SWAT RNs: Supporting Bedside Leaders with Clinical Judgment

SWAT RNs: Supporting Bedside Leaders with Clinical Judgment

SWAT RNs serve as expert consultants and mentors to nurses working as bedside leaders in various clinical settings. With clinical practice experience of five or more years in the areas of critical care, emergency nursing, and flight nursing, these nurses enjoy the adrenaline rush that comes with quickly assessing patients at risk for condition deterioration.

SWAT RN Role

The role of the Specialized Workforce for Acute Transport Registered Nurse (SWAT RN) has evolved in national healthcare organizations. Early detection of patients experiencing physical decline is the hallmark of the SWAT RN role. Having identified an early condition decline, bedside nurse leaders working in various clinical settings collaboratively work with SWAT RNs to promptly stabilize and prevent patient injury and death. 

Susan Dresser, Cynthia Teel, and Jill Peltzer, in their 2023 article entitled, Frontline Nurses’ Clinical Judgment in Recognizing, Understanding, and Responding to Patient Deterioration: A Qualitative Study, noted that nurses who work at the bedside are essential in the recognition of patients’ decline and initiating contact with the SWAT RN. Hence, the SWAT RN is a nursing role that is instrumental in the promotion of the nursing process and the National Council of State Boards of Nursing’s 2019 Clinical Judgment Measurement Model within the acute care setting, as they work collaboratively with bedside nurse leaders to facilitate positive patient outcomes.

A Hypothetical Case Study

The following hypothetical case study provides an opportunity to explore the SWAT RN role and examine how this role collaborates with bedside leaders to improve patient outcomes.

Case Presentation

Bernard Salzo is a 38-year-old male employed as a carpenter and painter. Unable to sleep and experiencing restlessness accompanied by shortness of breath for the last two days, Mr. Salzo presents to the emergency department (ED) at 3:00 a.m. with difficulty breathing. The triage nurse obtains his vital signs: blood pressure 134/82 mm Hg, respirations 30 breaths per minute, heart rate 102 bpm, temperature 99.8 F, and oxygen saturation on room air, 94%. The patient appears anxious and restless, requiring redirection as the triage nurse processes him. The patient states, “I have not been sleeping that well. I kind of feel discombobulated.”

History and Assessment 

Mr. Salzo’s medical history is significant for childhood asthma and hypertension. His hypertension is managed with an ACE Inhibitor, Lisinopril 15 mg PO daily, and diuretic Furosemide 10 mg PO daily. Prescribed Montelukast sodium 10 mg PO once daily and a Proventil HFA inhaler twice daily and as needed for asthmatic symptoms. Mr. Salzo’s asthma has been stable for the past ten years. Mr. Salzo is a nonsmoker and abstains from alcohol.

Mr. Salzo is triaged, assessed by an ED nurse, examined by an ED provider, and admitted to a Medical-Surgical Unit. The nurse in the Medical-Surgical Unit suspects worsening respiratory distress, noticing that Mr. Salzo has become increasingly anxious and is moving about restlessly in bed during the admission assessment. Oxygen therapy via nasal cannula 2 L O2 is placed on the patient, and the nurse contacts the SWAT RN, who arrives in less than 5 minutes.

The SWAT RN provides a rapid assessment of the patient and reports their findings to the patient’s healthcare provider and bedside nurse leader.

  • Alert and anxious, use of accessory muscles of respiration, respiratory distress
  • RR- 32 breaths per minute and labored, BP- 143/88 mm Hg, T- 100.3 F (temporal), oxygen saturation- 90% on room air (sitting)
  • Peak flow- 185

HEENT, Skin, Neck

  • No bruits, nor thyromegaly or adenopathy
  • Bilateral tearing of the eyes noted with conjunctivae that are edematous and inflamed
  • Pharynx with clear postnasal drainage; nasal mucosa edematous with clear discharge
  • Fundi without lesions
  • Skin is supple, diaphoretic, pink, and flushed

