruelty, and that wears on you when you care for a large volume of patients or when you peer review the work of fellow program team members.
“Most of our nurses have full-time jobs, and family, and are attending school—and they do this work in their free time. Why? Because they are highly skilled, compassionate men and women who have a passion for caring for patients who need our care. The greatest reward we have is watching our patients, who have arrived in devastation, leave as survivors of their crimes with resources to seek justice. They know they were believed and cared for and that they have support in the coming weeks and months ahead of them.”
If you are thinking about getting into this kind of work, Holbrook has tips for you:
- Make sure you are going into this work for the right reason. If you have been assaulted in the past, make sure you have had therapy and worked through it. Being burdened with these types of cases has an ugly way of bringing out memories, and we do not want you to be re-victimized.
- Know that you need to “stay in your lane.” As a forensic nurse, you cannot be an advocate for your patient or you risk having a patient bias. As a collector of evidence, an FNE must maintain neutrality.
- Take care of yourself. Most nurses only stay in the field for two or three years because of burnout.
For more info, go to www.bmoresafemercy.org.
Nowadays, you don’t have to go very far to look at your medical records; you can probably pull them up on your phone right now. Though the use of electronic medical records (EMRs) is pretty widespread, providers still face some major challenges, and health systems aren’t yet taking full advantage of the technology. One way this is obvious to patients and practitioners is through the absence of collaborative tools — if patients’ EMRs are so easy to access and share, why aren’t doctors collaborating with their other providers for the best possible care?
As professionals, we have to ask ourselves if it’s worth the investment. It’s clear that physician to specialist or physician to psychologist collaboration would benefit clients. Arun Gupta, the CEO of Quartet Health, argues that this is especially true in the behavioral health realm. Technology that could close communication gaps between physical and mental health — Gupta argues that, in these two areas, “a mountain of evidence to suggest that a bidirectional relationship exists” — could make care more effective and more affordable.
But how do we find smart, secure tools to link all of our patients’ providers? Adoption should be a three-step process. First, and perhaps last, we need to embrace the collaborative approach. Understanding why provider-to-provider or department-to-department communication is so useful will help justify the expense. And for doctors and specialists who take a value-focused approach, that might be particularly difficult. Next, we have to look into actual tools that have been developed for this very purpose and figure out how to integrate them into our practices.
Embracing the Collaborative Approach
Let’s take a look at some reasons why making EMRs more collaborative can benefit patients and result in improved outcomes. In a 2014 study published in the AMIA Annual Symposium Proceedings Archive, researchers compiled data from five American electronic health record (EHR) systems and observed provider interactions for 60 hours.
The study determined that the EHR itself played four roles in collaboration: as a repository, a messenger, an orchestrator, and a monitor, but that due to poor quality documentation, there was decreased trust among patients. The study concluded that “both organizational and technical innovations are needed if the EHR is to truly support collaborative behaviors.” So, indeed, there’s no denying the need for a collaboration-focused EMR. But what about this bidirectional business?
As Gupta points out in his essay, the most glaring missed opportunity for collaborative health care comes in the gap between physical and behavioral health providers. Gupta cited a recent study showing that people with asthma are almost two and a half times more likely to screen positive for depression, and that those with type 1 or type 2 diabetes are more likely to suffer from depressive disorders.
But collaboration can be good for addressing the logistics and disconnection within health care, too. You may know that the Department of Defense instituted the Bidirectional Health Information Exchange (BHIE) in an effort to close the communication gap between the DoD and the Department of Veterans Affairs, primarily to study pre- and post-deployment physical and mental health.
The Louisiana Public Health Information Exchange (LaPHIE) is a similar program that links providers between emergency rooms, primary care departments, inpatient units, and specialty ambulatory clinics to help address a broken HIV/AIDS care continuum in that area. A 2017 study showed that in the first two years of the program, LaPHIE saw an incredible improvement in the HIV care continuum.
Upgrading to Smart Medical Devices for Every Visit
We all know that high-tech medical equipment is a necessity of contemporary care, but we often don’t consider how much even the smallest, most commonly used devices can contribute to a better patient experience and a more collaborative approach. Streamlining data, and making it effortless to record and share, is the most important way to create secure, collaboration-ready EMRs.
Take, for example, the humble stethoscope. Once limited only to whoever was in the room, audio recorded from a digital stethoscope can now be effortlessly recorded and transmitted via Bluetooth to a smartphone or tablet. Gone are the days of describing the audio with the written word. If you’re a primary care doctor who needs to share your patient’s results with a specialist or surgeon, all it takes is a simple tap of the touchscreen.
For patients where monitoring vital signs over a long period of time is key, recording data sets through a digital patient monitor that measures ECG, heart rate, blood pressure, blood oxygen, breaths per minute and temperature, can help tie large data sets up in a nice, little bow. They now make smart attachments for stethoscopes and other medical devices that turn them into connected, collaboration-ready tools, so you can still use your preferred model.
Weaving in Software and Apps
The last piece of the puzzle is the hardest one, especially for large medical systems. Implementing new software is a challenge for any business, whether it be a family medical practice or a massive hospital system. But finding the right collaborative EMR software is an important step in implementing this methodology. It’s arguably the most important one, because it, as the previously mentioned study suggests, acts as a repository, a messenger, an orchestrator, and a monitor.
But finding software that fits the bill isn’t all that much of a challenge; Even Google has its own tools for health care providers. Theirs is unique in that it emphasizes the collaboration factor by allowing health care systems to easily and securely share X-rays, CT scans, and voice and video files through Google Cloud. Of course, if you haven’t yet migrated your EMRs to the cloud, it’s an important step to ensuring that records don’t get lost.
