Although Angela Warnke, RN, director of nursing at the Greenhouse Treatment Facility of the American Addiction Centers, now manages a team of nurses doing direct patient care, until about six months ago, she was a “working” manager, working directly with patients going through withdrawal.
Warnke works with patients ages 18 and older. She says that people as old as in their 60’s and even 70’s are detoxing from opioids and other substances. “Day to day this work is similar to many other types of nursing in that it involves continuous assessment, interventions, medication administration, and caring for the whole patient and their family,” explains Warnke. “Some days I work to physically stabilize patients, some days I listen to people who need to talk, some days I teach groups on the physiology of addiction, some days I just offer hope. Most days are a combination of all aspects of nursing.”
With the opioid epidemic on the rise, many other nurses may be working with recovering addicts and people detoxing in the near future. “Everyone knows or is someone who has struggled with addiction,” says Warnke. “I have the gift of also seeing and experiencing the joy and freedom of recovery. This is a treatable disease, and recovery changes everything.”
During the first half of her career, Warnke worked in critical care in the Medical/Respiratory ICU of a hospital with 960 beds. Then, she worked in an ER that would often see between 250 and 350 patients each day. She thought that she would miss the challenges she experienced when she moved into substance abuse recovery nursing. Instead, she says, she found her home there.
“To be effective in helping people recover from substance use disorders (SUDs) one has to care for the whole person. People’s minds, bodies, and spirits are hurt by SUDs, and I get to engage people and help them heal on all these levels. I get to do the work of caring that I went to nursing school for,” says Warnke. “By far the most difficult challenge of this work is having a front row seat to the effects of this disease. Addiction gets worse as diseases do and kills as diseases do. The tragic loss of life—often very young life—is incredibly painful.”
As for the greatest rewards of her job, Warnke explains it in this way: “I think many people imagine my job is to be treated poorly by whatever they imagine ‘addicts’ to be. In reality, I work with people from a true cross-section of our culture who have quite unintentionally developed problematic relationships with opiates and other substances.
“In general, I work with people who will go on to live full lives, new lives, great lives. While recovery is intensely difficult and requires trying and trying again, our population literally ‘comes to life’ in our care. I get to see people who ‘come in hot’ stabilize. I get to see people who have been beaten down get life back in their eyes. There is nothing else like it.”
When asked what she would say to a nurse who might be considering this type of nursing care, she answers, “Do it.”
“This is the epidemic of our generation, and we need all hands on deck. Find a mentor. Be ready to research everything known about addiction. This is a developing field. Get serious about learning that nothing is personal. Take care of yourself. Give love,” says Warnke. “Every day I get the chance to be better than I was the day before. I feel like I get paid to become a better human being. Like all types of nursing, the job is to meet people where they are at and bring them out with me.”
When dealing with patients, there are times in which nurses need to be their advocates. But have you ever thought about if the instance occurred when you had to act as your own advocate? Janetta Olaseni, RN, BA, HN-BC, CHC, administrator and director of nursing at Hands of Compassion Home Care, Inc., had to do just that.
In February 2013, Olaseni says that while performing a monthly breast self-exam, she discovered a painless lump about the size of a bouncy ball in her left breast. Of course, she went to see her gynecologist. But he told her that it was a normal cyst and that since she was young and didn’t have a family history of breast cancer not to worry about it. If it did become painful, he told her, she could have it removed. Despite what her doctor told her, she felt that something was wrong.
“I immediately did not feel good about his diagnosis and started making plans to have it removed,” says Olaseni. As time went on and life got busier, seeing a surgeon became less important.
“In the meantime, the small ‘ball’ had grown and started to hurt and fill with fluid,” says Olaseni. She quickly made an appointment to be seen. Like her gynecologist, though, the surgeon was treating the lump like a normal cyst and would drain the fluid. After three weeks of this, she requested a lumpectomy.
In September, when she woke up in the recovery room, Olanseni’s surgeon told her that she couldn’t remove the entire lump because she would have had to have taken out nearly half her breast. The once 3 cm lump had grown to 8 cm.
When the biopsy came back, Olanseni’s diagnosis was Stage 3b Invasive Ductal Carcinoma.
Today, Olanseni is cancer-free, but who knows what could have happened if she hadn’t insisted on the surgeon listening to her.
“This journey made me so much more compassionate and empathetic towards my patients and their families,” says Olanseni. Ten years ago, she started a home health care company that emphasizes facilitating compassion regarding patient care.
“When you’ve been on the other side with the hospital gown on, having your hair shaved because you do not want chemo to take it out, when you’ve had your porta cath accessed daily, when you’ve had the radiation beam hit close to your vital organs, when you have undergone multiple surgeries, when you’ve gotten therapy and wound care, then you are a true patient advocate,” says Olanseni. “Not only can you say you understand, you really do understand.”
