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Why Mid-Level is a Dirty Word

A colleague of mine recently described herself as a “mid-level provider.”thumbs-down1

I cringed.

There is nothing mid-level about her.  She has spent over six years in a university and hundreds of clinical hours learning to become a Nurse Practitioner, not half of a physician.  She spent years as a bedside nurse prior to advancing her education to become a NP.  Physicians and nurses have two separate career paths in which they collaborate to care for men, women, and children.

When I first heard the term “midlevel” I wondered if the Advanced Practice Nurse (APRN) is in the middle, who is above and below?  If APRNs are viewed as below physicians, does that make her above registered nurses?  An APRN has advanced assessment skill and practice authority, but she is still a nurse.  She always maintains her registered nurse license.  An APRN does not graduate from or stop being a nurse when she becomes an advanced practice nurse!

Words mean things. Why would anyone want to go see someone for their healthcare needs that is described as “mid-level?”  APRNs produce the same good outcomes as other primary care providers.  Their outcomes are not mid-level, their care is not mid-level, and their experience is not mid-level.

The use of “mid-level” comes from the U.S. government.  They use the terms mid-level and non-physician practitioner to describe APRNS and Physicians Assistants (PA).  The APRN Consensus Model encourages the use of the term Advanced Practice Nurse (APRN) to describe Nurse Midwives, Clinical Nurse Specialists, Nurse Anesthetists, and Nurse Practitioners.    With the implementation of the APRN Consensus Model, throughout the majority of the United States, the use of APRN is increasing. It is being used more in legislative language too.  Despit this progress, the use of “mid-level” is still rampant. We need to encourage the use of APRN in our professional circles.

 

 

Standing together, as healthcare professionals, we can promote the good work of APRNs by using an accurate descriptor.  Our patients are listening.

 

 

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Joy Who?

The internet was in an uproar. Miss Colorado, Kelley Johnson, delivered a monologue about her experience of being “just a nurse” for the talent portion of the Miss America pageant. I watched it on YouTube the night of the contest. Like many nurses, I felt all the warm, fuzzy, nurse feelings and even got a little misty eyed. By Tuesday morning, the news reached my Facebook nursing groups. Joy Behar and Michelle Collins had mocked Miss Colorado on The View. Ms. Collins thought it would be a good laugh to poke fun at the heartfelt monologue delivered by Nurse Kelley. Ms Behar chimed in with the question, “why does she have a doctor’s stethoscope around her neck?”

A doctor’s stethoscope! Behar poked a sleeping bear with those words. Nurses roared into action as the disparaging remarks reached nurses across the globe. Hashtags like #nursesshareyourstethoscopes, #nursesrock, #nursesmatter, #notacostume, #mytalentisnursing, #nursesunite and #notjustanurse began trending on social media. I wish that Ms. Behar and Ms. Collins had supported Nurse Kelley, not only as a healthcare professional, but as a woman. It was disturbing to watch an all-woman-panel mock another woman for sharing her talent, the art of nursing.

The backlash from three million nurses was swift and strong. Pictures of nurses wearing stethoscopes flooded my news feeds. I spent time retweeting every one of my fellow nurses posts about the scandal. I was caught up in the collective outrage and for a few days I felt united with my sister and brother nurses.

Weeks later, the nurse hashtags have stopped trending and the conversation has changed to other hot topics. All of the nurse empowerment energy has evaporated.

Have we once again become stethescope#justnurses?

Joy Behar’s comment was careless. It was a throw away thing to say to fill up space and to seem like she had something intelligent to add to the conversation. I don’t believe that she meant it maliciously, she was being thoughtless. Her thoughtlessness united nurses in a way that I have not seen since nurses jumped on planes and busses to help in the aftermath of Hurricane Katrina. The energy on social media was exciting. It was gratifying to read supportive comments and see nurses being given positive attention. I loved seeing all the stethoscopes and reading nursing stories about where those stethoscopes have been. For a few days it has felt like nurses were united and a part of a large community. United in their outrage of being publicly mocked.
It is now clear that nurses have the ability to direct national conversations. Where have all the hashtags gone? Why aren’t there trending hashtags like #endhealthdisparity, #decreasepatientratios, #stoplateralviolence, #nurseautonomy, or #APRNsIncreaseAccessToHealthcare? Healthcare policy and laws are influenced by a handful of lobbyists and legislators. These lobbyists and legislators number far fewer than three million nurses, but their decisions affect the entire nation. Can you envision a healthcare system being directed by our modern day Florence Nightingales and Clara Bartons, with the support of the national nursing community?
The best thing that could result from this stethoscope spectacle would be for nurses to finally find their voice.