Lungs

  • No egophony or fine crackles (rales); scattered coarse crackles present
  • Expiratory phase is prolonged with wheezes auscultated bilaterally
  • Diaphragm percusses low in the posterior chest with 2 cm; chest expansion is limited

Cardiac

  • No clicks or gallops
  • Tachycardia, regular
  • Notable slight systolic ejection murmur (SEM) at the left lower sternal border (LLSB) without radiation

Abdomen, Extremities, Neurologic

  • Capillary refill at 3 seconds, no clubbing, no edema; extremities clammy
  • Bowel sounds present, no hyperactivity; abdomen non distended
  • Liver percusses 2.5 cm below the right costal margin, but overall size 8 cm, no tenderness or masses
  • Cranial nerves intact; DTR 2 + and symmetric; sensory intact; strength 5/5 throughout

Preliminary Laboratory Results

  • pH- 7.48; PaO2- 70; PaCO2- 33 mm Hg
  • HCT- 33.0% and HgB- 7.2 g/dL
  • WBC- 7,680
  • PLTS- 246,000

Bedside Nurse Leader and SWAT RN Collaboration

The SWAT RN maintains closed-loop communication with the bedside nurse leader assigned as the primary care nurse for Mr. Salzo. The bedside nurse leader and SWAT RN discuss the patient’s time of initial decline, treatment approaches that were effective, and next steps. The SWAT nurse respectfully acknowledges the bedside nurse’s prior knowledge about the patient’s health history and recent health status change while modeling clinical judgment in managing the clinical case scenario.

General Outcome

Mr. Salzo complains of chest tightness. Intravenous access via Mr. Salzo’s right arm in the cephalic vein was secured. The bedside nurse leader inquires about potential allergen exposure and the use of methylprednisolone (Solu-Medrol) intravenously. The SWAT RN and team decided to assess the patient’s response to a bronchodilator. The SWAT RN administers Albuterol nebulizer treatments. An electrocardiogram (ECG) reveals sinus tachycardia (Figure 2.). The elevated white blood cell count (WBC) is suggestive of infection. A chest x-ray shows a large area of opacity in the right lung. A sputum sample is obtained and sent for culture and sensitivity. Blood cultures were obtained as well.

Admitted to the Medical-Surgical Unit with the primary diagnosis of asthma exacerbation and pneumonia, Mr. Salzo starts the intravenous (IV) antibiotic ceftriaxone (Rocephin) 1 gm twice daily. On day 2 of antibiotic therapy, a repeat chest x-ray reveals the presence of a mass in the right lung. Further diagnostic tests reveal that the mass is a malignant neoplasm. Mr. Salzo was diagnosed with lung cancer adenocarcinoma.

Education

The unknown or atypical presentations are the driving factors in bedside nurse leaders utilizing clinical judgment in the decision-making process to ramp patient assessment to the level of consultation before rapid patient deterioration occurs. Mr. Salzo’s diagnostic presentation appeared typical for asthma. However, his elevated WBCs suggested infection was present. The resolving pneumonia treated with IV antibiotic therapy revealed a malignant tumor mass, adenocarcinoma.

Adenocarcinomas typically proliferate within the cells that line the alveoli. According to the Centers for Disease Control and Prevention (CDC), in 2022, 50% to 60% of lung cancers were diagnosed in patients with no smoking history. The CDC noted in 2022 that 10% to 20% of nonsmoker cancers are squamous cell carcinomas and 6% to 8% small cell lung cancers. The CDC also noted that risk factors associated with lung cancer include family history, pipe smoking, cigarette and cigar smoking, beta-carotene supplements in heavy smokers, human immunodeficiency virus (HIV), and environmental risk factors. Mr. Salzo’s dual occupation as a carpenter and painter, both environmental risk factors, likely placed him at risk for the development of lung cancer. Wood dust can be inhaled and enter the airway and lung tissues, causing scarring and irritation. The paint contains benzene solvents that, inhaled, can lead to oral and lung cancers.

