Category: Clinical Corner

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Clinical Corner: Working in Various Types of Long-term Care Nursing Facilities

Long-term care
It may take different levels of skills and experience to work in various types of long-term care nursing facilities — but it takes a big heart across the board to serve long-term care patients!

By Melissa Nguyen, Clinical Nurse Manager at Medical Solutions

While visiting my grandmother in a long-term care facility, I saw a handwritten sign on the employee lounge door that caught my attention. It read: “Our residents do not live in our workplace, we work in their home.”

This simple yet meaningful message really changed the way I looked at long-term care nursing — especially now that my grandmother was a resident. Most of her fellow residents were spending their final days, months, or years with healthcare professionals who were understaffed and underappreciated. Some residents never had visitors, some had family members regularly dissatisfied with their loved one’s care, and some wanted nothing more than for someone to just hold their hand. Each resident had a unique story and their nurses played an essential role in that story.   

Prior to working as a Clinical Nurse Manager at Medical Solutions, I did not realize there were differences in the types of long-term care facilities. Now I know there are skilled nursing facilities (SNF), long-term care (LTC), long-term acute care (LTAC), and assisted living facilities (ALF).

So, how are these various long-term care facilities different? And what type of experience should a travel nurse or allied health traveler have to successfully work in each specific type of long-term care facility? Read the following examples to learn more about the variety in long-term care facilities and what skills you’d need to succeed in each setting.

Mrs. Smith’s Case

Mrs. Smith is a 76-year-old recently diagnosed with early-stage Alzheimer’s. Until recently, she’s been able to bathe and dress, make herself meals, and take all her prescribed medications as directed. Over the past few weeks, her daughter noticed Mrs. Smith forgetting to take her blood pressure medication and frequently skipping meals. 

Assisted living facility (ALF)

Mrs. Smith qualifies for assisted living because she is unable to safely live alone but does not require heavy nursing needs (such as wound care or IV medications). Assisted living will help Mrs. Smith stay on track with her medications and provide meal services every day.

Travelers — whether RNs or allied health professionals — interested in working in an assisted living facility would need basic knowledge of medication administration, the ability to obtain vital signs, and the ability to obtain labs. 

Skilled nursing facility (SNF)/long-term care (LTC)

Several months after moving to an assisted living facility, Mrs. Smith falls and breaks her leg. She goes to the hospital where she has surgery, however, she now needs assistance with dressing changes for her post-surgical site as well as rehabilitative services. She is discharged to a skilled nursing facility (SNF), where nursing staff will administer her medication and complete her dressing changes. She will also receive physical therapy and occupational therapy services. After several weeks, Mrs. Smith’s surgical wound has healed and she has completed her physical and occupational therapy, but she still requires assistance with mobility and taking medications. She is now transferred to the long-term care (LTC) side of the facility where nurses will help bathe and dress her, administer medications, and transfer her safely in and out of bed.

Travel nurses interested in working in SNF/LTC must have experience working in SNF/LTC with higher ratios than what is normally seen in acute care. It is not uncommon for an SNF/LTC RN to have a 1:20 ratio or higher. Nurses who have only worked acute care are generally not successful as they may struggle with higher ratios than what they are used to. 

Mr. Jones’ Case

Mr. Jones is a 50-year-old man who was admitted to the hospital after a 1,000-pound tree fell and crushed him. He suffered multiple broken bones, a collapsed lung, and a bruised heart. After several days, he stabilized, but required a tracheostomy and remained on the ventilator. 

Long-term acute care (LTAC) ICU

Mr. Jones’s injuries were healing, however, he needed to be weaned off the ventilator. He still needed intensive therapy to build strength and to learn how to breathe, talk, and walk again. He is transferred to a long-term acute care ICU where he begins the process of weaning off the ventilator.

Travel nurses interested in working in LTAC ICU must have experience working specifically in LTAC ICUs. Nurses who have only worked in an acute care hospital ICU are generally not successful as they struggle with the ratios in LTAC ICU (which often carry high acuity patient ratios of four or more). Nurses who have worked stepdown in an acute care facility may be considered if they have ventilator experience. Nurses who have only worked LTC would not be considered good candidates for this position as they do not have experience with acuity levels of LTAC patients. 

Long-term acute care (LTAC) med-surg

Mr. Jones has been successfully weaned off the ventilator and moved to the LTAC med-surg floor. He still requires IV antibiotics and frequent dressing changes for his wounds. In addition, he will continue intensive therapy learning how to walk, talk, and eat on his own. Travel nurses interested in working LTAC med-surg must have either worked in an LTAC med-surg unit in the past or have worked stepdown/tele, med-surg or float pool in an acute care facility and have experience taking ratios of at least 1:5. Nurses who have only worked LTC would not be considered good candidates for this position as they do not have experience with acuity levels of LTAC patients.

As the United States population ages, there will be a higher demand for long-term care and long-term acute care nurses. It is a specialty that comes with its set of challenges, but that equally has its rewards. For many residents, it is their final journey in life and as nurses, we can make a lasting impact on how their final chapter ends. As Maya Angelou famously said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

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Clinical Corner: Nurse Burnout All Too Common

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If you’re experiencing nurse burnout, you are not alone!

