I am now in week #7 of the program, almost halfway through the orientation process, and it has been everything I wanted from nursing school and so much more. The time and talent that is being invested in me and my cohort is immeasurable. There are days where we feel like we’re back in school with lectures, PowerPoints, and exams. Then when we are on our various units—not as students or helpers, but as the actual nurse giving patient care and putting our critical thinking to work—all the sacrifices, the long hours studying, the lack of sleep, and the chaos of interviewing is worth it.
No week is exactly identical, which is good since no day on the unit will be an exact carbon copy of the previous day. Each clinical experience takes us from novice and advanced beginner to competent and proficient on our journey to expert.
The program lasts a year but is divided into two portions. The first 16 weeks are orientation. We are assigned one acute care unit and one critical care unit. My cohort of 13 was given five acute areas and four critical areas to choose from. We are each assigned preceptors. Under the guidance of clinical nurse specialists (CNS) and the managers we prep for final placement, which will come at the end of week 15 to 16.
So if you think the interviewing is done, it’s not. The units we transfer to will hold interviews and we will be officially and permanently placed by the end of orientation. I 90% love it, 10% hate it. I love it in that I am getting multiple experiences on various floors and working with many different nurses. I am gaining a well-rounded history that will forever play a role in my role as a nurse. I hate it in that I have to decide which one unit to make my home. I wasn’t one of those students that only had their eye on one specialty and closed the door to all others.
So here is how my weeks have been going so far.
Week One: Getting to know you
During this week our cohort met each other for the first time. We spent this week expressing relief to be in the program and excitement about unit placement and giving patient care. Each eight-hour day, our minds are filled with policies, procedures, maps of the facility, and training on computers and equipment. We are shown the online learning center that contains all the learning modules we must complete in 60 days. By the end of the week, we are mentally exhausted from the large quantity of information but eager to put our new licenses to work.
Week Two: Getting to know your unit
During this week we spent four glorious days on our assigned units and worked as nurses for the first time. Under the supervision of a preceptor, we actively engaged in patient care, getting to know the unit and becoming comfortable with our new positions. We call the physician, the pharmacy, or the family. We spend this week getting comfortable with the fact that we are the nurse and all that being a nurse truly means.
Week Three: Getting to know the fundamentals, again
This week is split into clinical days on the unit and classrooms days. Clinical nurse specialists speak to us on topics from patient safety and satisfaction to palliative care and medication safety. Patient and family-centered care along with the professional role and practice model are reviewed constantly. On the unit the preceptors are allowing us to care for 1-2 patients independently using them as resources as we practice time management and delegation.
Week Four: Building on the foundations
We are now a fourth of the way through orientation and this week is divided into more classes with a couple of days on the unit. The topics this time around cover vascular access, infection prevention, and isolation practices to pressure ulcer prevention, ostomy care, and glycemic standards. Some of the cohort will work their first weekend and others will loop or have a day visit to a different unit, such as the operating room or the emergency department.
Week Five: Practice makes perfect
This week is full of nothing but clinical days. We are thankful for the break from class time and are glad to get back to patient care. As we are getting to know the interdisciplinary team and our unique patient populations, we are also being evaluated by the CNS assigned to our units along with our managers and preceptors. We’re starting to feel the crunch of wanting to take on more (3-4) patients, being confident when using SBAR, and completing those ever-present learning modules.
Week Six: More certifications, more practice, more of more
It is back to two clinical days and two classroom days. ECG, stroke, bariatric patients, trauma, and more medication safety are on the agenda. We are notified that we will have to take an ECG exam in a few weeks and it would behoove us to do as many practice problems as possible. We are also encouraged to get our NIH stroke certifications, sooner versus later, and be prepared to move through all phases of the certification process.