The National Council of State Boards of Nursing Clinical Judgment Measurement Model provides the nursing profession with a roadmap for enhancing critical thinking, clinical decision-making, and clinical judgment within the clinical setting. SWAT RNs, because of their advanced clinical practice experience and knowledge, effectively role model closed-loop communication and evidenced-based practice clinical interventions and provide clinical expertise “in live-time” to bedside nurse leaders during emergent patient cases.

Conclusion

Mr. Salzo, transferred to an oncology unit, begins cancer treatment. The bedside nurse leader provides him with education about his new diagnosis. His clinical presentation to the ED for an asthmatic exacerbation and the combined efforts of all healthcare team members have contributed to Mr. Salzo’s diagnosis and current implementation of treatment for lung cancer. The early involvement of SWAT RNs is instrumental in supporting bedside nurse leaders (and nurses in other settings) with the provision of rapid assessments and necessary diagnostics in ensuring the consistent delivery of evidence-based practice care for patients entering healthcare systems. In the 2020 article, Using Benner’s Model of Clinical Competency to Promote Leadership, Barry Quinn discusses the novice to expert level nurse in clinical practice. Because the SWAT RN is an expert level nurse, their role is essential in developing leadership and competency of bedside nurse leaders in recognizing patients with rapidly declining physiological problems. Hence, SWAT RNs’ roles are beneficial in promoting clinical judgment in bedside leaders at all practice levels (e.g., novice to expert).

PRIDE Month and Nurse Advocacy

PRIDE Month and Nurse Advocacy

Every June, the nation celebrates PRIDE Month and healthcare organizations can use the time to support and celebrate their LGBTQIA+ employees and patients. Whether you’re an LGBTQIA+ nurse, an ally, or someone who wants to learn more ways to offer support, this month encourages education, community, and celebration.

Anthony Pho, PhD, MPH, ANP-C, is a Propel postdoctoral scholar for The PRIDE Study at the Stanford University School of Medicine, and says nurses have the power to ask their organizations to be a welcoming and inclusive workplace. In doing so, nurses can be their authentic selves at work and patients will feel their health concerns are recognized, accepted, and heard.

Pho, who is also a board member for GLMA: Health Professionals Advancing LGBTQ Equality, says that anyone interested in how an organizations supports the LGBTQIA+ community simply has to run a quick internet search and see what comes up. In that space, a lack of information speaks volumes, so organizations want to make sure they foster an environment that’s inclusive in words and actions.

Luckily, the collaboration and organization that helps advance important initiatives and bring the community together is a specialty of many nurses. “Nurses are all about committees and organizing,” says Pho, laughing. “Whether that’s the next delicious potluck or recognizing service excellence, it’s built into the nursing culture to have a committee for something.” While nurses connect with each other this way, it also creates a powerful group. “It’s one way for nurses to engage with the larger hospital system,” Pho says.

Nurses can join committees for diversity, equity, and inclusion (many organizations also add justice to that list), to learn about and work toward issues impacting many groups and including LGBTQIA+ nurses. “That’s one way hospitals can advocate for and support LGBTQIA+ nurses and patients from an equity point of view,” says Pho. “And making sure LGBTQIA+ and other groups are mentioned from an equity point of view is a first step.”

Organizations that have advocates who publically endorse and advocate for LGBTQIA+ issues and concerns are essential, says Pho. “The public part of that support is really important,” he says. “It’s important that the leadership all the way to the top provides that support.” Ideally, that means employees are able to show public support for LGBTQIA+ issues and therefore, colleagues and patients, and the top leadership of the organization has done the same–preferably through a medium like a video.

“When you see the dean of an institution or the leaders at the top of an institution making a public statement, that’s very powerful,” says Pho. And a visible statement is something that nurses can use to refer back to when they want to advocate for LGBTQIA+ issues. PRIDE Month is a great springboard for that statement.

