Category: Professional Development

5 Myths About Working on a Graduate Degree

By Janet Tucker, PhD, RNC-OB

Have you often thought when you find out a co-worker is working on a graduate degree, “That’s not for me — I don’t have the time or the money and besides I enjoy what I am doing now”? I did not seek a graduate degree until my children were in high school and after beginning; I wish I had started on that journey earlier! Let’s address some of the myths.

  • I do not have time in my life right now.
    I delayed a pursuing graduate degree because I thought I would be on campus as much as undergraduate classes require. Many graduate nursing programs offer online and on campus options or a combination. I often advise nurses, just stick your toe in the water and try one class. You can fit the assignments in your life no matter what shift you are currently working. Just trying one class a semester is “doable”
  • I am not sure I can afford the tuition
    There are many options-private and public colleges. There are scholarships and some employers offer tuition reimbursement. It is an employee benefit-check it out!
  • I have not been in school in years. I am not sure I am smart enough for graduate school.
    I hear this one a lot. You are smart-you are a RN and passed boards! Hands down for most nurses, our first program is the most difficult whether it was a BSN, diploma or AD program. You will be pleasantly surprised that a graduate degree builds on your existing knowledge and you will be encouraged to focus on your specialty area for assignments. You will often be able to combine an assignment with a project you wanted to do at work anyway. Plus for all of us “seasoned” nurses, when we have to use an example from practice, we have years of case studies and examples to use in assignments.
  • I really enjoy being at the bedside, I don’t want to do anything different right now
    Great! We need advanced degree nurses using their expertise and practicing evidence based practice in every setting. A graduate degree will open doors that you may not even think about right now. There may be an amazing opportunity that will come your way that requires an advanced degree.
  • I am not sure I can keep up with the technology now-discussion boards and on line classes.
    I was not confident either, however if you have middle or high school age children or neighbors, they will enjoy helping you. You will quickly adjust just as you have to EMRs.

I share all these myths because this is what I heard as I was working on my MSN and then a PhD. I began my MSN part time at the age of 50 when I was working about 24 hours a week and had all three children still at home. I did not intend to pursue a doctorate degree, however I became fascinated at the opportunity to influence care through research.

I started on my PhD one year after completing my MSN. I worked full-time during my PhD journey and I completed it within 4 ½ years. To add to the craziness, all three of my children got married during this time. It has now been a year since I graduated and I am an assistant professor at a university. I am able to continue to work occasionally in a clinical setting, conduct research, and teach the next generation of maternal child nurses.  I never would have dreamed that this would be my journey when I began taking that first graduate course. Therefore, if you are considering giving it a try, jump in, the water really is great. There are many others ready to encourage you along the way.

Janet Tucker is an assistant professor at the University of Memphis Loewenberg College of Nursing, where she is currently teaching maternal child nursing. She completed her MSN in 2010 and PhD in 2017. Her research interests are expectant women experiencing a fetal anomaly diagnosis.

 

AWHONN Resources

With generous support from individual and corporate donors, AWHONN’s Every Woman, Every Baby charitable giving program provides the opportunities to AWHONN members to apply for research grants and project grants who work in continue to improve the health of mothers, babies and their families. Additionally, AWHONN’s commitment to support emerging leaders also provides opportunities to apply to academic scholarships and enhance their professional development through attending AWHONN’s Annual Convention and information of education resources. , For more information on AWHONN scholarships and professional development opportunities visit http://www.awhonn.org/page/awards

 

Nancy Nurse & Moral Distress

Cheryl J. Bonecutter, RNC, WHNP-BC, MSN, DNP

Nancy Nurse walks into the hospital for her twelve hour shift like she has hundreds of times before in her eight year career as an obstetrical nurse.  Tonight, like so many other nights, she contemplates if she will have an enough nurses to care for the ladies presenting in labor tonight.  She dreads the thought of having another discussion with Dr. Kantwaite about delivering a baby before the 39th week and the evidence that has been presented to him multiple times by the nurses and chief of the department.  The chief is so frustrated and tired of dealing with Dr. Kantwaite that he has stopped answering the calls from the nurses pushing this physician’s blatant noncompliance with safety and best practice through their chain of command.  Nancy documents and reports these occurrences to her nurse manager who throws up her hands, asking what can she do to resolve these problems.  She knows through several candid conversations with her manager that there is approval to hire only a limited number of staff in the budget and she is always pressured regarding the productivity of the unit.  The moment-to-moment operations of the labor and delivery unit is challenging at best.  The needs of one patient turn into needs for two patients or more with the mother through recovery and the baby as they transition into life on their own.

