What do you do with 154 nursing students who are suddenly unable to participate in the hands-on nursing (clinical) care that makes up 60% of their education each week?
That was the challenge facing Mary Ann Jessee, PhD, director of PreSpecialty education at Vanderbilt University School of Nursing, and the 30-plus faculty who instruct those first-year (prelicensure) nursing students in patient care.
With the spread of COVID-19, the students’ clinical education in hospitals, clinics and other facilities was suspended in mid-March. VUSN was unwilling to postpone clinical learning and possibly delay the students’ path to becoming advanced practice registered nurses. So faculty got creative.
“For a couple of weeks, we had been determining what we would do if students weren’t able to be in the clinical setting,” Jessee said. “The course coordinators, Erin Rodgers, DNP, and Heather Robbins, DNP, and I brainstormed what would it look like to do a virtual experience for students that would enable them to experience the same clinical learning. Could we use the Simulation Lab and have the students participate by telling someone in the lab what to do?” The faculty consulted VUSN Simulation Lab Director Jo Ellen Holt, DNP, who responded enthusiastically with suggestions.
The result was a virtual live-streamed learning experience with students using their instructors and Simulation Lab staff as avatars to interact with the school’s high-fidelity nursing mannequins and provide patient care.
“One instructor acted as the student’s eyes, ears and hands while another observed and coached, just as they would do with actual patients in the clinical setting,” Rodgers said. “Students instructed their avatar on what to do, step-by-step. The avatar reported the results, and then the students as a group evaluated whether that skill was implemented correctly and discussed the outcome.”
The students joined the simulations via video conferencing, working in the same six-student cohorts as for their in-person clinical learning. Each student experienced directing the avatar and discussed the scenario with their group.
“What we’re trying to mirror is the typical direct patient care experience and clinical conference, but in a virtual format,” Jessee said. “We had to determine how to recreate those patient interactions, and in those, ensure that students had the ability to conduct assessments, prioritize patient needs, make decisions about care, implement that care and evaluate the results.”
Throughout the simulation, the instructor is observing and coaching, as they would with actual patients. “In the virtual clinical experience, the faculty member can’t see the student doing the assessment or preparing for safe medication administration. The student needs to explain it before the avatar acts so the faculty can see that the student knows how to do it. This allows faculty to assess the same competencies in the virtual simulation as in the clinical setting.”
The School of Nursing’s PreSpecialty program is for students with bachelor degrees in a field other than nursing. They spend 12 months in intense generalist nursing learning, then spend 12-18 months gaining specialty education. In addition to directing the PreSpecialty level, Jessee serves as assistant dean for academics, generalist nursing practice.
The virtual clinical simulation is only one strategy that the PreSpecialty faculty are using for clinical skills. The school also uses the Virtual Healthcare Experience portal, developed by Canadian schools of nursing to engage students in highly complex scenarios using actors, as well as materials from the Institute for Healthcare Improvement, ReelDX videos and faculty-created case studies.
VUSN PreSpecialty clinical faculty created multiple virtual clinical simulations to support pediatric, adult, obstetric and psychiatric-mental health care. Students whose clinical experiences did not require the simulation lab participated in similar virtual situations within a simulated home or office setting.
Before starting the virtual curriculum, the School of Nursing consulted the Tennessee Board of Nursing and the Commission on Collegiate Nursing Education (CCNE) to determine how the simulations would relate to the students’ future licensing. “They sent us confirmation that simulation can be used one-to-one in place of direct patient care,” Jessee said. “Every hour that students are logging in these virtual activities counts toward their preparation for the national council licensure examination, NCLEX.”
Student reaction has been positive. “Students are amazed that we created these things. They’ve had great experiences—it’s been intense and challenging—and they’ve had good team work,” Jessee said. “One student told her instructor that she felt the virtual clinicals were valuable and that they’d helped her with exams in other courses.”