By Laura Friend, Clinical Nurse Manager at Medical Solutions

I had just turned 23 years old when I graduated nursing school and was offered my dream job in the emergency department where I’d worked as a tech during the few years prior. I was working overnights, as most new grads do. It was my third week off orientation, around 3:30 a.m., when the EMS radio started to crackle: “Medic 46 is in route to your facility with a 16-year-old female, unrestrained driver. Rollover accident. Code 99 at this time. ETA 6 minutes.”

As some of you know, “code 99” means the paramedics are doing CPR in the ambulance on their way to the hospital. I remember thinking, “This isn’t going to be good. I’ve never seen a code 99 from the field make it. Sixteen years old, that’s not that much younger than me. I wonder why she was out so late; she should’ve been at home, safe.” Right then, the sirens started blaring right outside our door. The paramedics wheeled the young patient in, chest compressions in progress. The code lasted less than five minutes in the ER. Cause of death: blunt force trauma to the head. Half of her face was gone.

I couldn’t sleep that day when I went home. Every time I closed my eyes, I saw what was left of her face — the only part of her body that even had a scratch on it. I heard her mother’s cries as I tossed and turned. I could still smell the metallic odor of blood, even though I’d already showered and washed my scrubs. I went to work that night on little sleep and saw that my coworkers from the night before hadn’t slept much either. None of us talked about it. We quietly went about our jobs and went home again. I made it about five years total in the ER before I left the specialty I loved and worked hard to be a part of because I realized I had grown hard, cynical, and jaded.

Nurse burnout is a hot topic in the healthcare field. According to a recent survey, almost 57 percent of nurses report feelings of burnout or feeling unengaged. Feelings associated with burnout include constant fatigue, a lack of enthusiasm about one’s job, compassion fatigue, or feeling unappreciated or unmotivated. Of the 57 percent of nurses who report having those feelings, 50 percent have no plans to leave their organization (Brusie, 2019). I wasn’t alone. Knowing that over half of all nurses feel some sort of burnout regarding their jobs, what can we do?

Research shows there are a few key items that would help nurse morale and engagement. These include giving nurses an opportunity to participate in decision-making that is directly related to their work, as well as giving nurses more autonomy when it comes to their skillset and expertise. It is also recommended to not only make employees feel like their hard work is meaningful, but to also give them goals in which to strive and recognize their accomplishments (Mudallal, Othman, & Hassan, 2017).

While those steps may take time, simpler and quicker ways to help decrease the effects of nurse burnout include talking about “the hard stuff” with coworkers, debriefing after events, and helping coworkers to take breaks at work. Individually, nurses must also take care of themselves, so they are able to best care for others; get enough sleep, exercise, and participate in enjoyable activities outside of work. Travel nursing also helps prevent burnout by securing better nurse to patient ratios at facilities in need. For those who choose to travel, the variety of travel nursing assignments available can also help them prevent their own burnout with frequent changes in scenery.

To our Medical Solutions nurses, we appreciate you! Thank you for all your hard work, day and night, to take such great care of your patients. Please remember to take care of yourselves as well as you care for your patients — and that our internal clinical team is always here to support you!  

Sources:

Brusie, C. (2019, April 7). Study Reveals Alarming Statistics on Nurse Burnout.

Mudallal, R. H., Othman, W. A. M., & Hassan, N. F. A. (2017). Nurses’ Burnout: The Influence of Leader Empowering Behaviors, Work Conditions, and Demographic Traits. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 54. doi: 10.1177/0046958017724944

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Clinical Corner: The Criminalization of Human Error and How to Protect Yourself

Mistake - Clinical Corner: The Criminalization of Human Error and How to Protect Yourself
Everyone makes mistakes, but as nurses, we must work diligently to avoid those that may put our patients’ lives in peril.

By Melissa Nguyen, Clinical Nurse Manager at Medical Solutions

I’ve been a nurse for 19 years and I remember my first medication error like it was yesterday. I was a new grad working in dialysis and I administered 5,000u heparin instead of 1,000u heparin. I recognized my error when my patient’s fistula wouldn’t stop bleeding when the needles were removed. I remember walking to the med counter and realizing the heparin label wasn’t the same color it usually was — the label looked exactly like the 1,000u heparin but the color of the label was a light blue instead of the usual light green. 

I still remember that feeling in the pit of my stomach that I was responsible for my patient’s excessive bleeding. How did I not notice the bottles were different? I contacted the nephrologist, notified my administrator, filled out an incident report, and sat with my patient for more than an hour and a half until the bleeding stopped. Aside from having to stay longer than normal until her bleeding stopped, I was lucky my patient didn’t have any further complications. 

Fast forward to February 1, 2019: That was the day that nurse RaDonda Vaught was indicted in Tennessee for reckless homicide in the death of her patient, Charlene Murphey due to a medication error at Vanderbilt University Medical Center. I couldn’t help but think of my own medication error and how drastically different Vaught’s error ended. 

In December 2017, Vaught was taking care of Murphey who was hospitalized for a subdural hematoma. Versed had been ordered by a physician prior to a full body scan to help ease her anxiety from claustrophobia. According to court records, Vaught was unable to find IV Versed in the patients ordered profile, so she enabled the ‘override’ function in the medication dispensing system and typed ‘VE’ into the search field. This break in protocol led to a series of mistakes that ultimately led to the death of her patient. 