Nancy Nurse has been assigned to care for a woman delivering an anencephalic baby.  The family has requested that all resuscitation measures be used to save their baby despite discussions with the parents on the mortality of anencephalic babies from the neonatologist and obstetrician.  Nancy realizes that Dr. Kantwaite is on call tonight and is already calling to induce a 37.3 week gestation primagravida patient.  Her cervix is closed but he wants the nurse to insert cervadil to ripen her cervix and start Pitocin in the morning.  Nancy has reviewed the prenatal record and finds no medical reason to induce this woman.  Nancy is also in charge tonight and has had one of the nurses for her shift call in ill.  This leaves them one nurse down tonight, giving her patient assignments as well as taking charge nurse responsibilities assisting the other nurses with their deliveries, transitioning babies and checking that the unit is stocked, paperwork is completed, staffing is evaluated for the next shift and all of the charge nurse assigned duties.  Nancy has planned to attend the clinical excellence meeting in the morning to discuss a new medication reconciliation process the hospital wants to implement through the computer system.     Moral distress, ethical dilemmas and ethical distress are all difficulties that nurses face on a daily basis in virtually every healthcare environment.  These quandaries can influence nurse engagement, job satisfaction, turnover, nurse attrition, patient safety and quality of care.9,23  The personal impact of moral distress can result in feelings of frustration, anger, anxiety, guilt, and loss of self-worth, depression, nightmares, resentment, sorrow, helplessness and powerlessness.23 Rather than experience these negative feelings, they may choose to transfer to another position or even leave the nursing profession in order to escape this distress.13(p258),23

Morals and ethics, although frequently used interchangeably, are different in definition.  The simple difference to distinguish morals and ethics is that “morality is about making the correct choices while ethics is about proper reasoning”.16  Healthcare systems across the nation, in some form or fashion, have an ethics committee, yet  morals committees or boards are absent.

Moral distress and how it effects the overall nursing engagement has been understudied and is frequently the “elephant” no one wishes to discuss in the organizational structure of healthcare.  Many factors and situations influence moral distress including staffing, physician practice, nursing practice, ethical climate, violence in the workplace and organizational policies but since moral distress in based on individual values and perceived obligations this varies from nurse to nurse.8   Nursing turnover, job satisfaction, quality of care, nurse attrition, caring attitudes, moral sensitivity and overall nurse engagement can be affected by moral distress.  Moral distress and ethical distress are continuing to be utilized interchangeably in research and education.  Ethics training focuses on ethical dilemmas and principles and may not include the tools needed to minimize the effects of the moral residue.  The American Association of Critical Care Nurses has developed the “4 A’s”.  Ask if you are feeling moral distress, Affirm your feelings, Assess and put the facts together and Act or create a plan and implement it.8  Other strategies that have been utilized include speaking up, be deliberate and accountable, build support systems and focus on changes in your environment at work.  Get educated on moral distress and get everyone involved.  Get down to the roots and develop polices, plan an inservice to train others.8

As we move toward improving our professional satisfaction with our work, improving quality of patient care and expanding our roles in healthcare; we must address the needs to diminish moral distress through effective tools that are easily accessed, supported by our institutions and professional organizations.  We know that how we engage in our work can be crucial to our outcomes.  Breaking down barriers in achieving our greatest work satisfaction, placing our mission first for our patients, developing a professional practice model and implementing tools to assist us with dealing with our moral distress will bring us closer to our purpose of caring.

Dr. Cheryl Bonecutter has been a registered nurse for over thirty years, and a Nurse Practitioner for over twenty years, specializing in Women’s Health, NICU, and Pediatrics.  She received her ADN degree from North Central Technical College (nka North Central State College) in Mansfield, Ohio, and thereafter, achieved her certification as a Women’s Health Nurse Practitioner from the University of Wisconsin-Milwaukee.  After completion of her BSN, Cheryl attained her MSN from Drexel University in Philadelphia, and followed that with a Doctor of Nursing Practice (also from Drexel University), graduating Summa Cum Laude as to both advanced degrees.

Cheryl has been active with numerous agencies and organizations, including the March of Dimes, AWHONN, and Sigma Theta Tau.  In support of women’s and children’s health policy, she has provided testimony to various committees of the Ohio, South Carolina and Texas legislatures, and has served on several local and state advisory boards.

Through her career, Cheryl has worked the entire vertical spectrum of Women’s Health, from bedside to provider to administration, and is currently working as a Nursing Administration consultant with Healthtrust in the Houston, Texas area.

References

  1. Advisory Board Company. Engaging the Nurse Workforce: Best Practices for Promoting for Promoting Exceptional Staff Performance. Washington, DC: Advisory Board Company; 2007.

 

  1. Bakibinga, P., Vinje, H., & Mittelmark, M. (2012, February 20) Factors contributing to job engagement in Ugandan nurses and midwives. 2012 March 29. International Scholarly Research Network Volume 2012.

 

  1. Baldrige Performance Excellence Program. (8 March 2012). Retrieved 4 March 2013 from http://www.nist.gov/baldrige/about/baldrige_faqs.cfm

 

  1. Bjarnadottir, A. (2011). Work engagement among nurses in relationally demanding jobs in the hospital sector. Nursing Science (Vard/Norden). 2011, March; Publ. No. 101, Vol. 31, No. 3: 30-34

 

  1. Corley, M.C., Elswick, R.K., Gorman, M., & Clor, T. (2001, January). Development and evaluation of a moral distress scale. Journal of advanced nursing, 3(2), 250-257.

 

  1. Corley, M. & Selig, P. (1992). Nurse moral reasoning using the nursing dilemma test. Western Journal of Nursing Research. 1992; 14(3): 380-388

 

  1. Elpern, EH., covert, B., Kleinpell, R. (2005) Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care; 14(6): 523-30.