One student gave feedback not on the clinical experiences but on her reaction to how VUSN has handled the COVID-19 crisis. “I have felt supported and seen by you, and all of my instructors in the past weeks…Earlier this week, our clinical group was discussing how, despite all the craziness going on in the world, we feel least concerned about our education and trajectory because of the incredibly talented faculty and resources at VUSN. Thank you!”
The faculty also judged the simulations successful. “We were able to develop meaningful, realistic virtual experiences that would provide students with opportunities to learn and demonstrate competency in essential clinical thinking skills,” Jessee said.
Although she doesn’t know of other schools that have created similar virtual clinical simulations, Jessee said that nursing schools across the country are developing various creative learning experiences. “We’re all working to enable on-time graduation of nurses to fill vacancies in the nursing workforce,” she said. “Our students won’t miss a beat.”
“It’s been stressful for students and added an extra workload on faculty but it has been so worth it to see the learning realized by the students,” she said. “It’s really rewarding.”
The National Association of Clinical Nurse Specialists (NACNS)
recognized six special clinical nurse specialists (CNS) during the
award ceremony at their 25th annual conference.
Each of the award-winners has made a significant contribution to raising the profile of the CNS by fostering research and/or improving practice, educational opportunities and service. According to the president of the NACNS, Sean M. Reed, PhD, APN, ACNS-BC, ACHPN, “The unique expertise and consistent value these six clinical nurse specialists have contributed to health care significantly advance the CNS profession by differentiating the CNS skill-set from that of other advanced practice registered nurses. Their contributions across a broad range of health care settings and specialties are leading to improved patient outcomes as well as greater support for CNS professional development programs.”
The 2020 Award-Winners
Click the award links to learn more about each recipient.
CNS Specialist of the Year Award for outstanding professional achievement demonstrating exemplary practice in patient care, nursing and health care delivery systems:
- Kathy M. Williams, MSN, RN-BC, APRN, AHCNS-BC, Adult Health Clinical Nurse Specialist/Master Clinician, U.S. Air Force, Eglin Air Force Base, Florida
Educator of the Year Award for outstanding professional
achievement as a CNS educator and commitment to excellence and
- Gayle M. Timmerman, PhD., RN, CNS, FNP, FAAN, Associate Professor and Associate Dean for Academic Affairs, University of Texas at Austin, School of Nursing, Texas
Evidence-based Practice/Quality Improvement of the Year Award
for efforts resulting in a significant impact on nursing practice and
patient and family outcomes:
- Erica A. Fischer-Cartlidge, DNP, CNS, CBCN, AOCNS, Nurse Leader, Evidence-based Practice, Memorial Sloan Kettering Cancer Center, New York
B. Davidson Service Award for extraordinary service to NACNS:
- Susan B. Fowler, PhD, RN, CNRN, FAHA, Nurse Scientist, Orlando Health, Orlando, Florida
Lyon Leadership Award for exemplary leadership in service to
- Susan Dresser, PhD, RN APRN-CNS, CCRN FCNS, Clinical Assistant Professor and Director, Adult-Gerontology CNS Program, University of Oklahoma Fran and Earl Ziegler College of Nursing, Oklahoma City, Oklahoma
Award for extraordinary service and contributions to NACNS
and the accomplishment of its mission:
- Anne E. Hysong, MSN, APRN, CCNS, ACNS-BC, FCNS, Critical Care Clinical Nurse Specialist, Northside Hospital, Duluth, Georgia
all of the honorees for their outstanding contributions to the
profession. Visit here to find
further information on the NACNS.
Healthcare workforce gains seen with Medicare-funded test program
An increase in government funding for clinical training opportunities for advanced practice registered nursing (APRN) is a feasible and affordable way to grow the primary care workforce, according to a Report to Congress on the Centers for Medicare and Medicaid Services (CMS) Graduate Nurse Education Demonstration.