According to prosecutors, Vaught ignored multiple warnings that the medication she was about to mistakenly remove was Vecuronium and not Versed. Vaught removed the Vecuronium, which unlike Versed, was a powder that had to be mixed before it could be given to a patient. She then mixed the medication and admitted to being “distracted” which caused her to miss the bright orange warning on the bottle stating “WARNING — PARALYZING AGENT.” Vaught then administered a lethal dose of Vecuronium, which ultimately paralyzed Murphey’s respirations leading to her untimely death. 

Co-workers described RaDonda Vaught as a respected, well-liked, competent nurse with a spotless track record. She admitted that she made a mistake by using the override feature and by not recognizing the warnings on the vial. Vaught’s supporters believe that criminalizing mistakes will lead to underreporting of errors and the inability to identify other factors that led to mistakes being made.

So, what can you learn from this case and how can you protect yourself?

Know the five basic rights of medication administration and use them every single time.

Right 1: Right patient

Right 2: Right medication

Right 3: Right dose 

Right 4: Right time

Right 5: Right route

Monitor your patients to watch for adverse effects.

In Vaught’s case, she did not record the administration of medication and left the room immediately without monitoring the patient. Murphey was found unresponsive and pulseless 30 minutes after the Vecuronium was given. Had Murphey been monitored, she would have shown signs of respiratory failure within minutes of receiving the medication. Be mindful of the medications you administer and the possible side effects that could occur.

Follow policy and procedures.

While overrides may need to be used under emergent situations, they are not to be used under routine circumstances. Safeguards are put in place for a reason. Should you find yourself in a similar situation where a medication is not showing up on a patient profile, do not override safeguards without contacting pharmacy, a charge nurse, or another fellow nurse to help troubleshoot. 

The blame should not be entirely placed on Vaught, as there were also failures identified within the hospital system. In the end, this is truly a tragic incident that led to the death of a patient and a nurse with pending criminal charges. No matter how you look at the situation, it is devastating for everyone involved. None of us are immune from making mistakes, however, it is our responsibility stay vigilant in adhering to basic fundamentals set in place that ensure patient safety!

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Clinical Corner: To Post or Not to Post — Social Media and Healthcare

Social Media - Clinical Corner: To Post or Not to Post — Social Media and Healthcare
Be smart about social media — both on and off the job!

By Natalie Olson, Clinical Nurse Manager, Medical Solutions & Sarah Wengert

Even though it’s become such an important part of our lives, social media is still a relatively new frontier — and it can certainly be a bit like the wild, wild west! The proliferation of websites and apps that allow users to engage in social networking with others, distribute information, and share their every thought, image, and lunch plate, come with great power and great responsibility. “To post or not to post” — that is the question — and healthcare professionals should be sure to ask themselves before they act!  

Using social media can significantly impact Travel Nurses and other allied health professionals, both at the individual level and in the workplace. It is important to understand that although there are positive aspects of social media use in healthcare, there are also negative consequences, as well as potential health consequences. As technology is increasingly applied in the healthcare field, this becomes increasingly true for all healthcare providers.

Benefits of Social Media on Nursing Practice

Nurses frequently use websites and apps that let them to share content with other nurses quickly, efficiently, and in real-time. In the travel industry, Travel Nurses and other allied health professionals often communicate with each other through online communities by asking questions about the industry, as well as sharing positive and negative experiences.

Ultimately, social media benefits Travelers, hospitals, and travel staffing agencies alike. One potential benefit that social media provides these three groups is that it improves provider communication. This can be a very effective way to help coordinate patient care and improve patient outcome. In some settings, nurses are required to use a smartphone to take photos of wounds and/or send text messages to physicians, which decreases the time to treatment.

Another benefit is the aforementioned ability to partake in professional nursing networks, like forums, blogs, Facebook groups, Instagram accounts, Twitter accounts, and other such platforms. These networks make it easy to share and obtain information, ask questions, and connect with others who have similar interests. Networking has become increasingly valuable because it lets nurses have open discussions with a more diverse community. This ample flow of information not only helps nurses personally and professionally, but it also enhances knowledge of best practices and real-world outcomes, which leads to better patient care overall.

Social Media Pitfalls

For nurses, one of the most common issues with social media use in the workplace is the violation of patient privacy. According to the Online Journal of Issues in Nursing, “Violations of patient privacy are a serious concern for nurses, as these represent a violation of professional standards, and can result in termination or suspension. Privacy concerns are paramount for nurses, as we are self-regulating healthcare professionals.”

Another danger is when social media becomes a distraction or interrupts the workplace — and this can be particularly important for Travel Nurses to be aware of. Nurses are frequently reprimanded in the workplace for being caught on their personal cell phones. Unfortunately, it’s not uncommon that Travelers are judged more harshly for having their personal cell phones out at work than permanent staff.

Social media can also be used for cyberbullying in the workplace. Nurses could face cyberbullying by direct defamation or attack via social media tools, and can also be impacted indirectly by being excluded from workplace social media groups or programs.

It is especially crucial as a Travel Nurse to be professional at all times and to make sure you’re aware of the privacy settings on all of your social media accounts. Doing so will help keep you safer from experiencing social media problems. Always adhere to published professional guidelines and policies when using social media. Don’t put yourself in a position where inappropriate use of social media leads to any professional ethical violations on your part!

Follow these social media rules to protect yourself and your patients:

  • Always protect patient identity
  • Take responsibility for everything you post
  • Be aware that termination is a real consequence
  • Optimize privacy settings
  • Never take pictures of patients on personal devices
  • Be cautious when connecting with patients and their families
  • Remember that information online is easily shared

As a Medical Solutions Traveler, if you are ever unsure about whether to post or not to post, you can ask your Career Consultant to put you in touch with one of our internal nurses for further guidance!