But what about HIPAA? Naturally, this is an issue that has held the industry back from certain technologies for decades — it’s why you still see so many pagers in health care facilities! But HIPAA shouldn’t be a roadblock. Make sure that you’re partnering only with HIPAA-compliant software providers and medical tools (those providers willing to assume liability for any HIPAA violations for failures on their behalf), using secure messaging and file sharing apps, and taking all the necessary consent steps before sharing any of your patient’s data.
Not all transplant nurses do the same kind of work. Because a kidney or part of a liver can be transplanted from a live donor, there are nurses who work with them every step of the way and for years after. Helene Wilkinson, RN, is a Living Donor Kidney Coordinator at University of Maryland Medical Center, in Baltimore. She took some time to answer questions about her job and how it differs from nurses who work with deceased donor organs.
Helene Wilkinson, RN
As a living donor transplant coordinator, what does your job entail? What do you do daily? Do you work solely with donors or recipients? Or do you work with both?
I help guide potential kidney donors through our workup process, schedule surgery, and provide follow-up for two years after surgery. There are two coordinators on our team that work solely with recipients, and my coworker, Jastine Paran, and I work up the donors. We have one other coordinator who works with the paired kidney exchange program, for donors who are not compatible matches for their intended recipients.
The first step in the donor process is evaluating questionnaires, which tells us about the potential donor’s medical history, surgical history, medications, allergies, and psychosocial information. If the donor passes the initial qualifications, we have them complete a blood test to see if they are a match for their intended recipient. If they match, I notify them, and then send them a long list of blood and urine labs to complete. I evaluate the results, and if they are normal, the donor is scheduled to come in for a “donor day evaluation,” which is a full day of testing to determine if kidney donation is safe for them.
During the evaluation day, the donor has an EKG, chest X-ray, and CT scan completed. The coordinators teach an hour-long education session and sit in with the surgeon for a consult with the patient. The donor also meets with a nephrologist and social worker. I compile all the information from these first three steps into a chart and present the information to our transplant committee, which meets every week. The committee consists of transplant surgeons, nephrologists, pharmacists, social workers, and financial coordinators. If the donor is approved by the committee, we schedule them for surgery and pre-admission testing. After surgery, we schedule a post-op evaluation appointment with the surgeon. Then we collect labs on the donor for 2 years postoperatively.
How is this type of coordinator different from one who works with recipients who are receiving donated organs from the deceased?
My role is separate from the deceased donor transplant coordinators. They focus on getting potential kidney recipients worked up and ready to be put on the kidney transplant wait list. They help recipients through their evaluation days, present the patients to the deceased donor committee, and register the patients on the wait list for a deceased donor kidney. I worked in the recipient coordinator role for 6 months before becoming a living donor coordinator. Both roles are very rewarding.
Why did you choose this type of nursing?
I worked on the kidney and liver transplant floor at another hospital for three years. I was ready to step away from working nights, weekends, and holidays, but felt a strong connection with the transplant population. One of my coworkers there had started working as a coordinator at University of Maryland a year prior, and she contacted me about a job position that opened. I interviewed and was offered the position within three days of finding out about the job. It felt like it was meant to be.
What are the biggest challenges of being a living donor transplant coordinator?
The biggest challenge of my job is notifying patients when they are no longer candidates for kidney donation. Our workup is in-depth, and every test requested by our team is to ensure that kidney donation is completely safe for our donors. There are times that I am working with patients for months, and there is a new finding that rules the donor out as a candidate. It is always heartbreaking to make that phone call.
Another challenge is when donors become stressed out about our workup process. There are a lot of unknowns, and sometimes we need to do last-minute testing prior to surgery. Occasionally, patients take out their stress about the process on the coordinators, which can be disheartening. It’s important during those times to step back, view the scenario from the donor’s perspective, and make sure to respond to every situation with compassion and empathy. I am grateful that I am close with the other coordinators in my office, and we have a strong support system to help each other through the tough times!
What are the greatest rewards?
The rewards of my position far outweigh the challenges. Kidney donors are a special patient cohort. These are people who are willing to undergo a surgical procedure to give a piece of themselves to friends and families. Some donors give their kidneys to someone they have never met. I get to partner with the donor through the whole process of giving a kidney to someone else. Every day, I witness the miracle of someone performing a selfless act to better the life of another. I am so deeply inspired by the actions of my donors.
I am also so grateful for, and inspired by, our transplant team. I have a great boss, Tina Stern, who supports me wholeheartedly in my coordinator role, and I work with multiple surgeons who have a deep-seated passion and determination to better their patients’ lives. The coordinators and assistants in my office have become family to me. We support each other and collaborate as a team to help get our patients to surgery as quickly and efficiently as possible. When people ask me if I like my job, I can honestly respond that I love what I do.
What would you say to someone considering this type of nursing work?
If you are considering a job as a transplant coordinator, I highly recommend first having some experience working as a nurse on a transplant floor or intensive care unit. A lot of our coordinators come from this background, and it helps to have the insights gained from working on these types of floors.
If you are feeling inspired about organ donation, there are a number of groups that you can get involved with for volunteer work. This includes organ procurement organizations, such as: The Living Legacy Foundation, which facilitates donation, transplantation, donor family support, and education throughout most of Maryland; Transplant Recipients International Organization; National Kidney Foundation; and UNOS, the United Network for Organ Sharing.