The $200 million initiative was started in 2012 to determine if Medicare funding for graduate clinical education for APRNs, similar to residency training for physicians, could help meet meet the health needs of the U.S. population.
“There is a shortage of primary care providers in this country and the education of more APRNs can be part of the solution to increasing access to care,” Barbara A. Todd, DNP, director of Graduate Nurse Education (GNE) Demonstration at the Hospital University of Pennsylvania in Philadelphia, told MedPage Today.
CMS awarded funding for clinical training programs to five hospitals, which then partnered with accredited schools of nursing and non-hospital community-based care settings to deliver primary, preventive, and transitional care to Medicare beneficiaries.
The five hospitals are Duke University Hospital in Durham, North Carolina; Hospital of the University of Pennsylvania, Memorial Hermann-Texas Medical Center in Houston, Rush University Medical Center in Chicago, and HonorHealth Scottsdale Osborn Medical Center in Arizona.
Lori Hull-Grommesh, director of demonstration at Memorial Hermann-Texas Medical Center, commented on program results in the Texas Gulf Coast area, noting that 95% of APRN graduates are employed in the community setting and are helping meet critical access needs. She said she believes that national funding would allow these results to be replicated in other states.
Linda H. Aiken, PhD, coordinator of the GNE Demonstration Consortium of University of Pennsylvania, agreed. “If permanent Medicare funding were available for the clinical training of advanced practice nurses in all states, the national shortage of primary care could be solved and Americans would be able to get timely healthcare where ever they live.”
The report stated that demonstration schools had significantly greater APRN enrollment and graduation growth than comparison schools. It also touched on financial incentives: clinical training for an APRN came to a total of $30,000 compared with $150,000 for just 1 year of community-based residency training for primary care physicians.
Although the GNE demonstration is slated to conclude at the end of June 2018, the five hospitals are currently collaborating with major national stakeholders in order to promote permanent funding to roll out the program nationally.
“All five sites are working together to promote efforts for ongoing funding, along with major stakeholders AARP and [American Association of Critical-Care Nurses], who were instrumental from the beginning,” explained Hull-Grommesh. This is being done through publications, meetings, presentations and discussions with our legislators, she added.
Aiken noted that various types of healthcare organizations, including physician practices and retail clinics, are hiring nurse practitioners in larger numbers and supporting efforts like the demonstration to increase the supply for advanced practice nurses. Also, healthcare settings are working to recruit more advanced practice nurses, especially for their valuable role in ending the opioid epidemic and addressing unmet mental healthcare needs, she pointed out.
This story was originally posted on MedPage Today.
According to Joyce Knestrick, PhD, C-FNP, APRN, FAANP, President of the American Association of Nurse Practitioners (AANP), Congress recently passed and President Trump signed “a comprehensive package of anti-opioid bills into law with a key provision permanently authorizing NPs to prescribe Medication-Assisted Treatments (MATs), further expanding patient access to these critical treatments.”
This passage is extremely important to those fighting opioid addictions as well as those health care workers who are treating them. “Recognizing the ongoing impact of the opioid crisis, Congress and the President moved quickly to get this critical legislation across the finish line. We applaud their actions, which acknowledge the vital role nurse practitioners play in treating patients with opioid use disorder with Medication Assisted Treatments (MATs),” says Knestrick.
What does this mean for the health care community? Knestrick answered questions to explain.
Why is this important—both for NPs and for opioid addicts?
First and foremost, for the millions of American families struggling with addiction today, passage of this legislation ensures patients continuity of care, knowing that their NPs can continue to provide their loved ones access to MAT treatment.
Second, knowing that NPs are now permanently authorized to prescribe MAT, we anticipate significant growth in the number of America’s NPs who will become waivered to prescribe MATs—which will help turn the tide of opioid addiction in communities nationwide.
How will this help more opioid addicts?