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Clinical Corner: Safety First!

By Phil Niles, Medical Solutions Clinical Manager

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Transportation safety is key while traveling to and from your assignment!

Healthcare professionals are not just patient safety advocates — they’re also public health and safety resources for the people in their communities. Injuries are the leading cause of death for Americans ages 1 to 44, according to the CDC. The good news is everyone can help prevent injuries and maintain a culture of safety. This month in Clinical Corner, we encourage you to learn more about important safety issues like preventing poisonings, transportation safety, and slips, trips, and falls.

Poisonings: Did you know that nine out of 10 poisonings happen right at home? You can be poisoned by many things, like cleaning products or another person’s medicine. Every year, poison control centers receive more than 2 million calls from people seeking medical help for poisoning. It is the leading cause of unintentional death, surpassing even motor vehicle crashes, and includes drug overdoses, inadvertent ingestion of drugs or chemicals, and exposure to environmental substances.

Meanwhile, drugs in the workplace have become a hot button issue in the healthcare industry. More than 100 people die every day from opioid overdoses, and 75% of employers say their workplaces have been impacted by opioid use, according to a recent National Safety Council poll. Only 17% of employers feel well-prepared to deal with the issue.

For the first time in U.S. history, the National Safety Council estimates that a person is more likely to die from an accidental opioid overdose than from a motor vehicle crash. In fact, workplace overdose deaths involving drugs or alcohol have increased by at least 25% for five consecutive years.

What you can do: Laws to fight opioid abuse are rapidly changing on the state level and may affect you as you accept traveling assignments in different states. Before your next assignment, make sure you have a full understanding of your soon-to-be state’s laws. You can regularly review the State Nurse Practice.

Risks of the Road: Summer brings out the orange. Orange cones, barrels, and signs reminding us all that road construction season has arrived. While almost everyone adjusts accordingly and knows that better roads are coming, there’s always someone who doesn’t plan ahead, slow down, or pay attention. In fact, distracted driving caused 3,166 deaths in 2017, according to the National Highway Traffic Safety Administration.  

What you can do: Navigating unfamiliar roads and new cities is an occupational hazard for many traveling healthcare professionals. To help address this, you can always plan out your travel route beforehand, drive slow through work zones, and limit possible distractions while driving. After all, you won’t be able to care for others if you have a major accident.

Falls: According to the Occupational Safety and Health Administration (OSHA), most safety incidents involve slips, trips, and falls. They cause 15% of all accidental deaths and are second only to motor vehicles as a cause of fatalities. Additionally, more than one in four seniors fall each year. Many falls lead to broken bones or head injuries. Slips, trips, and falls extend to the patient in the hospital, and nurses must be vigilant in assisting all staff and patients with fall prevention. Risk factors for anticipated falls include an unstable or abnormal gait, a history of falling, frequent toileting needs, altered mental status, and certain medications. Among hospitalized older adults, about 38% to 78% of falls can be anticipated. Evidence shows that one-third of reportable falls with injuries in hospitalized older adults are linked to bathroom use. More than half are associated with medications known to contribute to falls, such as anti-anxiety and anti-psychotic drugs. Also, about 40% of falls occur within 30 minutes of an hourly rounding visit by healthcare providers.

What you can do: Nurses hold the key in a critical step in the fall prevention process by communicating the patient’s fall risk and required interventions to colleagues, the patient and family, and significant others who need to support the interventions. Using a systematic process to identify and address the fall risk can nearly eliminate anticipated falls, prevent unanticipated falls from recurring, and significantly decrease accidental falls.

Safety is everyone’s responsibility! A “culture of safety” describes the core values and behaviors that come about when there is a collective commitment by leadership, managers and health care workers to emphasize safety. All nurses, whether permanent or temporary, should be concerned with safety and should work as safely as possible. You should keep safety at the top of your mental checklist, no matter what task you are performing for yourself, your patients and your community. When safety is given top priority, everything else begins to “fall” into place.

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Clinical Corner: Love the Skin You’re In!

GettyImages 145058112 - Clinical Corner: Love the Skin You're In!
Summertime is almost here! So before you head out to enjoy the sunshine, refresh your memory with these top sun protection tips!

By Phil Niles, Clinical Nurse Manager, Medical Solutions

It’s spring! The long-awaited sun is shining, flowers are blooming (along with allergies), and our sun-starved winter skin is soaking up the rays! Feeling the glorious warmth of the sun is not just a welcome gift, it’s also beneficial to our health. For example, sunlight can alleviate sensitivity reactions to some autoimmune disorders like psoriasis, according to the National Institute of Health. Sunlight also stimulates Vitamin D production, increases our serotonin levels, and causes our bodies to release endorphins. In other words, the sun makes us all feel good!

Moderate sun exposure benefits our well-being, but, as anyone who has suffered from a sunburn before knows, too much sun exposure can be problematic. May is Melanoma and Skin Cancer Awareness Month, and with summer fast approaching, it’s more important than ever to know how to protect your skin.