We have power to influence, educate and advocate for the healthcare changes that we know we need. We can command a national stage whenever we choose to unite behind a cause. Its time to come together to influence issues that affect our friends, neighbors and families. Nurses are never just nurses, it is time to prove it.

To take action start here: American Nurses Association

 

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The Little Blue Button

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A “code” is the term that medical professionals use to describe the orchestrated chaos that surrounds a patient that is on the brink of death.  Depending on the facility a code may be called a Code Blue, Code Red, Code CPR, or sometimes Code 99.  They all mean the same thing.  A person is about to die unless there are medical interventions made immediately.  Sometimes it means that death will come no matter how hard we try to stop it.

 

A few months past graduation I experienced my first code on my own patient.  The man had been verbally abusing me all day.  I had been running around trying to make him happy and also care for my other five patients.  He was bellowing from his bed that he was going to die.  A lot of patients speak in that way, but something about the way he said it terrified me a little.  All his vitals, physical assessment findings and that he was able to yell with so much energy all assured me that he was stable.  I called the physician anyway.  He agreed to assess the patient. I went to check on my suddenly quiet patient.  When I walked into the room I knew something was different.  I will never forget how grey he looked.  I froze in a moment that felt like eternity while I listened and looked for breathing.  It only took a few seconds to confirm.  I reached up above his head and pressed the small blue button.

 

I was the person yelling now.

 

I called above the alarm sound for help. Help came.  Almost before I could lay the patient flat in the bed, a nursing aid, with a football player build, began chest compressions.  Respiratory commanded the head of the bed, bagging and preparing for intubation. A metal crash cart clanked into existence, pushed by my charge nurse.  The emergency room physician and intensive care nurse rushed in together. The ICU nurse asked who the primary nurse was.  All I could think was ‘Oh Crap! That’s me.’  She told me to grab the chart (that’s back when patient’s records were big, clunky, 2-ringed, plastic folders stuffed with a ream of paper printouts and handwritten notes) and call the patient’s physician.

 

I ran to the desk and called the doctor again. He was just getting off the elevator. We met at the patient’s bedside. I calmly answered questions about history, vitals, and labs, all while the resuscitation dance continued.  I was calm only on the outside.  Inside my mind raced, searching for what I might have missed.  This man had been screaming at me all shift.  How could we be coding him now?  I couldn’t think of anything I could have or would have changed.  Even now looking back, with much more experience, I know gave him appropriate care.  I watched the code continue, clutching the hard plastic chart.  I optimistically observed that his color was pink again.  Surely that was a good sign, I told myself.

 

As if someone had flipped a switch, everything stopped.

 

The ER physician called time of death after nearly 40 minutes of trying to coax my patient back to life.  I watched as my patient lost his rosy color while the team waded through the open package wrappers that had been hastily discarded on the floor.  The CNA stayed and helped me to clear the debris and prepare my patient for the morgue.  The aftermath of the code was over quickly.  I think that is what stunned me the most.  The physicians and nurses went on caring for their patients.  Housekeeping came and cleaned the room for my next admission.  I did not have time to cry or sit in disbelief or process what had happened.

 

The shift went on and so did I.

 

I have since been to countless codes.  Sometimes I am doing the compressions.  Sometimes I am the nurse directing the chaos.  Occasionally I am the primary nurse questioning every action I did or didn’t make that shift. Luckily one aspect of patient codes has changed since I was a new nurse.  It is now an expectation in many hospitals that a debrief occurs after a code, regardless of the outcome.