As primary care professionals, NPs really are on the front lines of combating the opioid epidemic. Tragically, eighty percent of patients addicted to opioids don’t receive the treatment they need, due in part to health care access challenges, stigma, cost, and other factors. Thanks to advances in Medication-Assisted Treatment—which combines medications that temper cravings with counseling and therapy—and this new law granting NPs permanent authority to prescribe MATs, the opportunities to reach and treat patients struggling with addiction are better than ever before.
In addition to helping addicts, will this make the process more cost-effective? If not, how else will it be beneficial to health care facilities and/or treatment centers?
We do know that treating people with addiction to opioids and other substances is costly—in part because of the need for in-patient treatment and more frequent hospitalizations. Yet, most people in need of treatment simply don’t receive it. As a nation, we are facing significant shortages of specialty treatment facilities for addiction, and this makes it all the more important to ensure that NPs and other primary care providers have the tools to meet the patient need for MATs
AANP has formed a collaborative with the American Society of Addiction Medicine and the American Association of Physician Assistants to provide the 24-hour waiver training for NPs and physician assistants. We invite NPs to visit AANP’s CE Center at https://www.aanp.org/education for more information.
The emergency department (ED) presents a set of unique challenges for patient care, not the least of which is unstable patients who are at great risk for falls. I once heard a nurse educator proclaim: “Everyone is a fall risk in an ED.” From the elderly to the acutely ill, most patients in the department are at possible risk of falling, whether due to their age, their complaint, or the medications and treatment they are receiving. Additionally, many EDs do not have bed or chair alarms available for gurneys to assist with patient falls. Fall prevention is almost solely in the hands of the busy ED nurse.
Here are six ways you can help prevent patient falls in the emergency setting.
1. Use universal falls precautions.
All patients—from the 30-year-old with abdominal pain to the 65-year-old post–total knee replacement—are at risk of falling. In your own practice, using universal falls precautions can be helpful. Treating all patients as though they have the same risk for falls is a good start. Additionally, performing individual fall risk assessments on each patient at the beginning of his or her visit is important to both assessing risk and documenting that risk in the medical record. If completing a falls risk assessment is not mandatory at your facility, consider printing out the Morse Fall Scale and attaching it to your ID badge for quick reference. A standardized tool can help you quickly quantify the risk of patient falls so you can intervene accordingly.
2. Plan your interventions.
My personal favorite fall prevention intervention is the call light. On patient care whiteboards in the ED rooms, I write my name and the phrase, “Please use your call bell for ANY reason” on the board. I orient patients to the call bell immediately and make sure that it is in reach. I explain to them why both side rails need to stay up. Additionally, you may place fall risk socks (or grippy non-skid socks) on your patient as soon as you get them undressed into a gown. Use a fall risk yellow arm band if they’re available to you.
3. Orient your patient.
“I’m going to be your nurse today, and the best way we can work together is for you to help me keep you safe.” I remind patients that even if they feel fine, that trying to get up after laying down or after receiving high-risk pain medications can cause them to feel weaker or dizzier than they might imagine. I encourage patients to use the call bell so I can help assist them out of bed for any reason, but it is also important to set expectations. “It may take me a few minutes to respond, but I will be there as soon as I can.” Try to point out IV lines and oxygen tubing to patients as well as their EKG cables and monitoring leads to remind them that they will need to stay in bed and cannot get up without assistance.
4. Active toileting.
One of the biggest reasons that patients fall is because they have to use the bathroom. For male patients I always place “just in case” urinals at the bedside, and I encourage female patients to use the call bell as soon as they think they have to use the restroom. It is also recommended that you offer toileting as frequently as possible so that you are able to prevent the “have to go right now” urge that draws patients out of their beds.
5. Teamwork works.
It would be impossible for a nurse to be able to be in all of his or her patients rooms at all times, especially within the environment of the ED. If you have a patient who is a high fall risk, who perhaps has dementia or is uncooperative, notify your charge nurse and your colleagues on the unit. Try to move the patient to a room in sight of the nurses’ station or near a hallway. Keep the curtains to the room open if possible to allow as much sight as possible from passersby. If staffing allows, perhaps you could request a safety sitter to help watch the patient to keep them safe.