Week Seven: Back to school
More ECG, looping experiences, learning modules, and clinical days. Time has passed quickly and after week eight we will transition to the next unit assignment. While preparing to say “see ya later” to our first unit stop, we are given study time to prepare the approaching ECG exam that requires 80% or better. We are all feeling the pressure of wanting to do well on everything and be perfectionists. We’re using our Reflective Learning time to process, decompress, and recess from our growing schedules and learning experiences.
Week Eight: Preparation for the next phase
This week will entail three clinical days and a classroom day. The ECG exam will be administered at the end of the day. The expectation is that we are consistently caring for 3-4 patients and growing in confidence in our skills and nursing judgment.
When I post again, I will have transitioned to my new unit, passed my ECG exam, and finished all my learning modules. Hopefully, I will have decided just where this new grad wants to make her first stop on her nursing journey.
Chapter one, part two is about to begin and I am excited. In three weeks I will begin the nurse residency program and take a step closer to my fulfilling my lifelong dream of being a nurse. Last month I received the coveted phone call from a facility I had applied to. After a long telephone interview and two panel interviews that spanned three months, I was offered a position in their nurse residency program.
So, you might be asking, why part two? Well, nursing school was part one—and it was a challenging but rewarding time in my life. And something tells me this new adventure I am about to embark on will be even more so. I haven’t even gone to orientation yet, and drug tests, immunizations, vaccination checks, and a host of other fun human resource activities are keeping me busy until the big day.
For those who do not know what a nurse residency program is, it is a bridge that takes the newly graduated nurse and aids in the transformation into a confident practitioner. The programs vary from state to state, with some being offered by schools of nursing or health care facilities. The length of time can also vary. I have heard of programs being as small as sixteen weeks to larger programs stemming an entire year.
Nurse residency programs are not to be confused with New Grad RN positions, even though both are paid positions. In the New Grad jobs, the nurse is hired on to a particular unit, trained, and expected to become a part of that health care team. Nurse residency programs work similarly to a medical residency where the candidate is moved around to various units, gaining exposure and experience. At the conclusion of the program, the candidate interviews with the unit where there was a potential “right fit” and if all goes as planned, this area becomes their specialty.
I have heard many a conversation about individuals not content where they are working because of various reasons: needed a job right away; family members work there; or nothing else was available. The last thing I want to do is have my very first registered nurse position be a disaster.
The goal of nurse residency programs is to give new nurses the opportunity to be exposed to true nurse life while they are gaining skills. The once-a-week experience from nursing school only goes so far. Many facilities institute these programs to aid in increasing retention rates of the newly trained nurses and allow them the time to develop their competence, communication skills, and become satisfied in their work.
The residency program I am starting lasts sixteen weeks, where you spend at least 4 weeks on at least two units. A new resident can spend up to 8 weeks on a unit and then switch to another one. One unit is acute care and the other is a progressive care unit. Choices range from oncology, orthopedics, and medical-surgical to trauma/neurology, transplant, and cardiac medical-surgical. The program runs like school where novice nurses are matched with preceptors on a regular work schedule and at the end of the shift, the cohort gets together in a post-conference meeting to discuss their day and what they are learning.
Along with learning the units and the facilities’ policies and procedures, new nurses participate in simulations with “live” mannequins that make breathing sounds, bleed, deliver babies, and go into codes. There will be special classes to brush on ECG and pharmacology. And yes, there will be an Evidence-Based Practice project that will have to be completed. Now we’re really sounding like nursing school. I’ll pause to say this: nursing is a lifetime of learning. So if you think you’re done with school after you get your pin and take NCLEX, think again.
At the eleven to twelve week point of the program, the interviews start. This is particularly important because you want to get picked up by the unit you worked on. Once the decision is made, at the fifteen to sixteen week mark the new nurse transitions into their new unit permanently, and the position takes on the expected look of a new graduate position. There is a small graduation of sorts upon completion. Those that have been through the program are not saying much to me about this. I have a feeling it must be truly spectacular because everyone that has gone through the program are still working on their units, still happy and still smiling.
