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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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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

tardis

 

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. 

doctor-who-its-bigger-on-the-inside

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.

Nurse Blog Carnival

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The Secret Awesomeness of Night Shift

The hospital feels different after 5 PM.  

The scheduled surgeries are finished for the day.  The short stays and clinics are emptied and closed.  Administrators, executives and their assistants all begin vanishing like the sun over the horizon.  The last few tired nurses clock out and the hectic cloud of day shift follows them into the elevator.  What is left behind is an alternate hospital universe that only true night shift staff discover and appreciate.

The bright lights are dimmed to signal to patients, visitors and staff that night has arrived.  The coffee and tea come out to greet the healthcare team to another night.  Some nursing units brew their own caffeinated delights,  others take turns making massive runs to Starbucks, Dutch Bros or another favorite coffee spot.  Patient assessments are completed and medications are passed.  Nurses and ancillary staff move quickly to check off all the tasks on their lists.  If they are lucky they will be able to tuck themselves in to the nursing station to chart and chat the hours away until dawn.

Everything is more a little more relaxed.  No topic is taboo by 4 AM.  Night shift staff know each other, the good, the bad and the unmentionables.  If a manager or administrator happens to come in on night shift, the news spreads quickly and the books, smart phones and uncovered cups disappear in an instant.  Those late night visits from administration are rare. Night-shifters learn to depend on each other like family.   

The calm can be misleading.

In the darkened corners of the nursing unit lurk the possibility of chaos.  Disaster can interrupt the laughter at the nursing station, despite the careful observation and care of patients.  When emergencies occur, the night shift team leaps into action.  The juicy conversations and cat videos are abandoned and the only priority is the patient.  An outsider may not see an emergency on a nursing unit as seriously as the team working in it.  It does not usually look like it does on television.  There are a lot of people.  Everyone is in motion.  It is often quiet with one or two people calling out times and actions.  Faces are focused.  Minds are alert and assessing, searching for causes and solutions within milliseconds of coming to the bedside.  They have done this before and settle into their comfortable roles.  The night shift team are a little more earnest and confident.  They know that reinforcements are not coming.  This is night shift.

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When the emergency has passed, for better or worse, the team returns to its tasks.  The work and night continue.  

Despite the craziness and sleep deprivation, night shift is awesome.  Most people dread working at night and do not understand why any sane person would choose to work the late shift.  It is not the frappicinos.  It is not the chance of watching cat videos for hours.  It comes down to the men and women sharing the nursing station with you.  They don’t always get along, but they are always in it together.  They create the secret awesomeness that is night shift.  

Shhhhhh don’t tell the boss! 

 

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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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10 Things that Labor Nurses Fear

All nurses have rational and irrational fears that haunt our waking and sleeping hours.

Here are 10 of the top labor nurse fears.

 

 

Realizing at change of shift you had a patient and didn't know it.
1. Realizing at change of shift you had a patient and didn’t know it.

 

 

 

 

 

 

 

 

 

Calling the father of the baby Grandpa by mistake.
2. Calling the father of the baby Grandpa by mistake.
Monitoring Multiples.
3. Monitoring Multiples.

 

 

 

 

 

 

 

 

 

Farting in a mother's room.
4. Farting in a mother’s room.

 

 

 

 

 

 

 

 

Calling in the OB because her cervix is complete and its really 1 cm and REALLY, REALLY thin.
5. Calling in the OB because her cervix is complete.                                                                             But its only 1 cm and REALLY, REALLY thin.

 

 

 

 

 

 

 

 

Falling asleep in the mother's room, at the nursing station, in the OR, or in the bathroom.  You are soon tired!
6. Falling asleep in the mother’s room, at the nursing station, in the OR, or in the bathroom. You are so tired!

 

 

 

 

 

 

 

 

 

Catching lice, scabies or any other critter from your patient and their visitors.
7. Catching lice, scabies or any other critter from your patient and their visitors.

 

 

 

 

 

 

 

 

 

Dropping the baby.  Those little guys are slippery!
8. Dropping the baby. Those little guys are slippery!

 

 

 

 

 

 

 

 

Not being to keep your game face on when the mom who has no drug history has a positive drug,  a mom whispers for you to check if the baby looks Asian , or a mom who bragged about her pain tolerance gets an epidural at 2cm.
9. Not being to keep your game face on when the mom who has no drug history has a positive drug, a mom whispers for you to check if the baby looks Asian , or a mom who bragged about her pain tolerance gets an epidural at 2cm.

 

 

 

 

 

 

 

 

 

 

The full moon, rain, and days that the OB offices are closed.
10. The full moon, rain, and days that the OB offices are closed.  

 

 

 

 

 

 

 

 

 

 

 

 

What fears about labor and delivery keep you up at night?

 

 

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Why the Golden Rule Doesn’t Apply in Healthcare

The Golden Rule has been preached to those in healthcare for decades.  As nurses we were taught that we should treat our patients as if they were our mother or grandfather.  I have heard doctors concluding consults with, “if it were my sister I would tell her to do X procedure.”  I know well meaning nurses whom call all their patients sweetie, because that is how they address family and they want to treat their patients like family. Empathy for our patients, care, and recommendations based on how we would like to be treated seems to be the ethical and correct behavior.  It is not the right thing to do.  To assume that we know what a person should choose or how they would like to be addressed is presumptuous at best and patriarchal at worst.

We should leave the Golden Rule concept in the past.

The Golden Rule, although a benevolent seeming concept, is fundamentally flawed.  Not everyone wants to be treated the way that someone else thinks is right.  This is concept is clearly evident in labor and delivery.  Women that choose to pursue normal means of birth, such as waiting for spontaneous rupture of membranes, are commonly labeled as difficult.  Women that decline an epidural or pain medications are often met with impatience and pressure to not suffer through the pain.  Mothers that wish to give birth vaginally, after one cesarean birth, are discouraged, badgered and bullied into submitting to a repeat surgery.  All this is done by health care providers that believe that they are treating the patient according to the Golden Rule.  Pain is bad, so healthcare providers want to take pain away from mothers.  Vaginal birth after cesarean comes with risks and they would not choose to try it.  By attempting to apply the Golden Rule in these ways, we are actually doing more harm.

We need to think about the Golden Rule in a new way.  It does not mean that we do for our patients what we would like done for ourselves or our loved ones.  We do not decide for a woman, what she should choose to do, based on what we would want our sister to choose.  A truer interpretation of the Golden Rule is respect for our patient’s wishes, requests and declinations.  Ultimately I would want my healthcare providers to respect how I want to be treated.  That is how I take care of my patients.  If they don’t want to know the details of every intervention, then I won’t tell them.  I know that education is important, but some patients do not want to hear how a urinary catheter works.  Many patients want to know every detail, and I accommodate their requests.  Personally, I prefer unmedicated labor and feel that moms miss out on something amazing when they get an epidural.  I do not treat my patients how I like to give birth.  I support them with what they prefer, whether it is an epidural, unmediated birth or somewhere in between.

I feel comfortable sharing my opinions when asked.  I give advice, but I never assume that I know what is the golden answer for each woman.

The old Golden Rule does not apply in health care.  Patient autonomy, as a priority in our nursing care, should become the new Golden Rule.  MC900439242

 

 

 

 

 

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