Just look at these stats:

  • Skin cancer is the most common cancer in the U.S, according to the American Academy of Dermatology.
  • More than 90 percent of all skin cancer is caused by sun exposure.
  • 1.5 million Americans will be diagnosed with skin cancer this year, according to the American Cancer Society.
  • One in 5 Americans will be diagnosed with skin cancer in their lifetime. 
  • Melanoma is the deadliest form of skin cancer.
  • A blistering sunburn during childhood DOUBLES the risk of melanoma as an adult.  
  • Men are twice as likely to develop skin cancer as women, and it is more common than prostate cancer, lung cancer, and colon cancer in men over 50.
  • Nearly 20 Americans die from melanoma every day.

How to protect yourself:

The good news is that most cases of skin cancer are preventable. We just need to be more sun savvy and properly protect our bodies. Fortunately, we have sunscreen to protect us when we want to be out and about, smelling the flowers and feeling the warmth of the sun on our skin.

It’s important to separate sun protection facts from fiction and the first step is often understanding your sunscreen label. The Skin Cancer Foundation recommends using a sunscreen with an SPF 15 or higher as one important part of a complete sun protection regimen. If you see “broad spectrum” and an SPF of 15 or higher on the label, you can be confident in the sunscreen’s ability to protect you from both UVA and UVB rays. Generic brands are okay — you don’t need to buy the most expensive sunscreen for it to work. However, sunscreen alone is not enough. Whenever possible, you should stay out of the sun from 10 a.m. to 4 p.m. and wear hats and sun-protective clothing to limit your chances of too much sun exposure. You should also avoid tanning and UV tanning booths.

Travel Nurses may find themselves in different climates and may be misled about how much sun exposure they may be getting in their new environment. For example, states with higher elevations tend to have higher levels of ultraviolet radiation. Additionally, sun exposure can still occur with cloud cover and even when it isn’t warm outside. To be prepared, apply at least a shot glass full of sunscreen to your entire body 30 minutes before going outside. The key to preventing a burn is to reapply every two hours. Keep small bottles of sunscreen with you to encourage reapplication. Keep some in your car, purse, backpack, etc. so you always have a ready supply for use just in case the sunshine is calling your name.

Yearly skin checks with a licensed dermatologist and doing your own skin checks can also help identify skin cancer or precancerous cells that can be dealt with early on and are considered highly treatable. Things to look for when checking your skin: a small lump, spot or mole that is shiny, waxy, pale in color, and smooth in texture, a red spot or mole that is firm, a sore or spot that bleeds or become crusty or doesn’t heal, rough and scaly patches on the skin, flat scaly areas of the skin that are red or brown, any new growth that is suspicious. Any of these should be examined by a doctor as soon as they are discovered.

Be a sun care role model:

Traveling healthcare professionals can use this month to raise awareness about skin cancer and help their patients act to prevent or detect it, both at home and in the community. As the most trusted profession, nurses are in an ideal position to be sun care role models and spread good habits to those around them. While encouraging sunscreen use, nurses can also partner with a local hospital, state fair, or similar organization to host or volunteer at a skin cancer screening event. Educating yourself and others will do everyone’s skin a favor. And that means we can fully enjoy the sun, knowing we have taken the appropriate steps to prevent overexposure.

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Clinical Corner: Nurse Burnout and Stress Management

Stress Meditation 1 - Clinical Corner: Nurse Burnout and Stress Management
Recognize Stress Awareness Month by checking in on yourself and finding healthy ways to manage stress and avoid nurse burnout.

By Phil Niles, Clinical Nurse Manager, Medical Solutions

April is Stress Awareness Month, and that’s relevant highly here considering two of the biggest challenges nurses face are chronic stress and burnout. I can tell you from my own experience that unchecked stress leads to physical pain, lack of energy, bitterness, feelings of dread, and becoming mentally checked out of caring for patients. When you burn out, nursing can become a never-ending hamster wheel of dreading everything negative that could happen during your day. These “could happen” scenarios become expected, inevitable truths in your mind each day, even if they do not occur. Pretty bleak, right? 

Healthcare in general is often listed as one of the top most stressful jobs in the United States. A few of the reasons for this trend include workload caused by insufficient staffing and long shifts without breaks. One of the most dangerous effects of this are increased risk for patient harm. Stress makes you tired and confuses your thinking, leading to mistakes and breaks in standard of care.

So, what can be done? Shall we all throw our hands in the air, toss our stethoscopes in the nearest trash can, and go live the hobo life riding the rails? Sure, I exaggerate a bit, but I know a few of you are holding your hands high yelling “Amen!” Obviously, there are steps that need to be taken by health care organizations, which some have done, to decrease the demand on nurses and improve the overall work environment.  Additionally, instead of asking only “What are they doing to help me?” we should ask, “What can I do to help myself?” We need to focus on ourselves and practice mindful self-care. How do we care for ourselves?

STOP and take a deep breath.

It is very common to get caught up in all the things that need to be done and the lack of time to do it. Stopping and taking a deep breath helps clear the frustration that can cripple your ability to think clearly and prioritize care.  After three or four deep breaths ask yourself, “What needs done right now?” You are only one person and cannot be in three places at once, even though it feels like we are asked to do this all the time. Start with the first thing that needs to be done and prioritize from there. Pop your head into the other patient’s rooms and let them know you haven’t forgotten them. This will help your patients feel respected and validated instead of ignored. 

Be vocal and a clear communicator.