Have you ever thought about changing career paths and teaching up-and-coming nurses? For those of you who have, we wanted to provide you with some information about what it’s like to teach, including the challenges and the benefits.
Michelle DeCoux Hampton, RN, PhD, MS, Professor and Doctor of Nursing Practice Program Director at Samuel Merritt University School of Nursing in Oakland, California, took time to talk with us about her experiences in teaching.
Following is an edited version of our Q&A:
What does your job entail? Do you specialize in specific topics that you teach? How many courses do you teach each semester?
I started in 2005 as a full-time faculty member teaching psychiatric mental-health nursing, health assessment, and synthesis for students throughout our accelerated bachelor’s program in nursing. Later, I began teaching an online course in research in the Master’s program and then the Doctor of Nursing Practice Program.
In 2013, I became the Director of the Doctor of Nursing Practice Program, and now I teach evidence-based research and several of the DNP Project courses that are geared toward providing mentorship to doctoral students as they complete their scholarly projects.
In my administrative role, 75% of my time is administrative work involving admissions, student advisement and progression, faculty support, as well as curriculum review and improvement, among other responsibilities. In my full-time teaching role, I taught about two courses per semester.
Why did you choose to teach?
My interest in teaching stemmed from my enjoyment of education from the student perspective and my many positive experiences with faculty and mentors.
I first tested myself as the Director of Staff Development in a skilled nursing facility to see how I would like being “on stage” before I ever applied for a teaching position at a university. I was able to learn a lot about adult education and enjoyed the opportunity to connect with the facility staff through our orientation and continuing education programs.
I advised many of our staff nurses about how to go about continuing their formal education and found it was one of the most enjoyable parts of my role in staff development.
What are the biggest challenges of your job?
Compared to being a staff nurse, one of the biggest challenges in teaching is that there is often no one to fill in for you—at least not at a moment’s notice. You often find that you work when you’re ill, on semester breaks to prepare for the next semester, and on your vacations. The flexibility is nice in a lot of ways, but the tradeoff is that you’re never really off the grid.
What are the greatest rewards?
One of my favorite parts of my job is to work with my doctoral students on their DNP Projects—usually an evidence-based practice implementation project. These students evaluate best practices through critical appraisal of the research literature, design practice change programs, implement changes that involve policy and procedure changes of the staff in a variety of health care settings, and evaluate the outcomes. Through each of their projects, they have provided improved health care to individual patients, communities, and within organizations. Seeing these projects develop from an idea to influencing real people’s lives is incredibly rewarding, and it never gets old.
What would you say to someone considering this type of work?
To me, the best teachers that I’ve known and worked with take a service-oriented approach to education—providing what the student needs to progress to the next level, to continue growth. This takes good observation skills, flexibility to change your approach based on where your student is and what his/her needs are, and a willingness to keep learning. The field of education, beyond what we need to know as nurses, continues to evolve and we have to evolve with it.
Is there anything else that is important for nurses to know?
In my early years of teaching, I felt like I needed to know everything—to answer all of my students’ questions on the spot. This expectation of myself produced a lot of anxiety and self-doubt for me.
Over time, I relaxed a bit more and accepted that even if students wanted me to have all the answers, that was not possible 100% of the time. Feeling confident in the knowledge that I had and my ability to research answers that I couldn’t answer right away effectively, enabled me to say that I didn’t know, but would find out or even enlist the support of other students to find the answer. It was a turning point for me. I don’t think I would have been able to sustain a career in education long term with my previous mindset.
Nursing is a stressful job. So when you think that a patient may have been misdiagnosed by another health care worker, it’s important to know exactly what to do—especially if the misdiagnosis could cause permanent harm or death. It’s important to protect your patients as well as yourself.
Jennifer Flynn, CPHRM, risk manager for Nurses Service Organization (NSO), took time to answer in detail what nurses need to do when they suspect a patient is not receiving the care they need.
What should a nurse do if s/he thinks that a patient is not receiving the care they need from another health care worker? What are the specific steps that s/he needs to take? Are these steps different depending on the procedures of the facility?
Every day, nurses are challenged to provide patients with the safest and most effective care possible. Many factors can affect clinical performance. For example, being sleep deprived, running late, being assigned to more patients than usual, or experiencing a breakdown in communication with other providers can influence a nurse’s ability to provide safe patient care.