I am eagerly counting down the days. I enjoyed my clinical rotations while in nursing school, so much so that if someone asked me what I wanted to do it was always that unit I happened to be working on. I just loved everything, with the exceptions of oncology, mental health, and pediatrics. Those areas were not at the top of my lists to start my nursing career. So I’ll be spending these last weeks, my vacation, reading, resting and reviewing for this new chapter in my life. Let the adventure continue!
Kimberley Ensor is a new grad RN from SDSU, a published author, and is currently earning her Masters in Nursing with an emphasis in teaching. Visit her blog http://nursekimberley.blogspot.com/ or follow on Twitter @KimEnsorRN
According to the U.S. Department of Veterans Affairs (VA), approximately 20% of our nation’s 23.5 million veterans are people of color. Like other racial and ethnic minority populations, minority veterans face a variety of unique health care challenges, ranging from chronic disease disparities and high levels of post-traumatic stress disorder (PTSD) to difficulties in accessing medical treatment.
Testifying before the House Committee on Veterans Affairs in July 2007, Lucretia McClenney, MSN, RN, director of the VA’s Center for Minority Veterans (CMV), noted that “in many instances, any challenges that minority veterans encounter as they seek services from VA are magnified by the adverse conditions in their local communities. These challenges may include [lack of] access to VA medical facilities (especially for American Indians, Alaska Natives, Pacific Islanders and other veterans residing in rural, remote or urban areas), disparities in health care centered on diseases and illnesses that disproportionately affect minorities, homelessness, unemployment, lack of clear understanding of VA claims processing and benefit programs, limited medical research and limited statistical data relating to minority veterans.”
The CMV’s mission is to identify barriers to service and health care access, increase local awareness of minority veteran-related issues and improve minority participation in existing VA benefit programs. As a result, VA medical facilities throughout the country are implementing strategies to provide veterans of color with more accessible, culturally sensitive care. Each VA health care facility has a Minority Veterans Program Coordinator (MVPC) who serves as a liaison and advocate for minority patients. And VA health care professionals are taking the lead in developing innovative solutions for closing the gap of health disparities, from outreach programs designed to increase minority veterans’ use of services to diversity training programs aimed at increasing staff members’ understanding of patients’ cultural needs.
Not surprisingly, nurses are playing key roles in these efforts. Here’s a look at how individual nurses are working to improve health outcomes for minority veterans, one program at a time.
Native American Outreach
Bruce Kafer, MSN, RN, is a member of the Oglala Sioux (Lakota) Tribe that resides on the Pine Ridge Indian Reservation in South Dakota. Adopted as an infant by white parents, he grew up with virtually no knowledge of his tribal culture. After tracking down his birth mother in 2000, he began to learn about his lost Indian heritage from his Tiospaye (Lakota extended family) and tribal elders. Now, as American Indian/Latino Outreach Coordinator at the Louis Stokes Cleveland (Ohio) Department of Veterans Affairs Medical Center, Kafer is drawing on his rediscovered heritage to provide culturally sensitive healing to Indian vets.