 

A debrief is conducted as soon as possible after the event.  All available team members are expected to attend.  It is a confidential and non-discoverable group discussion of the event.  The purpose is to discuss the facts, problems, barriers, needed improvements and to acknowledge and share feelings.  This is not a time to place blame or try to find fault with one another. This opportunity to discuss the event and acknowledge how we feel about it is a valuable practice.  I never want to feel that losing a patient is business as usual.

 

Debriefing is the pause that we need to take to acknowledge, gain knowledge and make adjustments for the next time we press that little blue button.

 

 


Debriefing Steps 

1. Introduction: The facilitator establishes the group goals and rules and reinforces the need for confidentiality about anything that transpires within the group.

2. Fact gathering: Each staff person describes what happened and facts are gathered.

3. Reaction phase: Led by the facilitator, the group examines its feelings, thoughts, and responses to the event experienced. If the debriefing session happens soon after the event occurred, there might not be any symptoms.

4. Symptom phase: If some time has elapsed since the event, group members may be experiencing symptoms. The facilitator helps the group examine how these reactions have affected personal and work lives.

5. Stress response: The facilitator teaches group members about their stress response.

6. Suggestions: The facilitator offers guidance on how to cope with stress related to the incident.

7. Incident phase: Group members identify positive aspects of the event.

8. Referral phase: The facilitator concludes with this phase, whereby specific individuals who require additional support are referred for individual follow-up.     

Adapted from: Hanna, D., & Romana, M. (2007). Debriefing After A Crisis. Nursing Management (Springhouse), 38-42,44–45,47.


This post was written as part of the Nurse Blog Carnival.

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*all accounts are fictional
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Book Review: Your Next Shift by Elizabeth Scala

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Fellow Nursepreneur, Elizabeth Scala, has captured the nursing spirit again with her second book, Your Next Shift.  This is a great read for any nurse, wether you have found your career bliss or are still searching.   

Elizabeth Scala shares her own savvy advice while managing to tie in philosophies from great thinkers from Churchill to Green Day.  Scala gives us a sneak peek into her personal reflections in which we easily can recognize our own struggles and fears.

“When you are OK with where you are currently at, you are able to celebrate everything about you and then exude that energy out into the world.” Elizabeth Scala

Your Next Shift is not a blueprint for becoming someone else. Scala guides her fellow nurses through a journey of self awareness while sharing her steps to success, however you define it.

I recommend this book for every nurse that feels that there must be more to nursing, happy nurses that want to level-up their careers, and nurses that feel the call of a slightly different path.

-Carrie Sue Halsey

 

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Nurse burnout: When passion isn’t enough

A few months ago I was asked by the editor of Sigma Theta Tau’s online magazine, Reflections on Nursing Leadership, to write an article about nurse burnout. They published it as a part of their Nurses Week line up. In the article I share my personal struggle with nurse burnout and how I overcame it. I am very pleased to have my writing published in Reflection on Nursing Leadership.

Please take a few minutes to read and share with your nurse friends.  Chances are you have felt burned out in your career.  Share in comments how you renewed your passion for nursing.

 

 

 

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13 Fundamentals for Practicing Nursing

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National Nurses Week is a time set aside for the public to recognize the amazing work of nurses.  Nurses will be the topic and focus of hospitals, newspapers and media outlets.  Our accomplishments, character and hard work will be applauded and we will receive all kinds of tokens of appreciation from employers, patients and family.

This year instead of another pen, coffee mug or tote bag, I want to give nurses something that that won’t end up in the summer yard sale.

 

Rosemarie Rizzo Parse’s 13 Fundamentals for Practicing Nursing

 

  • Know and use nursing frameworks and theories.

You can begin with Parse’s theory of Humanbecoming, which is an insightful nursing theory that describes how nurses and patients co-create the health experience.  Parse marries the art and science of nursing in a beautiful and applicable way.

 

  • Be available to others.

Nurses are busy.  Do not let the fast pace of healthcare prevent you from being available.  Remember to be available for the nurses around you. No one understands you quite like a fellow nurse. Take the time to listen, help and care for one another.

 

It is a poor coping mechanism to view patients as diseases, room numbers or annoyances.  Nursing is stressful, people are not always kind, and you may never hear a thank you, but it is important to value everyone as a human presence.