Nurses may also look into the Healthcare Equality Index (HEI), which is “the national LGBTQ+ benchmarking tool that evaluates healthcare facilities’ policies and practices related to the equity and inclusion of their LGBTQ+ patients, visitors and employees.” The HEI, says Pho, is the teeth behind any kind of health equality program as it offers evidence and evaluation on how organizations can become leaders in many areas.

And when organizations bring folks together for advocacy work, a mindful approach is needed. “It’s important to tap someone interested in health equity and then invite others who are representative of your organization,” says Pho. “That’s the key to amplifying those voices.” He notes that relying on underrepresented employees and making them responsible for DEI initiatives is detrimental as it is not only on their shoulders–it is an organization-wide responsibility and interest.

Nurses can also join organizations such as GLMA which will hold a GLMA Nursing Summit 2022 and has resources and connections in the GLMA Nursing Section.

Support and action are the key to helping promote issues throughout the year, not just during PRIDE Month. “If you want to change the universe,” says Pho, “you have to show up to the table.”

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Clinical Nurse Educator Irma Teune

Clinical Nurse Educator Irma Teune

As part of National Nurses Week, Minority Nurse is exploring the many paths nurses take to find a career where they feel like they are making an impact.

Irma Teune, BSN RN MSCN CCM is a bilingual clinical nurse educator with Horizon Pharma where she educates patients and families about chronic granulomatous disease (CGD), a rare primary immunodeficiency disease in which the body is especially susceptible to infections from bacteria and fungi.

As frightening as it is to learn you or a loved one has CGD, it can be even more difficult to understand when your primary language is different from that of your medical team. Teune’s ability to speak comfortably in Spanish and English means she can put her patients at ease while giving them the exact information and guidance they need to manage the disease.

Minority Nurse asked Teune some questions about her career path and how she is making a difference as a nurse.

1. How did you discover the field of nursing was right for you?

Like most people who pursue a nursing career, my primary passion is helping people living with chronic illness – and for me, my sister inspired this desire in me. When I was 27 years old, she was diagnosed with multiple sclerosis. It was an overwhelming time for our whole family – I received many questions from my family and her husband concerning her diagnosis and treatment since I was a registered nurse. The more I became involved with my sister’s health, the more I understood the perspective of family members of people with chronic diseases, and how the lives of caregivers are often just as impacted as the patients. I recognized the effect a caring, understanding nurse could have on patients, as well as their families, by playing that role within my own. I wanted to be part of that positive impact for patients and their families!

2. What led you to becoming a clinical nurse educator?

I first became a CNE for an MS therapy – because for me, it really was personal. I was very knowledgeable in MS diagnosis and treatment, so it was a natural fit for me to move into this role. After about six years, I was looking for a change and pursued an opportunity with Horizon Pharma. I’m now part of a support program for people who are prescribed Horizon’s therapy for chronic granulomatous disease (CGD), a primary immunodeficiency that only 20 children are diagnosed with in the U.S. each year.

For families impacted by this rare disease, it can be difficult to find a healthcare provider that is familiar with the disease, which only increases their fears. And their fears usually stem from not knowing what to expect next or how to manage the condition. That is why educating these patients and their families about CGD is so rewarding for me – it’s the first step to helping them become confident in handling any challenges that may come their way. I not only help patients manage their treatment plan, but also ease some of the burden that comes with being a caregiver. For example, my patients and their families can contact me with any issue—whether it is an insurance question, or a concern about the patient’s health, I will look into the matter and connect them with the right resources. I love it.

3. As our global community becomes increasingly smaller, many people may receive treatment in a place where they do not speak the primary language. How does that barrier impact everything from their ability to decipher a care plan to their hope for a good outcome? How is that magnified when the diagnosis is complex or a rare disease?

For any patient, it can be difficult to understand the complexities of their health and the healthcare system, as well as find the resources to support the best possible outcomes. These issues are further complicated when you are not a native speaker of the language of where you are being treated, as clinical details and context can get lost across multiple channels of communication. Language barriers also inhibit the trusting and positive relationship between the patient and provider that is so important for effective treatment.