The Changing Face of Minority Veterans When you hear the term “minority veteran,” what image comes to mind? First of all, it would probably be a person of color. The person you visualize is also likely to be male, and perhaps even an older man who fought for his country in a historic conflict like World War II or the Vietnam War. But in recent years, the traditional profile of minority veterans has begun to expand and evolve. Patients from other types of underrepresented populations are becoming a growing presence in the VA health care system, bringing with them a whole new set of unique health challenges and needs. While women may not be a group that comes to mind under the “minority” heading, female veterans are definitely a minority within the VA system, says Jacinda Beug, BSN, RN, who works in the Women’s Health Program at the Southern Arizona VA Health Care System in Tucson. The program, along with its outlying clinics, treats about 5,500 women annually, providing primary care, prenatal care, gynecological and obstetrician services. Many of these patients are veterans of Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). In 2003, says Beug, 6% of America’s 23.5 million veterans were women. Today that figure is 7.4% and is expected to climb to 8.7% by 2013. “We were noticing that [within the overall population of veterans coming back from Iraq and Afghanistan], women had their own specific concerns and needs,” says Norma Hernandez, RN, manager of the medical center’s OEF/OIF Transition Program. These special concerns include mental health issues, post traumatic stress disorder (PTSD) and sexual trauma. The Women’s Health Program focuses on providing gender-specific care, and it has an all-female staff—including doctors, nurses, receptionists, clerks and dietitians—to make the patients feel more comfortable, says Beug. Another new “minority” group to surface within the VA is the young veteran. “[Because of OEF/OIF], many younger veterans are coming into the system. We’re treating age groups ranging from 17 and 18 up to 90,” Beug says. Hernandez agrees that the younger patient population within the VA medical system has become a minority group with its own set of specialized needs. The VA is used to serving older veterans, she explains, and is now having to adapt to these younger vets’ needs and develop different treatment modalities to meet them. This is an example of how the VA is constantly evolving, creating new programs and services as specific needs arise, Hernandez adds. For awhile, the special needs of Vietnam veterans were the catalyst for new programs. But now OEF/OIF is bringing in a new special-needs population of combat veterans. The percentage of OEF/OIF veterans in the VA system right now is less than 5%, says Hernandez, but that figure is misleading. Military personnel serving in OEF/OIF are predominantly reservists and National Guard troops who bounce between two different roles. They are activated, come home, are discharged into the VA system, but then can be reactivated back to active duty. “That creates a variety of issues and concerns we need to keep abreast of,” she says. “Their situation keeps fluctuating. It used to be you did active duty, were discharged and then became a veteran.” The unique combat injuries suffered by OEF/OIF veterans, such as those caused by improvised explosive devices (IEDs), are also creating a whole new set of challenges for VA nurses, says Dianne Lethaby, RN, CRRN, Polytrauma Nurse Case Manager at Southern Arizona VA’s Polytrauma Network Site. The site is one of 21 facilities in the nation designed to provide long-term rehabilitative care to veterans who experience severe injuries, including traumatic brain injury, hearing loss, amputations, fractures, burns and visual impairment. The Tucson Polytrauma Network Site, which treats about 320 veterans from Arizona, Texas and Colorado, operates clinics that give patients access to a medical provider, social worker, speech/language pathologist and psychologist, all in one visit. If time permits, the clinics will try to fit in sessions with physical and occupational therapists. “Essentially, [the younger veterans] want to get back and get on with their lives. They’re young and have families to support,” Lethaby says. “It’s been a challenge getting them into the system.”
Kafer, who works with Native veterans both in Cleveland and in Arizona, is also a PhD student at Case Western Reserve University in Cleveland, where he is conducting research with Indian vets to add to the limited body of knowledge available about this population. Through his research, he has discovered some compelling statistics about Native Americans who have fought for their country. During World War II, for example, 40% of the Cheyenne Nation volunteered service to the U.S. military. During the Vietnam War, 90% of eligible Cheyenne volunteered for duty, with the overwhelming majority serving in combat areas. Yet despite this long-standing history of service, Native Americans have historically underutilized VA services, Kafer says.
“Part of my role,” he adds, “is to help bridge that gap and make services more accessible.” To accomplish this, Kafer does outreach to the American Indian community, participating in powwows and other cultural events, visiting reservations in remote locations and working with Native veterans and elders from a variety of tribes to develop culturally appropriate programs.
There are about 562 federally recognized Indian tribes in this country and 365 state-recognized tribes, each with their own unique cultural traditions and, in many cases, their own indigenous languages. Therefore, VA nurses who work with Native veterans often find themselves treating a patient population that is not homogeneous but highly diverse—a concept Kafer calls “diversity within diversity.” Still, he says, while culture and language may differ from tribe to tribe, there are some basic beliefs about health, illness, healing and spirituality that are common to all Native people.