 

  • Respect differences in view.

Whether you are a new graduate or about to retire, you are a nurse with opinions.  Differences in opinions are good!  Respecting differences of view is important too.  Creating a safe and welcoming environment, for everyone to share their view, will allow nursing knowledge to evolve and grow.

 

  • Own what you believe and be accountable for your actions.

If you believe in something or someone, stand up and speak up.  If you turn out to be wrong, admit it and move on.

 

  • Move on to the new and untested.

Change is hard.  No one likes it, but change is necessary and good for us and nursing.  If we did not push forward and try new nursing interventions we would still be sterilizing our own needles and fetching coffee for physicians. Parse’s theory is a paradigm shift away from medical thinking that embraces nursing as a standalone science.

 

  • Connect with others.

Compassion, caring, respect, understanding are all qualities that nurses help nurses to connect with the healthcare team, including the patients.

 

  • Take pride in self.

You are not “just a nurse.” Being a nurse is exceptional.  Don’t shortchange your contributions to healthcare.  You are brilliant, own it!

 

  • Like what you do.

If you hate your job, find one where you can be happy.  There are endless opportunities in nursing.  You owe it to yourself and your patients to like coming to work every day.

 

  • Recognize the moments of joy in the struggles of living.

Life is hard.  Take time to recognize and feel joy when you find it.

 

  • Appreciate mystery and be open to new discoveries.

Nursing is a beautiful work. We are the companions to humanity throughout the life span and in every imaginable condition. We continue to discover what it means to be human day after day.  Be open to the mysteries of life and embrace what you find.

 

  • Be competent in your chosen area.

            What have you been doing since you graduated nursing school?  Have you been to a conference, read a journal, taken a class?  Choose your nursing niche and keep learning.

 

Taking time for self is vital in order to prevent compassion fatigue and nurse burnout.  Nurses are known for putting themselves last.  Their own health, spirituality, emotion and mental needs are often put aside in order to care for others.  Take care of yourself!  Take a few minutes to meditate, pray or sit quietly during a hectic shift and you will feel the difference, and so will your patients.

 

Thank you to all my nursing colleagues around the world!  This is the week that everyone remembers that nurses are a special kind of awesome. 

Let’s remember this about ourselves the other fifty-one weeks of the year!

 

 

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Bournes, D., & Mitchell, G. (2014). Humanbecoming. In Nursing Theorists and Their Work(8th ed., pp. 464-495). St. Louis: Elsevier Mosby.

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3 Small Ways to Bring Mindfulness to the Bedside

Nurses multitask.  We are expected to be flexible.  We accomplish more than any one person should be capable of achieving in twelve hours. We do it all with a smile on our face, at least most of the time.  Behind the smile, our minds our often far from the bedside.  We are thinking about the patient in another room, when pharmacy will tube up the medication that is late, whether our lunch buddy is back from eating, and the charting that needs to be finished from morning assessments.  It is difficult to be truly present with the people that we provide care.  There are many distractions for our attention and energy.  Nursing is also an emotional career.  Supporting, caring and healing people exposes nurses to intense emotion from patients, family and friends of the patient and the nurses own emotion.  Stress, crazy workloads and intense emotions can be huge barriers to nurses having mindfulness at the bedside.

Three tips to put mindfulness in action at the bedside:meditation-clipart-meditation-clipart-animal

 

  1. It is what it is This is one of my go-to-mantra’s.  This is not a surrender to fate, it is an acceptance of the limits of my power as a nurse.  When I truly have done all the intervening and advocating possible, I accept the outcome.

 

  1. Being present Mindfulness requires us to pull up a stool, sit down and be with our patients.  It is letting go of everything else in the world for a small space of time in order to be present.  It is important to connect with each other human to human.  Being present also allows our attention to focus on this patient’s needs, fears, wants and hopes.  Not being present causes errors and decreases the trust from the patient

 

  1. Suspending judgement Being critical of our patient’s actions, feelings, choices or lifestyle prevents us from being present and having mindfulness. It is important to meet people where they are in life.

 

We will not always be able to be 100% mindful as a nurse.  These three tips can help us be more mindful with our patients for their benefit and ours.