6. Speak up.
If there are conditions on your unit that continually put patients at risk for falls, report them to your manager and supervisors. It is everyone’s responsibility to help prevent patient falls.
Prior to the 1950s, neonatal jaundice was a common problem and one of the leading causes of death in premature infants — that is, until a British nurse made a fortuitous discovery.
Sister Jean Ward, whose reputation for excellence in rearing puppies landed her a job running the preemie unit at Rochford General Hospital in Essex, England, was a “keen” believer in the restorative effects of fresh air and sunshine and on warm days would wheel the frailer infants into the hospital’s sunny courtyard.
Not wanting to raise any eyebrows with her unorthodox practice, Ward would usually scurry the babies back inside to their incubators before the hospital’s pediatricians made their rounds.
But one afternoon in 1956, Ward ushered a group of doctors over and sheepishly showed them the preemie in her care. The infant was pale yellow from head to toe, except for one deeply bronzed triangle of skin.
Mystified, one of the doctors asked if she had painted that portion of the baby’s skin with iodine. It wasn’t a paint job, Ward assured him. The darker patch of jaundiced skin had been covered up by the corner of a sheet while the infant was outside. It was the rest of the infant’s yellowish skin that had faded, she explained, apparently from the sun exposure.
Ward’s astute observations helped to pave the way for phototherapy treatments that are still used today to treat infants suffering from hyperbilirubinemia — and she’s just one of many nurses whose bedside discoveries have revolutionized the way we care for patients.
Other groundbreaking nurse inventions, as noted in this 2014 Medscape article, include everything from disposable sanitary napkins to crash carts to ostomy bags to disposable baby bottles. It was also a nurse, who in 1911, created the first mannequin to function as a patient simulator for nurses in training — and newer generations of nurse inventors and researchers are tackling other vexing problems in health care.
With hospital-acquired infections on the rise, Ginny Porowski worried about the health hazard created by waste bins overflowing with contaminated isolation gowns — a common sight on any floor with patients on contact precautions. So a few years ago, the North Carolina nurse invented a new type of gown that can be disposed of more easily. Unlike the typical isolation gear, Porowski’s GoGown has a special inside panel allowing the wearer to wrap a used gown into a small, compact bundle for safer disposal. Health care providers never have to touch the outside of the gown and used bundles sink to the bottom of the trash container, rather than billowing out the top.
A Chicago-area nurse’s research, meanwhile, is changing the way some Illinois hospitals approach newborns’ first baths.
Courtney Buss, an RN at Advocate Sherman Hospital in Elgin, Illinois had been hearing a lot of buzz about the benefits of delaying a newborn’s first bath for at least eight to 24 hours, but she was unable to find much in the way hard evidence supporting the “wait-to-bathe” approach. Looking for answers, she decided to conduct her own investigation.
At most hospitals, newborns typically receive a sponge bath soon after birth to remove the white, waxy, cheese-like substance called vernix caseosa that covers their body. But Buss’s 2016 study showed that leaving the protective layer of vernix intact for at least 14 hours can dramatically reduce bouts of hypothermia and hypoglycemia in newborns.
Over the course of nine months, as bathing was delayed, Buss found that the percentage of infants suffering from hypothermia dropped from nearly 30% to 7% and hypoglycemia rates plummeted from 21% to 4%, according to the Chicago Tribune. Delayed bathing also dramatically improved breastfeeding rates among the babies because the vernix helps neonates pick up on their mother’s scent, which makes latching easier.
The hospital system where Buss works has since instituted a “wait to bathe” policy at half its hospitals and her research underscores what the nursing profession has long known — that important discoveries aren’t restricted to those in white lab coats. Innovative scientists also wear scrubs and even answer call bells.