 

  1. Epstein, E.G., Delgado, S.(2010, Sept 30) Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 3, Manuscript 1. Retrieved 3 March 2013 from http:www.nursingworld.org/MainMenuCategories/EthicsStandards/Courage-and-Distress/Understanding-Moral-Distress.html

 

  1. Ganz, F. & Berdovitz, K. (2011). Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing. 2011, October 22; pp. 1516-1525

 

  1. Hamric, A., Borchers, T., & Epstein, E. (2011 April 14) Moral distress and ethical climate in nurses and physicians in intensive care unit (ICU) settings. Retrieved 8 February 2013 from http://www.virginia.edu/inauguration/posters/2.81.Biosciences.Hamric.Borchers.pdf

 

  1. Jameton, A. (1984) Nursing Practice: The Ethical Issues. Prentice Hall, Englewood Cliffs.

 

  1. Jones, C.B. & Gates, M. (2007) The costs and benefits of nurse turnover: A business case for nurse retention. OJIN: The Online Journal of Issues in Nursing. 12(3).

 

  1. Lawrence, L. (2011) Work engagement, moral distress, education level, and critical reflective practice in intensive care nurse. Nursing Forum. 2011, October-December; 46(4): 256-268

 

  1. Magnet Recognition Program Overview. (2013) American Nurses Credentialing Center; Retrieved 10 March 2013 from http://www.nursecredentialing.org/Magnet/ProgramOverview

 

  1. Malmin, M. (2012, April) Changing police subculture. FBI Enforcement Bulletin. Retrieved 9 March 2013 from http://www.fbi.gov/stats-services/publications/law-enforcement-bulletin/april-2012/changing-police-subculture

 

  1. Morals vs ethics: the problem with trolleys. (13 December 2010). The Philosopher’s Beard. Retrieved 3 March 2013 from http://www.philosophersbeard.org/2010/10/morality-vs-ethics.html

 

  1. Nathaniel, AK.(2006) Moral reckoning in nursing. Western Journal of Nursing Research. 28: 419-38

 

  1. Pauly, B., Varcoe, C., Storch, J. & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethic. 2009; 16(5)

 

  1. Rivera, R., Fitzpatrick, J., & Boyle, S. (2011, June). Closing the RN engagement gap. The Journal of Nursing Administration. 2011; 41(6):265-272

 

  1. Schaufeli, W. B., Salanova, M., Gonzales-Roma, V., & Bakker, A.B. (2002). The measurement of engagement and burnout: A two sample confirmatory factor analytic approach. Journal of Happiness Studies, 3, 71-92.

 

  1. Simpson, M. (2008 July 8). Predictors of work engagement among medical-surgical registered nurses. The Journal of Nursing Research. 2009 February; 31(1):44-65

 

  1. Wilkinson, J.W. (1987/1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16-29.

 

  1. Zuzelo, P. (2007). Exploring the moral distress of registered nurses. Nursing Ethic. 2007; 14 (3) retrieved from: http://www.lasalle.edu/schools/snhs/content/pdf/moraldistresss.pdf

 

Pediatric Clinical Experience – Incorporating Core Values into Care

By Michael Burke

As nursing students in the pediatric clinical setting, the character and values we display are crucial to not only our own growth, but also to the well-being of our patients. We all understand that the “student” label is often correlated with inexperience, and can lead to feelings of uncertainty and apprehension from patients. In the pediatric setting, hearing “student nurse” can add an extra level of anxiety for parents whose vulnerable, sick children are at risk. While parents may be wary of having students as caregivers for their children, there are several ways to help put them at ease and give confidence to both parties. In the pediatric setting parents are often exponentially more nervous than the patients themselves, but through positive practice values and confidence, the student nurse has the ability to truly make a difference when it comes to providing the best family and patient centered care possible.

According to Ruhl, Golub, Santa-Donato, Cockey, and Bingham (2016), nurses who give care integrate six core values into their practice including compassion, engagement, integrity, courage, humility, and wisdom. During our time as students in the pediatric clinical, I found that of these six core values, integrity served me the best and helped me grow the most when it came to family centered care. Integrity is something that is valued in all facets of life, but is expected in the nursing field. It is something that nurses pride themselves on not only because of the types of people who pursue nursing, but also because it can have a very positive influence on patients and families. Integrity is shown through honesty, respect, and judgment-free care and the nurse with integrity will stand up for the patient and family even while risking criticism and/or distain (Ruhl et al., 2016).