According to the 2015 NSO/CNA Nurse Professional Liability Exposures Claim Report, failure to invoke the chain of command was identified as a common allegation. Nurses are responsible for invoking the medical chain of command when necessary, in order to trigger a practitioner’s intervention for the patient. Closed claims involving the failure to invoke or utilize the chain of command accounted for 7.5% of the treatment and care closed claims, and reflect a higher average payment as compared to all claims in the report.
Nurses must be comfortable with utilizing the medical chain of command whenever a practitioner does not respond to calls for assistance, fails to appreciate the seriousness of a situation, or neglects to initiate an appropriate intervention.
Consider this scenario: a nurse failed to initiate the chain of command when the practitioner would not respond to her concerns of identified non-reassuring fetal distress. The nurse called the practitioner several times to give an update on the patient’s condition, which continued to deteriorate. Each time the nurse requested that the practitioner come see the patient, the practitioner said it didn’t seem necessary. As a result, the infant suffered birth-related brain injury, requiring lifelong care. The nurse was named in the malpractice lawsuit alleging failure to invoke the chain of command and failure to report changes in the patient’s medical condition. While the nurse had documented making the phone calls to the practitioner, the nurse neglected to include what was told to the practitioner and the practitioner’s response.
Nurses know that treatment and care of every patient starts with timely attention to their needs and persisting to the point of resolution. However, nurses may feel apprehensive about chain of command issues. Fear of disciplinary actions, loss of their jobs, or being labeled as a “troublemaker” are other concerns.
The following strategies can help reduce apprehension regarding chain-of-command issues:
- Proactively address communication issues between nursing and medical staffs, and identify instances of intimidation, bullying, retaliation, or other deterrents to invoking the chain of command.
- Notify leadership of individuals or areas that prevent nursing staff from invoking the chain of command or impose punitive actions for doing so.
- If the organization’s current culture does not support invoking the chain of command, explain the risks posed to patients, staff, practitioners, and the organization, and initiate discussions regarding the need for a shift in organizational culture.
Are nurses usually taught this in nursing school? What should they know about speaking up?
Education in this matter is an ongoing effort. It starts in nursing school, but it must be continuously addressed, communicated, and supported for it to become part of practice.
The first step in protecting yourself from legal action is to know and understand your facility’s policy and procedures on invoking the chain of command to resolve concerns about patient care. In many facilities, policy and procedures manuals are readily accessible. If no chain-of-command policy or procedures exist, find out who in your facility is responsible to do so.
Don’t hesitate to call the appropriate practitioner when there’s a change in your patient’s condition. Most facilities have policies that require this. However, some nurses may feel intimidated by appearing to question a practitioner’s management of a patient.
Express clearly what, if any, action you would like the practitioner to take. If you think your patient needs to be seen, say so. After the conversation, document exactly what you told the practitioner about the patient’s condition.
If you believe the practitioner isn’t taking your concerns seriously, go to the next person in the chain. If necessary, go up your facility’s chain of command until the concern has been addressed. As you contact different staff members in the chain of command, be sure to make a note in the patient’s chart.
By invoking the chain of command, not only do nurses fulfill their obligations as patient advocate, but they protect themselves from liability.
What should nurses not do if they think their patients aren’t getting the care they need?
Advocating for a patient may not always be easy, but it is part of a nurse’s responsibility. Advocacy includes the duty to invoke both the nursing and medical staff chains of command to ensure timely attention to the needs of every patient, and persisting to the point of satisfactory resolution. Not following the chain of command puts the patient’s safety at risk and exposes nurses to the potential of a malpractice lawsuit.
Document each of the steps taken, and the reasons they were taken, to advocate for the patient’s care. Refrain from speculative or subjective comments, including ones regarding colleagues and other members of the patient care team.
Can a nurse get in trouble for reporting something like this? How should they approach this so that they do what is most professional?
To be an effective advocate, nurses first need to understand the laws and regulations governing their practice. Nurses who understand their scope of practice, state practice act, and facility policy and procedure are best able to use established processes to advocate effectively for their patients while protecting themselves from retaliation and litigation.
Effective communication is key. One technique available to nurses is SBAR, which is an acronym for Situation, Background, Assessment, Recommendation. This communication style can be used to facilitate prompt and appropriate communication. It is a way for nurses to communicate effectively with one another, and between the health care team. It allows for important information to be transferred accurately.
Allegations of malpractice can result from miscommunication or lack of communication between practitioners and nurses. By carefully documenting the information about the patient shared with other members of the patient’s care team, nurses can significantly reduce communication-related risks.
By enhancing their communication skills, nurses can minimize the risk of claims. Some communication strategies include:
- Clearly articulate your concerns so that others are able to respond.
- Consider what information to share, when to share it, and with whom it should be shared.
- Ensure communication among caregivers is professional and respectful.