“In traditional Native American culture, health and healing begin first in the spirit, then the mind, then in the body,” he explains. “In the Western model of health care, it’s an opposite paradigm—health and disease begin first in the body, then in the mind, last in the spirit.”
Kafer won an award from the Society of American Indian Government Employees (SAIGE) for a VA diversity training video he helped produce, called “Native America: Diversity Within Diversity.” Created as part of the VA’s R.E.A.C.H. for Diversity program, the video has been distributed to all VA medical centers nationwide to increase employees’ understanding of the unique challenges Indian veterans face.
“Native America resonates with me and my history,” Kafer says. “I’m in a unique position to contribute to improving health care for Native American veterans because I understand about bureaucracy, government and the various phenomena that can impact tribal access to health care.”
Kafer is also involved in another innovative diversity training project, the Gathering of Healers program at the Southern Arizona VA Health Care System in Tucson. The program brings the facility’s staff together with Native veterans and elders to learn more about American Indian culture and how to provide culturally competent care.
“Staff come back from the Gathering of Healers and are more aware of the special needs of this [population],” says Yvonne Garcia, BSN, RN, the facility’s American Indian Nursing Case Manager. “They learn to treat people with cultural humility. They want to know more about them instead of making assumptions.”
Garcia, who is part Mandan Indian, also works with the Indian Health Service to complement services delivered to Native veterans.
Researching Health Disparities
Carol Baldwin, PhD, RN, CHTP, CT, AHN-BC, associate professor and director of the Office of International Health, Scientific and Educational Affairs at Arizona State University College of Nursing and Healthcare Innovation in Phoenix, is a nurse researcher who has focused some of her recent work on studying chronic disease disparities in Mexican American veterans, a population about whom very little health information is available. She led one study which found that, compared to non-Hispanic white veterans, Mexican American veterans were significantly more likely to have diagnosed type 2 diabetes and that having a high body mass index (BMI) put them at greater risk of developing the disease.
More recently, Baldwin published a study in the September 2007 issue of the Journal of Nursing Scholarship that compared homocysteine levels and other stroke risk factors between Mexican American and Caucasian male veterans. High homocysteine levels in the blood have been associated with increased risk of cardiovascular diseases, such as coronary heart disease and stroke.
Baldwin conducted her research in Tucson at the Southern Arizona VA Health Care System’s Minority Vascular Center. She found that Mexican Americans have higher homocysteine levels regardless of whether they scored a high or low risk for stroke. She also determined that the Framingham Stroke Profile, a commonly used stroke risk assessment tool, was derived for a predominantly Caucasian population and does not necessarily provide relevant stroke risk factors for people of other races and ethnicities.
Baldwin says her findings suggest that Mexican American veterans, like other minority populations, face barriers to stroke prevention and therapy, including lower income and education, as well as dietary, genetic and environmental factors.
There has also been very little research conducted on the health care needs of Puerto Rican veterans, says Constance Uphold, PhD, ARNP-BC, FAAN, a research health scientist with the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville. Her current work focuses primarily on the health challenges experienced by Puerto Rico veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).
In one study, Uphold—who has a master’s degree in transcultural nursing and a doctoral degree in family health nursing—examined mental health issues affecting Hispanic veterans and their caregivers and families. She documented stressors from each group’s perspective, as well as successful coping models. Based on her findings, Uphold and her colleagues developed 12 culturally competent fact sheets for veterans, family members and clinicians. These educational materials are tailored to Puerto Rican veterans, complete with colors and symbols from the Puerto Rican flag. She’s now working to secure funding to reproduce and disseminate the fact sheets.