On the final clinical day of our pediatric rotation, I was assigned to a 42-day-old male patient who had presented one day earlier in respiratory distress, which was later determined to be a symptom of positive metapneumovirus. When I first entered the room with my clinical instructor, the introductions revealed that the patient’s mother was also a nurse, but had no experience with pediatrics and was understandably very concerned about her son. As a student in this situation, I could tell that the mother was instantly uncomfortable with my presence, but the clinical instructor did a great job of integrating me into the conversation and into the patient’s care. Weighing only 3.18kg with a respiratory infection, the patient was rather unstable throughout the shift, often fluctuating from low 90’s O2 Sat down to the low 80’s at some points even with supplemental 0.2L/min O2 by nasal cannula. The patient was prescribed PRN nebulizers, corticosteroids, and suctioning for these situations and with busy nurses and a busy clinical instructor; it was my responsibility to be on top of the patient’s status. Over the course of the shift it was often me alone with the patient and the mother, and from her perspective, I can imagine her hesitant feelings about this, especially considering her profession. However, through use of the core values, most notably integrity, I was able to gain her trust over the course of the shift. If there was something that she was more comfortable having the primary nurse do instead of me, I showed understanding and alerted the nurse. If she had a question and I did not know the answer, I would find the primary nurse or my instructor in order to find out. If I did know the answer I would simply and confidently respond. I could tell that her comfort level increased over time and by the end of the shift, she trusted my judgment enough to leave her son in my care while she took a dinner break. As a student, the important thing was not to know everything; the important thing was that I had the judgment and honesty to know my limits and ask for help when needed.

Reference

Ruhl C., Gulab Z., Santa-Donato A., Cockey D. C., Bingham D. (April/May, 2016).  Providing nursing care women and babies deserve. Nursing for Women’s Health Journal, 20(2), 129-133

Mike_BurkeMichael Burke was born in Boston and raised in Carlisle, MA by his parents Kate and Jim. He attended Concord-Carlisle High School and went on to earn a BA in Anthropology and a minor in Journalism from The George Washington University in Washington DC, where he also served as captain of the division 1 men’s soccer team. Currently a student nurse in his final semester at MGH Institute of Health Professions, Mike hopes to continue to progress as a student and future nurse by providing the best care possible to his patients.

A Special Thank You to Our Preceptors

Elizabeth Rochin, PhD, RN, NE-BC
Vice President of Nursing, AWHONN

After long days or nights, and years into a career, we as nurses may forget what initially brought us into nursing. If you want to remember, simply ask a student. In fact, I had the opportunity to ask fourteen nursing students just today why they chose nursing as a career path.

Here is a sampling of what they said:

  • “I wanted to make a difference in someone’s life.”
  • “There is nothing more pure than helping someone in need.”
  • “I knew since I was three years old that I wanted to be a nurse. I think I inherited it, my mom and grandmother are nurses.”
  • “This is my second degree. I discovered in myself a very strong need to help others, and went back to school. This was the right decision.”
  • “I was originally in sales and marketing, and realized that I loved making connections and promoting relationships. This was the perfect way to do both.”
  • “The first time a patient said, ‘You’ll make a great nurse,’ I knew I made the right decision.”
  • “I can’t imagine doing anything else. This is the perfect way to give back.”
  • “To use my hands to help heal a patient, or help to bring a new life into the world, I can’t think of anything better.”

Most of us will remember thinking about one or more of the quotes above, and will bring us back to our own days as a student nurse, and renew the passion in our work.

For the next several weeks, colleges and universities throughout the nation will graduate the newest members of women’s health, obstetric and neonatal nurses. We congratulate and welcome you to your new lives and careers. Nursing offers such diversity in career paths, and the opportunities for expert bedside care, advanced practice and nursing leadership roles have never been greater. There has never been a more exciting time to be a nurse!

But it is also important that we understand and remember that at one time or another, we were all new. None of us came into nursing knowing everything. We all needed a hand to hold us steady, and a guide to offer direction and counsel in how to move from a new graduate to a team member who could safely and effectively care for patients and their families.

Occasionally we forget what it felt like to be new. And we must be willing to remember. The greatest gifts we can bestow upon our newest nurses are understanding, time and expertise. We must commit to assisting our new graduates to grow and develop, and assist them to make the difference they want to and know they can make.

I would like to take this moment to thank all of our outstanding preceptors who strive to give our new graduates (and all new nurses, for that matter!) the best possible experiences and learning opportunities. Preceptors are those nursing team members who work with a new nurse for 12-20 weeks, and sometimes much  longer, to ensure appropriate training and competence. Preceptors are the “life blood” of nursing, and your effort and dedication to your orientees and organizations does not go unnoticed. Thank you for taking on this vital role and for shaping the next generation of women’s, obstetrics, and neonatal nurses.

Five Staff Portraits for Reston HospitalLiz  has over 25 years of Women’s and Children’s experience and  has devoted her professional career to the care of women and children with roles as a staff nurse, nursing educator and most recently executive leadership. She has presented nationally on patient experience and mentoring new nursing leaders. In 2008, Liz was named to the Great 100 Nurses of North Carolina, and is a member of Sigma Theta Tau. In addition to her clinical work and expertise, Liz has taught at the baccalaureate and graduate levels at East Carolina University College of Nursing. She is board certified as a Nurse Executive by the American Nurses Credentialing Center.