Let your Charge know what you have going on and what you can take on to help the team. The only way they know you are feeling overwhelmed is if you communicate. I’m sure many of you have been to assignments where you felt like you could not depend on anyone. Be the positive change of teamwork you want to see! Offer your help when you can and ask for help when you need it. Assuming everyone knows you are extremely busy is the cause of a lot of unnecessary frustration. 

Stay hydrated!

Most nurses are pushing their kidneys into early failure with poor hydration. Dehydration can cause fatigue, headaches, lack of energy, and slower thinking. I can hear it now … “I don’t have time to pee let alone drink any water!” Yes, you do! It is just not a part of your daily work habit — yet. Prioritize yourself for your own health, but also because, in the end, taking care of yourself makes you better able to care for your patients.     

Leave a bad work day at the door and do not assume it will be the same tomorrow.  Easier said than done, I know! It does take work to not let the “black cloud” of a bad day follow you home and shape your mood for the rest of the day and the next. Commit to making time for yourself. Nursing is a very engaged, social profession. Decompression in a quiet space is necessary to let your mind relax. Even if it’s just the drive back home while listening to a podcast, music, or nothing at all! Take an extra spin around the block if you’re coming home to an equally busy household, which many of us are. You’ll thank yourself for the extra five minutes. Your brain needs the downtime!

Take advantage of the resources available to you. 

As a Traveler you may feel alone with no one to call on for support. This is not true! You can always contact your recruiter and some travel companies, such as Medical Solutions, have in-house nurses, such as myself, available to talk with you and truly understand where you’re coming from. This is often an unknown resource to many Travelers. Just talking something out with another nurse does wonders to get it off your shoulders and help you breathe a little easier. 

Stress is a very real and damaging force if not dealt with through healthy channels.  Remember this Stress Awareness Month and all year-round that the only way to provide skilled, compassionate care for your patients is to care for yourself first.

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Clinical Corner: What the Dialysis?!

What The Dialysis - Clinical Corner: What the Dialysis?!
Clinical Corner demystifies dialysis!

By Phil Niles, Clinical Nurse Manager, Medical Solutions

As healthcare providers, many of you have cared for a patient that is dependent on dialysis. Yet, even you may have wondered, what the heck is dialysis? Well, let’s talk about that! A friendly dialysis RN shows up on their dialysis day, takes up your sink, clogs your room with machines, and, in the end, leaves you with a healthy smell of bleach lingering in the air. What happened? You know the basics of the process: The blood is “cleaned” and fluid is removed from the patient over three-four hours. The patient has an access such as a catheter, fistula, or graft that the dialysis RN accesses for the treatment. Patients commonly have three four-hour treatments per week. But, what else is going on during the treatment?

First, we start with water. A single dialysis treatment uses over 150 liters of water. Water from the faucet cannot be used because there are impurities, trace heavy metals, and chlorine in standard faucet water. This is all fine and dandy for us to drink, but during dialysis this water will come into contact with the patient’s blood, so it must be as pure as possible. One of the machines that a Dialysis RN brings into the room is a reverse osmosis machine or RO. This machine moves solutes from a concentration to a higher concentration producing high-concentrated water (waste water) and very low concentration water (RO water). The RO water is used for the treatment and delivered to the hemodialysis machine by a product hose. Tap water generally has total dissolved solutes level of 100-200 parts per million. Dialysis water is 10-15 parts per million — a much lower concentration. Before the water can be used the Dialysis RN must conduct a series of quality control tests to be sure the water is good to use. The main test is a chloramine test. Chloramine is a derivative of ammonia that’s used to treat drinking water. It cannot be in the product water because regular levels of chloramine would cause seizures and potentially death in your dialysis patients. After all the tests are complete, the water is considered good and the hemodialysis machine can now be set up.  

The dialysis machine is then put through its own tests and it is “strung.” Stringing the machine means installing the blood tubing and dialysis filter, and priming out all of the air in the system. During this process “acid” and “bicarb” are added to the water being delivered by the RO. Acid is acetic acid or vinegar with electrolytes added specific to the patient’s needs. The bicarb is just sodium bicarb. The machine mixes dialysate at a ratio of one part acid, two parts bicarb, to 40 parts water. The pH is blended to the pH of normal blood. Dialysis patients are usually in early metabolic acidosis before treatment. The dialysis treatment normalizes this, while also balancing electrolytes and removing excess body fluid. 

Once the machine is set up and has passed all quality control tests, the patient can be accessed and bled on to the dialysis tubing, which is called the circuit. Patient access is either an externalized catheter or internalized fistula or graft. The catheter is commonly surgically placed in the right or left jugular vein then tunneled under the skin four-six inches to where it comes out into two limbs, the arterial and venous access. The blood being accessed is venous blood. The arterial limb is called arterial only because it is moving away from the body. The “venous” limb returns cleaned blood back to the patient. A fistula is an access created by a passthrough or “fistula” between an artery and a vein that was not there before. This causes higher pressure arterial blood to flow through a lower pressure larger vein. Over time, usually two-three months, the vein enlarges due to the increased pressure and the walls of the vessel thicken. At this point the newly developed fistula vessel can be accessed by larger fistula needles. New fistulas are accessed by 16-17-gauge needles until the vessel becomes accustomed to the needlestick. Standard dialysis treatments are run with 15-14-gauge needles. Two needles are required — an arterial needle to pull blood to the dialysis machine and a venous needle to return the newly cleaned blood. Needles are placed at least an inch apart from each other to prevent recirculation, or recleaning of freshly cleaned blood. A graft access is a synthetic tube that is placed under the skin connecting a vein to an artery. The optimal access for a dialysis patient is a fistula. However, not all patients are candidates to receive one. 