- Carefully and timely communicate patient assessments and observations to other members of the health care team.
- Read back or repeat verbal orders to the practitioner who issued them to verify accuracy and understanding.
Nurses can ask to become more involved in developing and influencing facility policy around advocacy and communication. Nurse leaders, health care administrators, and organizations can change the culture of retaliation and blame, which tends to point fingers instead of recognizing issues and problem solving.
All nursing jobs have instances of stressful situations in them. It’s the nature of the field. But working at a Shock Trauma Center can be even more so.
Rashidah B. Francisco, BSN, RN, CCRN, CPAN, TCRN, with the Lung Rescue Unit at the University of Maryland R Adams Cowley Shock Trauma Center (STC), took some time to answer our questions about her amazing job.
What follows is an edited version of our Q&A:
As a Shock Trauma Nurse, what does your job entail? What do you do on a daily basis?
On the Lung Rescue Unit, our shifts are extremely unpredictable. Taking care of some of the sickest patients in the state of Maryland—and possibly the world—at the only Primary Adult Resource Center is something that demands skill, dedication, communication, and a sense of teamwork like no other.
Our exclusive Veno-Veno extracorporeal membrane oxygenation (VV ECMO) unit at Shock Trauma is one of the only units of its kind in the country. Our patient population on this unit consists of patients in need of a machine that bypasses their lungs to deliver 100% oxygen to the patient’s blood, as their lungs are incapable of this function. Having the critical care skills, knowledge, and critical thinking to recognize when your patient is in trouble is half the battle of managing this patient population.
Our patients are suffering from acute illnesses and come to us at the most critical moment in their lives. Because of this, we have little time to think, but must come together as a team and put our skills and expertise to work. The interventions for our VV ECMO patients can also be very different from your typical ICU patients, but are directly in line with evidence-based practices. We may prone our ECMO patients, walk them, and get them out of bed daily and into a chair to optimize their recovery.
Why did you choose to work at Shock Trauma? How long have you worked there? What prepared you to be able to work in such a stressful environment?
Coming to Shock Trauma was not my initial plan, but critical care has always been a dream of mine. I have been in the nursing profession for almost 20 years (three as a patient care technician, 11 as an LPN, and seven as an RN). After going through a critical care fellowship at a large hospital in Virginia, and spending a couple of years on their complex critical care unit, I felt that I was ready for something bigger and more challenging. I wanted something that would enhance my skills, and push me to go further in bettering myself and my career.
When asking myself where I could go to be a part of the best, where only the best is expected of me, and where my skills and education would be the only determining factor in how far I can go in my career, I chose Shock Trauma. I have been at STC for over 4 years, and there is not one day that I have not been pleased with my career choice.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Gratefulness and self-reflection helps me to de-stress. Reflecting with my team and relying on them while I am at STC helps me to keep things into perspective.
What are the biggest challenges of your job?
The biggest challenge of my job is knowing that I cannot save everybody—that everyone’s story is not to be taken on as my burden, but it is my duty to do the best that I can. Knowing that I am human, and I can only do so much. Remembering that I am here by choice, and that some of my patients, no matter what choices they have made, are there because they have to be, and are depending on me to utilize my skills to help them in their most critical hour. Remembering that it could be me lying in the bed, and them taking care of me.
What are the greatest rewards?
Seeing a patient get off of ECMO and return home or go to one of our critical care units. Just seeing that they have reached a point where they are able to evade such a lifesaving piece of equipment is a reward. Hearing a patient’s voice after they have been extubated. Seeing them walk after being in the prone position intermittently for days. Hearing that a patient who has been waiting months for lungs has finally gotten them.
Being a part of a team—that these things are just as important to them as they are to me—is also a reward in itself. To have someone who is going through the struggle with you and cares as much as you do.
What would you say to someone considering this type of work? What kind of training or background should he or she get?
No matter what your background, come with a sense of teamwork, with a sense of family, and with the ability to take on the most challenging situations, but with the humblest attitudes. Be ready to learn, no matter what you think you know. At STC, you will see and learn things beyond what you even thought. Have a strong critical care background for some of our units, but if not, have an open mind and a willingness to learn. Be ready to see and care for people who are very different from what you may have experienced, but be ready to save them, and care for them as if they are one of your family members.
Is there anything else that is important for fellow nurses to know?
Wearing the pink uniform is something that for the last four years I have been very proud of. It is to me like putting an “S” on my chest when getting ready for my shift. However, it is something that comes with a heavy responsibility and a possession of skills that I am expected to have and use when I walk through the doors of STC. My days are not blissful, my days are not easy, but they have been more rewarding at STC than they have my entire nursing career.