Navigating a Labor Experience: As a Student

By Amy Smith, Student Nurse at MGH Institute of Health Professions, Boston

I could feel the excitement in the room as I entered. The couple was receptive to my questions and suggestions; and the woman was more than happy to involve me in her care.  I tried to build rapport even though I was nervous in my role as a nursing student. This was the first time I had assisted a woman in labor and, after her membranes were artificially ruptured, her contractions started to come about two minutes apart.  At one point, I had my hand on her back and her husband smiled at me across the room and signaled for to me to remove my hand!  It was a great moment in which the support person and I connected!  I remained quiet during her contractions and I asked her if she wanted me to breathe with her but she said she had it under control. I kept thinking back to my own labors and what I felt I wanted from support people so I asked her if she would like lower back counter pressure but she refused.  The family had not done a childbirth preparation course so I assumed that their interest or skills with working through labor was limited.  I thought that they would need my help more yet her prenatal yoga practice seemed to have given her the tools she needed to get through her labor. The tools I offered her personally were meditative.  I told her to focus on her favorite place, to discuss her needs and frustrations with us in between contractions and reassured her that I was there for her to breathe with her and regulate her breathing as needed.

Reflecting on the Nursing Care Women and Babies Deserve virtues I used during this experience, I believe they were humility and engagement. Humility in that I had to understand I did not know what was best for this family. I assumed they would want and need what I needed during childbirth or skills I learned from the comfort measures video I used to prepare for this clinical experience. The woman decided what she needed and I was there to support her. In respecting their wishes I could engage with the family. Before I left them for the day they commented, “We felt like we had our own doula”.  It was easy and a pleasure to engage with this couple and follow their commands and offer suggestions. I told them I had never wanted to stay at clinical so much as I did with them. I will always remember this family.

 

Additional Resources

AWHONN’s Nursing Care and Women Babies Deserve Poster –  AWHONN’s statement on ethical nursing practice, Nursing Care Women and Babies Deserve, is rooted in the American Nurses Association’s Code of Ethics for Nurses, and provides nurses with core elements of ethical nursing practice for our specialty and corresponding examples of the virtues of ethical practice in action.

Read a commentary about Nursing Care Women and Babies Deserve in AWHONN’s journal Nursing for Women’s Health. Consider submitting your own story of how you or your colleagues practice nursing care that women and babies deserve at https://www.awhonn.org/?NursingCare

nursepicamyAmy is an ABSN student at MGH Institute of Health Professions, Boston.  She was a stay at home mother for 12 years,  a community coordinator for a non profit kids running program and a volunteer at Dana Farber Cancer Institute in Boston before deciding to enter the nursing field.  With extensive volunteer experience from a camp for blind & visually impaired adults and children, to co-president of an elementary school PTO, she enjoys working with diverse groups of all ages.  Amy aims to work in labor and delivery after graduation in August 2017 but is also interested in global health and epidemiology.  She has intentions to keep making a difference in the lives of those she may never meet again.

Ladies on a Mission

1 Comment

Guatemala

by, Lori Boggan, RN

When we enter the medical profession, we make a lifetime commitment to the service of others.  As nurses, we serve our patients, our community, our friends, and our family.  No other profession has such a deep connection to and is so trusted by society.  We are the ones at the bedside day and night.  We are the ones that our patients trust with their privacy, their secrets, and their lives.

Volunteer nursing is no foreign concept for American nurses.  In fact, the earliest “nurses” were nuns, or family members of those active in the Civil War.  They were in the trenches before any formal nursing education or organization existed.

For most, nursing is a calling.  Nurses are innate caregivers.  What is it about a nurse that is willing to use her own money, travel to an unfamiliar place sometimes lacking basic accommodations, and work long hours without pay?  It is the drive to care for those in need.

The following interview is with one of AWHONN’s own that goes above and beyond.  Nancy Stephani Zicker, a labor and delivery nurse from Central Florida has journeyed to Guatemala yearly since 2014 to help less fortunate women in need of gynecological surgery.  She journeys with her friend and obstetrician, Dr. Cecille Tapia-Santiago, of Volusia ObGyn Daytona Beach.  In addition to gynecological surgeries each year, Dr. Tapia sees patients in the mission’s clinic and educates Guatemalan midwives.  I interviewed both ladies in hope to inspire others to join mission work.

How long have you been going on missions?

Nancy:  I have been going on yearly medical mission trips every March since 2014.

Cecille:  I have been doing 1-3 mission trips a year since 2000.


Where has your mission work taken you?

Both: Guatemala


Why Guatemala?  Is there any particular need there with regard to women and infant’s health?

Cecille:  Absolutely. When we go there we provide contraceptive care, well woman care, and manage surgical conditions (uterine fibroids, large ovarian cysts, and pelvic prolapse being the most common).


Describe a typical day in the life of a volunteer nurse.

Nancy:  Each year that I have gone, I have been assigned to work as a circulating nurse (and sometimes scrub in to tech or assist) in the OR. There are clinic nurses, OR nurses, PACU nurses and ward (floor) nurses.

FullSizeRender-100We go in to a completely bare room and make it a functioning OR.

As an OR nurse, we first have to unpack and sort all of our supplies, as well as set up the operating rooms. We arrive on a Saturday late afternoon and get right to work. Sometimes we set up in community centers and sometimes we set up in an actual hospital. This usually takes Saturday evening and all day Sunday to accomplish.