The biggest rule to follow is to never allow the extremity with the fistula or graft to be occluded, including and especially taking blood pressures. All lab draws and blood pressures must be done on the non-fistula extremity. Occluding the vessels or the fistula itself can lead to it clotting off and potentially losing that access. Many long-term dialysis patients do not have many options for accesses, so it is so important to protect your dialysis patient’s access while in your care. This is their lifeline!

The dialysis process itself is a fairly simple one that works on two principles — a concentration gradient and a pressure gradient. Diffusion, as most of you are very aware, is the movement of solute from a high concentration to a lower concentration. This is the entire science of electrolyte balance in a dialysis treatment. Potassium is usually high in a dialysis patient needing treatment. The dialysate mixed by the machine has a specific potassium prescription based on a sliding scale. This prescription will bring the patient’s potassium to a normal level after dialysis. The dialysis treatment does this with all electrolytes. It is important to note that the dialysis treatment only balances electrolytes in the blood. Higher levels may exist in the tissue and as dialysis progresses these higher levels continue to shift to the blood stream throughout treatment. Lab values are not accurate until at least an hour after dialysis treatment. It is highly discouraged to order labs before this so that inaccurate results are not given. 

The other half of the dialysis treatment is fluid removal. This is accomplished by the dialysis machine exerting a specific negative pressure on the dialysis filter that causes fluid to move from the blood stream to the dialysate side of the filter and be disposed of. Generally speaking two-four liters of patient fluid is removed from the patient during a four-hour treatment. Fluid removal is the component of the dialysis treatment that can lead to episodes of low blood pressure in the patient. This occurs when fluid is being “pulled” faster than the patient’s vasculature can tolerate. The ability to tolerate fluid removal varies greatly from patient to patient. Blood pressure and other vitals are watched and recorded at least every 15 minutes during treatment. Fluid removal also requires work from the body to shift that fluid.  Patients are often very tired after treatment due to this. 

And there you have it! I hope this sheds a little light on the often-mysterious ways of dialysis and gives you more knowledge to better care for you patients. I also hope it makes you more aware of what your kidneys do for you! Uncontrolled diabetes and high blood pressure are the top causes of kidney failure. Love, protect, and care for your kidneys!

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Clinical Corner: Team Nursing and Delegation

Team - Clinical Corner: Team Nursing and Delegation
Team Nursing can be a great, collaborative experience for patients and healthcare workers — as long as you know how to navigate the process!

By Phil Niles, Clinical Nurse Manager, Medical Solutions

Many of you have encountered the concept of team nursing during your travel and/or nursing careers. If you have not encountered it, you might one day hear something like, “Your assignment will have you taking a 1:10 assignment.” Then you might say, “What???” and they might reply, “Don’t worry — it’s team nursing!” Even more confused at this point, you might ask, “Well, what is team nursing?” What a great question! Let’s start with some definitions.

Team nursing is pairing nurses of varying skill sets and experience levels to care for a larger group of patients. This team can consist of an experienced nurse and a new nurse, a RN and an LPN, or either of these two with the addition of a nurse aide. The team is intended to create a collaborative, supportive environment that will collectively meet patient needs and promote improved communication between team members.

Team nursing is not meant to be an authoritarian hierarchy with one person ordering everyone else around. In fact, many factors go into determining how the workload is divided. Team members collaborate at the beginning of the shift to divide tasks amongst each other according to skill, scope of practice, and familiarity with each patient. A common misconception of team nursing is thinking you’d have to control every detail of care for all patients assigned to you. It’s difficult to get out of the mindset of primary nursing (one nurse to a group of patients) and give up a little control and the idea that you need to do everything yourself. For Travelers working an assignment with team nursing for the first time, it can be a challenge at first to adjust. So, let’s address a few questions you may have about team nursing as a Traveler.

What can my team members legally do in their scope of practice?

This is probably the most commonly asked question and an important topic to address. Scope of practice of LPNs and nurse aides varies by state, so it’s important to study up on the Nurse Practice Act of the state you are traveling to ahead of time. Each state’s Board of Nursing website is a good resource for this. You can also reference the National Council of State Boards of Nursing (NCSBN) website. Click here and you’ll find they have a drop down box where you can select your state and to generate a link to its Nurse Practice Act. You can also ask the floor manager or even the team members themselves! It is important to remember that hospitals may not allow the same scope of practice that a state lists as acceptable, so never assume anything. Even after reviewing your state’s Nurse Practice Act, make sure to ask the manager about the hospital’s specific LPN and nurse aide scope of practice.

What if something goes wrong with a patient whom an LPN or aide on my team was assigned to?

What is your accountability when delegating tasks to others? Every member of the team is accountable for their own actions. For example, an LPN may be held accountable for negligent or improper care that resulted in patient harm. However, the RN may also be held accountable for improper delegation or not intervening in the negligent care if the RN had knowledge that the care was not to standards of care.  There is a balance to be struck between delegating care and assuring that care was carried out. The RN is in a supervisory role in team nursing when the other member of the team is a LPN or aide. No one in a supervisory role should ever assume when you hand off a task that it was completed without verifying this themselves. As the RN Traveler in a team nursing scenario, you will likely see the same patients throughout the day while doing separate tasks. Take this time to also verify that all care was delivered and appropriate. 