 

This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at The Balanced Nurse Blog. Find out how to participate.

 

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Nursing is Bigger on the Inside

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I love Doctor Who.  For anyone that is not familiar with this British television program, the basic premise is as follows.  There is a cool alien that looks human, but regenerates every few season to look like the next actor to play him.  This alien is called the ‘Doctor’ because no one can know his real name.  The Doctor is a time lord from a planet called Gallifrey and he travels in what looks like an old police call box, much like a telephone booth.  This police box, the TARDIS, takes the Doctor anywhere in time and space, but that is not the only amazing thing about the it.  The TARDIS is bigger on the inside.  We don’t know how big, but imagine the Star Trek Enterprise stuffed into a telephone booth and you get close. 

Nursing is like the TARDIS.  

People think they know about nursing.  The public only sees the outside. They see that nurses work 3 days a week and are paid well. They see that nursing is not a glamorous job. They see smiling faces and skilled hands.  

Nursing is bigger on the inside. 

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A lot of nurses look cute in scrubs, but even those scrubs lose their appeal when they are covered in various bodily fluids.  I am frequently told by family, friends and random strangers that they could never be a nurse.  I get it.  Nursing is not for everyone.  

Some of us do work 3 shifts a week.  Those 12 hour shifts stretch into 14 or 15 hour days when you add in lunch, report, extra charting and commute time.  The majority of nurses that I have known work much more than 36 hours a week.  

For the most part nurses can at least fake a good mood and do their best to smile.  Smiling and chatting with patients they perform the technical skills that keep patients safe and comfortable.  

Nurses need to be smart, caring, brave, strong willed, strong stomached and have a sense of humor.  We see the worst and best of humanity in our work.  We are happy when our patients do well and cry when they are not.  Nurses monitor, clean, feed, medicate, assess, educate, entertain, console, listen, advocate for and document about patients day and night.  After doctors, therapists, family, friends and even dietary leave for the night, nurses remain at the bedside.  

Caring for patients is rewarding, gratifying and exhausting.  To be trusted to such a degree by a stranger is an honor.  Helping people meet health goals or guiding them through milestones is an amazing feeling.  Even when our patients pass away, helping the patient and family through the process is fulfilling.  

Nursing is much bigger on the inside.  It is easy to get lost in charting, policy reviews and quality audits and forget the art of nursing.  Nurses need to be reminded of the amazing impact that we have on peoples lives.  Nurses not only impact health at the bedside, but have the power to transform healthcare practice.  

 

Take time to remember how big nursing is and why you do it. Energize and renew your yourself at the Art of Nursing 2.0 event from anywhere in the world.  

 

 

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This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at ElizabethScala.com. Find out how to participate.

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A Call to Labor Nurses: Go to the Bedside

One to One Nursing Care for Actively Laboring Mothers

Not all hospitals are able to, or choose, to staff their labor units according to AWHONN guidelines.  Many hospitals recognize that one to one nursing care for actively laboring mothers is the gold standard and is safer for mom and baby.  I have worked in both types of facilities.  Nurses that are able to care for mothers one to one can give a great gift of time and attention to their patients.  Mothers in labor do better when they have continuous support.  I feel lucky to work at a hospital that strives for one to one staffing.  I am making a call to labor nurses, go back to the bedside.  I love working with you ladies and gents.  You make me laugh.  The nursing station is a fun place to joke around with people whom understand you in a way that even your family can not.  I love swapping war stories and sharing photos of babies with you.  As much as I love this interaction with you at the nursing station, I ask you to go back to the bedside.  The mothers need us.  Laboring mothers need continuous support.  Remember labor sitting?  We need to bring that back!  With continuous support mothers are less likely to need medical interventions.  You will be able to recognize subtle differences in your patient’s status.  You will have more time for observation, assessment, education and supporting the mother and her family.  One to one staffing is a great gift for both the nurse and the mother.  Sometimes a mother will request less of your presence at the bedside.  This is rare.  All mothers should have continuous support during labor, even when they have has an epidural.

Quietly sitting, charting and guiding the mother is reassuring and decreases maternal stress.

It may seem awkward at first.  It will become normal very quickly.

 

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