Monday morning, the surgeries begin. Depending on the number of cases scheduled, we usually are in the OR from 8am-5pm. Once all surgeries are done at the end of the week, we have to break down the ORs to leave the space as we found it and inventory all supplies so we can order more for next year.  We all have had to improvise and be creative with available equipment and supplies. It’s quite the challenge, but the entire team comes together and we make it work.z


20140306_102410Cecille, describe your work educating midwives in Guatemala

It’s THE BEST PART. Midwives in Guatemala are mostly lay (no formal training at all). Guatemala has one of the highest infant mortality rates in the world. We do 1-2 day seminars and teach basic infant resuscitation as well as basic management of labor, delivery and postpartum complications. The midwives have to deal with a lot of prejudice from the physician community and often won’t get paid for their service if the patient has to be transferred to a hospital.  So anything they can do to show their critics that they are furthering their education and are doing right by a patient is helpful.

Is there any one particular patient story that you can share that stands out in your mind where you felt you really made a difference in that patient’s life? 

Cecille:  One of the midwives came back to a refresher course and told us that she gave CPR to a baby with apnea. Initially the family was resistant and thought the baby was dead. The midwife pulled out her certificate from the seminar and showed the family. She told the family to let her try and do CPR. She successfully performed mouth to mouth and chest compressions and the baby was fine!  We also had a young lady with an enormous pelvic mass that was compressing her entire abdomen and pelvis. She had been turned down by everyone and when we saw her, she was cachectic and probably a few weeks away from dying. We removed an enormous yet benign ovarian cyst. It was over 50cm in diameter and weighed 25 pounds.

How has mission work changed your practice?

Nancy:  It has made me a better nurse. Seeing and working with the patients I see on my mission trips has renewed my love of nursing and my compassion for people in general. The patients I see on these trips are so profoundly grateful for the care they receive.  It helps to renew one’s zest for nursing.

Cecille:  It hasn’t really changed how I practice at home, but you have to be a particular type of person to do well on these trips. In order to do this type of work you have to be patient, flexible, meticulous, and creative. You can’t go to these trips if you’re going to expect U.S. standards of equipment, timeliness and availability of things you have every day at home (for example blood, cautery, suction, light).  I have seen time and time again physicians, nurses and staff struggle because they have unrealistic expectations of what it’s like to operate in third world conditions. And by the same token seen plenty (like Nancy) that just sail, adapt and just sail.

How has mission work changed you as an individual?

Nancy:  Personally it has made me realize that as humans we all want the same things- we want our children healthy, we want access to quality healthcare, we want to be able to be happy in our daily lives, and we want a peaceful existence.

Cecille:  It refreshes my choice and faith in my profession. Medicine has changed so much. The physician/patient relationship many times is not what it used to be. We live in a defensive medicine environment that often plays in to how we practice here. Over there, patients and families trust and believe that, just like at home, I do my very best to provide the very best care my skill set allows, and that I will never go above that skill set and take unnecessary risks. That trust factor makes any responsibility tolerable.

Guatemala

What advice would you give a nurse contemplating mission work?

Nancy:  It’s important to choose the right organization to join, one that interests you. Each one has a different application process and requirements, as well as when and where they go on their trips. They all differ with their missions and what they offer. I have gone on 3 trips so far, and have applied for my 4th with the same group. It’s called Cascade Medical Team, whose parent organization is Helps International. I have friends that have used various other organizations. It’s important to choose one that fits your interests and your budget, as well as the dates you’re available to go. Also, for me on my first trip, it really helped that I went with someone I knew and who had experience with volunteering for medical mission trips. Not only was she able to give me a heads up on what to expect, but it is just amazing to be able to share the experience with someone you know- someone who understands why you would want to, or should want to, volunteer for such a trip
.

How can a nurse prepare for his/her first mission?

Nancy:  Be open-minded. Prepare to go out of your comfort zone and learn new things, both in the nursing/medical field and also culturally.

FullSizeRender-101Where to next?

Nancy:  To date, I have only been to Guatemala. At this point in time, I only volunteer for one mission trip each year and I have found that I really enjoy helping the people there and so have concentrated my trips to Guatemala.

Thanks for sharing, Nancy and Cecille!  And thank you for your service!  For more information on their work with Cascade Medical Team, visit www.cascademedicalteam.org.

Lori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/ or on Instagram.

Specialty Training for Novice Nurses

by, Heretha Hankins, MSN-Ed, RNC

Twenty-five years ago when I was a young, new nurse there was a lot of talk about the nursing shortage. Every nursing magazine speculated on how patient care would suffer if we didn’t train more nurses. Several years ago I looked around and saw tangible evidence of this looming shortage for the first time in my career. At first limitless overtime was available and then came incentive pay and bonuses as an effort to cover the shortage. Finally, nursing broke the unwritten golden rule. We started accepting new grads into specialty areas.

When I started nursing school I knew I wanted to work in L&D but my instructors explained that I must first work “general nursing” (med-surg) before I could even consider a specialty like OB. Today there is such a low pool of applicants for multiple open positions we are seeing a growing trend of graduate nurses entering specialty areas. After six months they are expected to possess critical thinking skills; one year later they train another new graduate. As we see an increase in the hiring of graduate nurses into critical practice areas such as OB, ICU and ER there needs to be a change to the training approach. The “each one teach one” approach is no longer effective.