What if the other members of my team do not communicate with me?

Team nursing relies on clear, consistent communication between all team members, so never be afraid to ask questions. Often, drops in communication happen because the other person assumes you already know the information. For example, a good way to approach this type of situation would be to say, “I’m going to see Mrs. X next. Did you already change her dressing? Do you have time to change it with me now, so we can both assess it?” This is a collaborative approach with clear communication. The other person will not be threatened or feel ordered around and will likely make a plan with you. On the other hand, an approach I do not recommend is to say, “Hey! When are you going to change Mrs. X’s dressing? You need to talk to me!” As you can tell, this may spark a bit of defensiveness and potentially damage your working relationship. Still, there are those that once in a while do not respond well to coaching, so you can always go to your charge for support if you feel your team is not working well together or have a concern about a particular team member. 

I hope this gives you guidance and arms you with information if you ever work in a team nursing environment. I also hope you see it as an opportunity to meet your patients’ needs in a new way.

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Clinical Corner: Assignment Safety

Safety First - Clinical Corner: Assignment Safety
Keeping yourself, your patients, and your license safe while Travel Nursing is essential to your success!

By Phil Niles, Clinical Nurse Manager, Medical Solutions

The ratios are too high, the hospital is too busy, and there isn’t any help! What do I do?!

As a Traveler, you may have felt these sentiments or even voiced them. Feeling unsafe on assignment is a scary experience — and that can be especially true in a new hospital where you really don’t know anyone. Who do you turn to for support in that situation? Because every scenario is different, there are no black and white answers, but let’s look at some assignment safety concerns commonly reported by nurses and how you can best address them.

Ratios

Many nurses report being “out of ratio” or facing high ratios. What exactly is high?  Well, it really comes down to what the nurse’s experience is and what their expectations are of a hospital. California is the only state with nurse:patient ratio laws. Med-surg, for instance is a 1:5 ratio there, but this ratio could be much different elsewhere in the country. Some states see up to 1:7-8 ratios and more!

So, what is “unsafe”? Well, one common average is 1:6 on a med-surg floor. If a Traveler comes from California and starts an assignment on the east coast, they could suddenly see 1:7 ratios when they are used to seeing 1:5. This is a drastic difference.  The nurse could suddenly feel overwhelmed and unable to meet the needs of the patients. Their expectation of the position may have been unrealistic as well. 

Perpetually Short-staffed Units

Another common complaint is that a unit consistently does not have enough staff to care for the patients on the floor, causing higher ratios as well. Most Travel Nurse positions exist because a hospital recognizes that there’s a critical shortage of nurses on their floors. So, travel assignments will often be short-staffed due to the nature of the work. However, this makes a big difference whether or not a hospital is actively seeking new permanent employees and/or Travelers to fill its gaps.

It’s important to do your research before accepting a position. Ask why they have a travel need when interviewing. This is a great way to get more information about this area. Even gauging how the interviewer answers the question will give you insight.

Being Asked to Take Patients Outside Your Skill Set and Comfort Level

This is a very serious situation. Travelers asked to take patients outside their skill set often feel like they have to — to keep their job and stay in good standing with their travel company. But hear this: No nurse should be forced into taking an assignment outside of their ability! Travelers must be vocal when this issue arises and calmly state the reasons they cannot accept a patient assignment. The worst thing you can do is blindly accept this kind of assignment and hope to “fake it, ’til you make it.” Be professional but be firm. Always know that anything that happens with the patient under your care will be your responsibility and under your license. Continue to take the issue up the chain of command if the hospital is adamant. Also, contact your recruiter! Many travel companies — including Medical Solutions — have in-house clinical staff that can be your advocate in the field. Find out if you have this resource before you accept an assignment with a company.

Being Asked to Cut Corners Because “That’s How it’s Done Here”

There are no circumstances where it’s acceptable to do anything outside of the standards of practice set forth by Joint Commission standards and state laws. A commonly reported situation is perm staff telling a Traveler that a physician does not like to be called at night. So, they just order labs and the physician signs it the next day. This is never acceptable, unless there is a protocol order signed by the physician in the chart already. Always call the physician. Will they be upset? Probably. But this is better than ordering something without an official physician’s order and having a complaint sent to the BON on you practicing out of scope. The core staff will do what they do, but don’t assume that risk yourself just because everyone else is doing it!

There are several other issues that Travelers tend to report as unsafe, and many of them are valid. Overall, what can you do to protect yourself?

Ask more questions. If the manager says their ratio is 1:5, but sometimes can be 6-7, then ask how often someone on the floor carries more than six patients. If the manager says Travelers float, then ask if they float round-robin with the staff or if they float first. Ask if floating mid-shift or more than once per shift is common. Ask where they expect Travelers to float. It is never out of line to ask questions during an interview. 

Also, take a personal inventory and know your expectations of each assignment. If your expectations don’t align with what the hospital expects, then it may not be a good fit. Trust your instincts! 

Lastly, talk to your travel company and have them work for you! Get enough information about an assignment from your recruiter before an interview so you can make an informed decision and be prepared to discuss any questions you have.

Traveling is an amazing experience, and you can make sure that it is just that and no less for you. Get answers to your questions, clarify your expectations, and find that perfect match!