This past February, Uphold became a co-investigator of a grant that will research stroke interventions and family caregiving for Hispanic veterans, as well as how to disseminate stroke prevention information to this population. The Spanish-language information will be posted on MyHealtheVet.com, an interactive Web site that encourages veterans to take charge of their own health.
Promoting Health Literacy
Teaching minority veterans with chronic diseases how to self-manage their conditions is also a priority for Jawel Lemons, RN, MS, FNP-C, associate director of Patient Nursing Services at the Charlie Norwood VA Medical Center in Augusta, Georgia. Lemons remembers watching her own father struggle with his health. The man who raised her had a third-grade education and couldn’t read the directions printed on his medicine bottles.
“I thought, ‘If he wasn’t living with me, what would he do?’” she says. “That’s when I came up with the idea for the labels.”
The “labels” in question were part of a highly successful health literacy program Lemons created and implemented at the Dallas VA Medical Center in Texas before transferring to her current position in Augusta last year. As a cardiology nurse practitioner in the medical center’s congestive heart failure clinic, she often received referrals from primary care providers for patients who appeared to be noncompliant with their medications. Assessing the situation, Lemons discovered that the real reason why the veterans weren’t taking their medicine was that they had low literacy levels and couldn’t understand the instructions printed on their prescription labels.
So she designed a protocol for teaching her low-literacy patients how to take their medications correctly, using pictures instead of words. She found colorful, easy-to-understand computer clip art symbols, copied them onto adhesive labels and stuck them on the patients’ medicine bottles. For example, a rooster pictured with a sunrise symbolized a morning medication, while a bed indicated a nighttime medication. Lemons also transferred the same symbols to the patients’ pill boxes. As a result, the patients’ health improved dramatically.
VA Travel Nurse Corps
Her current goal is to establish special needs clinics across the VA system, with physician consults on site and nurses who are trained to make sure medications are properly labeled. She also hopes the concept of using picture labels will catch on with pharmacies.
Another way Lemons is empowering minority veterans to take control of their health is by providing them with culturally relevant dietary guidelines. “A lot of our [patient education] information is geared toward the average [majority] American, but there’s not much on the different cultures,” she notes.
Suggested menus for a low-salt diet, for example, are usually designed with Caucasian patients in mind and don’t always address the foods that African American or Hispanic patients may include in their regular diets. Lemons provides her patients with the general list of approved foods, but she also offers additional food lists that take into account a patient’s particular culture.
This is another example of how minority patients can be labeled as “noncompliant” when the real problem is that they simply could not overcome cultural barriers to their care, Lemons emphasizes. “If they don’t understand how to eat and take their medicine, they’re not in control of their ailment,” she says. “It really impacts the cost of health care when you have people who end up in the hospital over and over because they just don’t understand what they’re supposed to do.”
One of the Department of Veterans Affairs’ newest initiatives for increasing minority veterans’ access to culturally sensitive nursing care is the VA Travel Nurse Corps (TNC). Designed for RNs who prefer the flexibility and adventure of travel nursing, this program will establish an internal pool of nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The TNC deployed its first nurse in December 2007.
Jacqueline E. Jackson, RN, MS, MBA, director of the TNC, says the new program is actively recruiting nurses from culturally diverse backgrounds. “[Minority] VA nurses bring not only cultural competence but respect and acceptance to the many culturally diverse patients under VA care,” she explains. “Nurses in the VA Travel Nurse Corps have an opportunity to travel the country working with a diverse VA patient population and a diverse VA workforce.”
For more information about the VA Travel Nurse Corps, visit www.travelnurse.va.gov.
Who Are Today’s Veterans?
Estimated U.S. Veterans Population: 23,532,000
Number of Total Enrollees in VA Health Care System (FY 2006): 7,900,000
Veteran Population by Race:
White Non-Hispanic 80%
Black Non-Hispanic 11%
Veteran Population by Gender:
Percentage of Veteran Population Age 65 or Older: 39%
Source: Department of Veterans Affairs, October 25, 2007
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