OK, so here is where I want to really talk to nurse leaders. How do you know when a nurse is successfully trained? Can you measure the progress? Is the retention rate of your unit impacted by turn over from the nurses with less than two years experience? When I asked myself these questions I was inspired to design and implement the Perinatal Nurse Training Program (PI.N.T).

Developing the Program

The PINT Program is a 16 week program which includes 72 hours of didactic information in the classroom setting with a curriculum and reading assignments. Peer-reviewed books are required purchases (build a practice on research not hearsay). We also incorporate AWHONN’s basic and intermediate fetal monitoring courses into the training to assure the information received is consistent with national standards. Yes, it sounds and looks like going back to school.  Didactic hours are spaced throughout the 16 weeks building on concepts as the nurse builds in practice.

Use of a focus plan and checkpoints makes progress measurable. The checklists are tasked-based because a new learner has concrete thought processes. Consistent feedback in 1:1 sessions helps to promote progress or strategize about practice opportunities. In the last four weeks there are two to three novice nurses assigned to one preceptor. This gives the novice an opportunity to strengthen a solo practice while keeping that preceptor safety net nearby. After the 16 weeks, periodic monitoring is used to assure practice assimilation, answer questions and offer support. By the one year anniversary of practice the novice must pass the National Certification Corporation (NCC) exam for fetal monitoring to be considered successful.

Prior to PINT unit based orientation was largely completed with using preceptor pairing. Small amounts of didactic were used but were generally attached to vendor presentations for products used in the practice. Many things such as fetal monitoring and high risk pregnancy care were covered by use of self-learning modules. It is also worth noting, prior to my arrival the educator position was vacant for approximately five years.

Road Blocks

The greatest obstacle identified was seen in the change with preceptor assignments. Traditionally a novice was assigned to one preceptor for all of orientation. In the PINT program the preceptor assignment is fluid but generally stable for two weeks. My philosophy for this approach is based in inherent human error and autonomous practice. No one is perfect and sometimes what works well for one may not work for another. Seeing multiple different practices allows the novice to build his/her own autonomous practice.

Measuring Success

My measurement of success for this program is in the pass rate of the exam and the increase retention of new hires on the unit. With a total of 71 novices trained to date we boast a 98% pass rate by one year of practice on the NCC exam, a two year retention rate of 75% and a one year of near 90%. Program evaluation surveys provide feedback from the participants regarding what they gained and what could be improved. The participants noted the program worked well for them and they appreciated the structure. I am most proud to know that this leads to increased patient safety and healthy moms and babies. As I recall that was what motivated me to want this practice when I was a new graduate nurse.

Advice For Nurses Wanting to Start A Specialty Training:

  • Provide didactic training on the routine patient type starting with normal before sending the novice to the unit or training on complex procedures.
  • Make time for didactic classroom throughout the process so time if given to build on concepts.
  • Start the process with cohorts so that each participant can connect with someone in the group.
  • Encourage journaling because it helps develop critical thinking.

HerethaHeretha Hankins MSN-Ed, RNC is a Professional Development Specialist at Holy Cross Hospital in Silver Spring, MD, affiliate of Trinity Health System. She is the creator/facilitator of the Perinatal Nurse Training (PiNT) Program which she has presented to the Central Virginia Nursing Staff Development Organization, Maryland Patient Safety Perinatal Collaborative and Trinity Health Perinatal Summit. With 20+ years of nursing experience she also freelances as a Nurse Education Consultant. Her professional passion is to train the best nurses to provide the best patient care. She is always willing to discuss this at [email protected] or any other forum.

Confidence Building for Nurses

by, Lori Boggan, RN

I would like to call myself a bit of an expert on the subject of confidence.  Working as a travel nurse for many years, mine has been tested over and over again.  The one thing I have learned is that confidence comes and goes and that is perfectly ok.  Some days are better than others.  Travel nursing has forced me to learn new routines, try every new kind of IV catheter, learn each new unit’s policies, and adapt.  In the last five years, I have managed to find myself in another country and added the super challenging task of learning a new language to the list.  It has tested my confidence and given me the opportunity to reflect.  Here are just a few tips.

Develop Routines

There are certain tasks we as nurses do repetitively in our day to day work.  We take reports, check our monitors, calculate our drips, triple check our medications.  No matter how much time it takes initially, make these a part of your day to day routine.  It will be as subconscious as breathing eventually and once mastered, it leaves space for the most important task of critical thinking.  Why is my patient’s urine output low?  Why has my patient suddenly had multiple episodes of desaturation and apnea?

If At First You Don’t Succeed, Try, Try Again

So you didn’t get that IV or blood draw on the first stick?  Ask any honest nurse and they will tell you that it has happened to the best of them.  Having a bad access day does NOT mean you are a bad, incompetent, less worthy nurse.  It means today is not your day and that is ok.  Tomorrow is another day.

Ask

Asking a question is a sign of strength, not weakness.  No matter how small the question or how many times you ask, keep asking until you understand.  When starting in a new unit, whether you are a brand new nurse or a seasoned one, it is your duty to ask questions.  The ones to worry about are the ones that do not ask questions.

Never Stop Learning

That is why there is such an emphasis on continuing education hours when renewing your license.  Continuing education is critical.  There is always something new to learn or some change in research that may change your practice.  Be open to change.