For patients with a rare disease like CGD, because the affected community is so small, basic information is relatively limited – even in English. That’s why it’s so helpful for patients to have someone in their life who can talk knowledgeably about their disease in their language. Speaking to someone in his or her own language breaks down the walls that surround them and helps minimize the barriers they face in accessing and understanding their therapy. Even better – it provides them assurance and confidence that everything is going to be okay.

4. As a bilingual CNE, how do your experiences with patients help elevate the work you do? How does it help the patient and the families who are affected by diseases?

As a bilingual CNE, the obvious benefit is that I can communicate with Spanish-language patients in their native language. This helps ensure they are able to successfully adhere to their treatment plan. Additionally, I can help identify issues related to a patient’s or caregiver’s cultural needs. With the trust I’m able to build with my patients and families, they’re able to fully express questions or concerns, and I can ascertain their level of comfort and comprehension in managing their condition, avoiding further difficulties down the road.

Most importantly, I can be more effective in giving patients and families the reassurance they need. Imagine a patient or family member is worried about their treatment coverage or health, and hears, “Hola, como estas,” when they reach out for help. Or, when I give a patient the confirmation that everything is going to be okay, “Todo saldrá bien.” It’s these nuances that can make all the difference for a patient’s or caregiver’s treatment experience. And I love bringing this insight and experience to my broader CNE team. My colleagues and I work so closely that to be able to share the experiences of our bilingual patients feels like an honor.

5. What gives you the greatest joy as a nurse and what is your greatest challenge as a nurse?

As a Horizon CNE, I support my patients for as long as they are taking CGD medication, which for many, can be for life. Even when patients do feel confident with their treatment plan, or when children gain more independence, I am always available for help and to answer any questions. One of the most rewarding parts of my job is seeing a patient grow, and not just in their disease management. CNEs often play a role for every important milestone, from a child’s first day of school to teaching a college student how to inject their medication on their own. We get to know our patients on a more personal level, and are able to share in their accomplishments and joys as well.

Rare diseases can be difficult for even the most experienced doctors to diagnose. Likewise, with CGD, it can be confused with other inflammatory or infectious diseases, as they share many of the same symptoms (such as fever, tiredness, abdominal pain, weight loss, swollen lymph nodes, etc.) Unfortunately, by the time these patients are correctly diagnosed, they are often exhausted and scared. Sometimes patients and their families feel dismissed by the healthcare provider’s inexperience in CGD to be able to recognize the condition or its severity. As a result, when I reach out to a new family, they may be wary or tired of their journey and not being heard by the clinical community. As I only work with CGD patients, the condition is basically my whole life; I work hard to assure these families that I understand and can validate their struggles, and that I will help them in any way that they need me.

6. If others are thinking of a career as a CNE, what kinds of education, experience, and expectations might they have?

As a CNE, you need to be just as passionate about educating patients and their families as you are about listening to them. For most people living with a rare disease, the journey to diagnosis can be long, arduous and lonely. Some patients dive into research when they are diagnosed, and others take more time to process everything, so I always let them share what they are going through to determine how I can best educate them.

It’s important to allow patients to share their thoughts and feelings, and to hold their hand through the experience and acceptance of their condition. It’s this openness and transparency that is so critical to improving treatment outcomes, and helping patients get the most out of the services I can provide.

7. What will you reflect on during National Nurses Week?

This National Nurses Week, I will be reflecting on how rewarding it is to watch patients and caregivers develop from uncertain newcomers to advocates for the rare disease community. While I only work with the same 50 or so patients, I know that the impact I have on their families’ lives is far-reaching.

For example, I recently met with a young man who is preparing to go to college to teach him how to inject and responsibly take care of his medication, helping him gain more independence. Additionally, one of my newer patients is a six-month-old child. I met with the child’s grandparents and guardian, who were understandably very nervous and worried for the child’s well-being. Seeing them more positive and hopeful at the end of my education session reminded me again of why I love what I do. Reflecting on my patients’ successes and growth fills me with pride, and reminds me of my own accomplishments in my career.

 

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