Speak Up

If something does not seem right, follow your instincts and say something.  Chances are you are right.  Always err on the side of caution.  You will learn to trust your own intuition.  Perhaps speaking up can create a change in policy on your unit.

Leave the Bad Days Behind

So you were not super nurse today?  Today was not your day?  That’s ok.  You are only human.  There is no super nurse.  Anyone who pretends otherwise is kidding themselves. We all have had that day where you wake up late, spill your tea in the car on the way to work, walk into a frantic situation in the unit, and then are assigned said frantic situation.  You just want to turn right around and go back to bed.  Take a deep breath.  You will get through it.

While the list can go on and on, I think the most important thing of all is to remember that confidence comes with time and practice.  Each new environment and new job will test your confidence.  And remember, try not to compare yourself to anyone else.  Be the best nurse you can be.

LoriProfileLori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/

Five Easy Steps to Save Lives and Promote Healthy Families

by, Donna Weeks

It’s staggering to think that 54 to 93 percent of maternal deaths related to postpartum hemorrhage (PPH) could be avoided.

So what can we do on our units to reduce the number of women with complications, or even death, from an obstetrical hemorrhage?

I have taken part in many discussions about high tech simulation and drills, and we are always asking ourselves:

  • How can we have effective drills without a simulation lab and simulation models?
  • Can low tech simulation play a beneficial role in decreasing obstetrical hemorrhage?

I recently took part in a pilot program that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)  trialed on postpartum hemorrhage risk assessments, evidence-based oxytocin orders, and hemorrhage drills and debriefing based upon a variety of settings.

Here are a few ideas that I have implemented without utilizing a simulation lab. These easy suggestions may help every obstetrical unit  raise awareness of obstetrical hemorrhage and contribute to decreased maternal morbidity and mortality.

First, have a mock code on your unit using your own crash cart.  You may be surprised to find out how many nurses are uncomfortable with finding key items in your crash cart.  Use a pillow to simulate a gravid uterus and have one nurse demonstrate left uterine displacement while other nurses deliver compressions and ventilations.  Additional nurses may find supplies, IVs, and medications in the code cart.

Second, devise a scavenger hunt and ask your staff to find the closest location of items needed during an obstetrical hemorrhage.  In many units the OB techs check the hemorrhage cart and the nurses may be less familiar with the items on the cart.  They may be leaving the room to get supplies and medications that are already on the cart.  In a true emergency this will use up valuable time.

Third, consider efficiencies. Do you have your medications locked in a Pyxis or Omnicell?  Do nurses have to remove the uterotonics one at a time? Due to the awareness raised by our hospital’s participation in AWHONNs postpartum hemorrhage project,  the day after our medication administration system was installed our pharmacy was notified that we needed a postpartum hemorrhage kit.  Now with one selection we retrieve ergonovine maleate (methergine), misoprostol (cytotec), carboprost (hemabate) and oxytocin (pitocin).

Fourth, how do you drill? What about drills in an empty patient room?  Have a drill in a patient room with nothing more than a mannequin.  Change the scenarios and include the less common situations.  With a type and screen being completed on most admitted labor and delivery patients it is not common to be ordering uncrossedmatched blood.  I use a scenario that includes a woman presenting to L&D with an obvious hemorrhage. This scenario presents the opportunity to review how and when to retrieve uncrossmatched blood.  What is your procedure?  Is there special paperwork or forms?  During one drill we strongly stressed the time element including how quickly we could generate a medical record number and how much time would be lost if an OB tech was sent for the blood. In our institution uncrossmatched blood may only be released to a physician or nurse.  Take the scenario further and include your massive transfusion protocol.  Review when and how to initiate the protocol.

Lastly, practice quantification of blood loss until it becomes routine.  Use scales, work sheets, and a variety of scenarios to keep staff informed and interested.  These can be presented by a charge nurse on any shift without preplanning.  It is just one more way to keep obstetrical hemorrhage on the forefront of everyone’s mind.  The more awareness we raise the better chance we have of early recognition and intervention. The goal is to have a healthy mother and healthy family.

DonnaDonna is a Perinatal Clinical Specialist at JFK Medical Center in NJ.  She has always loved OB nursing and also enjoys teaching.  She is currently an adjunct instructor at Kaplan University and Walden University.  She was the Hospital Lead for AWHONN’s PPH Project.

 

 

Citations

Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., . . . Callaghan, W. M. (2005). Preventability of pregnancy-related deaths: Results of a statewide review. Obstetrics & Gynecology, 106, 1228–1234.doi:10.1097/01.AOG.0000187894.71913.e8

California Department of Public Health. (2011). The California pregnancy-associated mortality review. Report from 2002 and 2003 maternal death reviews. Sacramento, CA: Author. Retrieved from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

Della Torre, M., Kilpatrick, S. J., Hibbard, J. U., Simonson, L., Scott, S., Koch, A., . . . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760.doi:10.1055/s-0031-1280856

Resources

Get free postpartum hemorrhage resources from AWHONN.

Learn more about AWHONN’s Postpartum Hemorrhage Project

For more in-depth info and to learn more about how to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity, join AWHONN’s newest implementation community on Postpartum Hemorrhage.