As the opioid epidemic continues to grow throughout the nation, it’s not surprising that this kind of addiction, as well as others, can also affect nurses. If you’re a nurse in New Jersey and have a problem with addiction, however, there’s a treatment program specifically designed to help you.
Established in 2003, the New Jersey State Nurses Association (NJSNA) Recovery and Monitoring Program (RAMP) has helped more than 2,000 impaired nurses since its inception, says Terri Ivory, RN, MSN, Director of NJSNA. “RAMP is the only program for registered nurses and licensed practical nurses of its kind contracted through the Board of Nursing,” explains Ivory. “RAMP is important because it supports impaired nurses and protects their licenses so they will be able to work again with monitoring once they have completed evaluation and treatment. What makes the program special is that nurses are taking care of nurses who understand the challenge of being a nurse.”
Ivory agreed to answer questions about the program. Following is an edited version of our interview.
Tell us about RAMP.
The goals of the program are to provide safety to the public though early detection and monitoring, reduce the time between identification and treatment, and provide a process for the nurse to recover that is non-punitive and non-public.
Entering the RAMP program, which is voluntary, protects the nurses’ licenses. While in the recovery phase, the nurses’ licenses may become inactive, but not revoked, which protects the licenses. The licenses can be re-activated once the process is completed and the return to work is issued.
How does it work? Is it a rehab/detox? Do you provide counseling?
RAMP is a recovery and monitoring program, which means it makes referrals for treatment, detox, and counseling. It is not rehab and detox nor does it do counseling.
The RAMP process includes evaluation, toxicology screenings, referral for treatment, weekly peer support group meetings, monthly reports, check-ins, monitoring, and a return to work process. There are peer support groups that RAMP participants must take part in during their time in the program.
Are all nurses accepted into the program? Do they need to apply? Does their employer get notified?
All RNs and LPNs practicing in New Jersey are eligible for the program and can be self-referred or referred by their employer or the public (such as family, attorney, friend). After a nurse self-identifies or is referred to RAMP, the first thing that happens is an evaluation process, which includes a psychological evaluation and random toxicology testing that can take up to 90 days. Nurses must check in with RAMP every day during the evaluation phase. During this time, the nurses do not need to disclose to their employers that they are in the program.
After evaluation, the nurse will get recommendations—whether to stay in the program or discharge—based on the results of the evaluation. If it is recommended a nurse stay in the program, the nurse must disclose the program participation to her/his employer.
Participation in the program may last up to five years.
RAMP notifies the New Jersey Board of Nursing (NJBON) as soon as the referral comes in, and the NJBON works with RAMP throughout the process. Dialogue with NJBON happens every two weeks or more often as needed. If nurses do not comply with recommendations, they are discharged from the program and reported to the BON.
It is within the nurses’ scope of practice to report fellow nurses.
Do the nurses pay for the program or is it covered by insurance?
Insurance does not pay for the program itself, which includes lab fees, evaluation fees, peer group fees, and therapist fees. All fees must be paid up front.
Hard medical costs, such as a lab fee or therapist, might be covered by medical insurance.
If they complete the program, how do they get back to working as a nurse? What tends to happen?
During their time in the program, a return-to-work program is implemented. Sometimes there are restrictions on work hours (no overtime), medication administration, and on specialty or place of employment. Nurses are monitored while they are working and monthly reports are sent to RAMP. Monitoring can be done for up to 5 years. Upon return to work, the only person that knows about the nurses’ participation in RAMP is the potential supervisor and human resources.
What have your outcomes been?
The overall success rate of the program is 60%. There are a total of 607 nurses in the program as of October 31, 2017: 493 nurses being monitored, 27 in intake stage with 23 monitoring out-of-state with 36 peer support groups, and five mental health groups. Two hundred thirty participants have been discharged as of October 31, 2017.
The most important thing for nurses to know is not to be afraid to report, either self-reporting or peer reporting. This helps close loop and gets the nurse the help they need. The main goal of the program is to have nurses to practice safely, protect the public, and protect the nurse.
RAMP has a 24-hour hotline for questions: 800-662-0108.
If you had to choose the place you’d like to be in during the holidays, most likely it wouldn’t be the hospital or a skilled nursing facility/rehab center. But for many patients, that’s exactly where they are.
Nurses are compassionate, so it makes sense that you would try to keep them feeling happy and cheery when they’re with you. We asked nurses for some tips on how to do it best. Here’s a sampling of what they had to say…
“I decorate the Christmas tree and make the patients part of the process by having them make ornaments in their art therapy. By placing the tree in a common area, I hope to give them a feeling of being home.”–Luisa Vega, DNP, PMHNP-BC, AGPCNP-BC, Psychiatric Nurse Practitioner at River Oaks Treatment Center.
“In most cases, Chanukah and Christmas are extra special times of the year for children. And most adults treasure December holiday childhood memories: dressing up in special clothes, lots of cookies, decorating the house, being in awe of shining lights, and, depending on the family, observing religious traditions. For children with chronic conditions or in hospice care, December can be a lonely, difficult, and anxious time. Many parents of my patients are unsure of what to do: I encourage my families to celebrate and encourage friends to join in. My colleagues and I call it ‘party at the bedside.’ Best of all, you can do it any time of the day or night—whenever the patient feels best, is most alert, and tends to be in the least amount of discomfort.”—Kate Dunphy, RN, Pediatric Hospice Nurse Case Manager, MJHS Health System.
“I talk to patients and ask about their family and any traditions they usually keep for that particular holiday. I also share some traditions my family has during the holidays.”–Maria Camacho, BSN, RN, IU Health West Hospital.
“We should be more kind and positive and lend an ear when they express concerns about not being with their families during the holidays. Just making sure we smile when greeting them or passing them in the hall can make a big difference. Being a patient during the holidays is extra hard because they are doing the right thing by being here, but also feeling bad about not being at home with their children, spouses, family, etc. I think incorporating extra fun activities and bringing special treats during holidays is great, and we do that here at River Oaks.”– Diana Nelson, BSN, RN, Staff Nurse at River Oaks Treatment Center.
“I ask patients about their family and traditions, and if family is coming to visit. I also draw a holiday-themed design on their Styrofoam cups and dry erase boards. Sometimes I’ll even print a holiday sign, color it and hang it in their room.”–Monaca Gentry, RN, IU Health West Hospital.
“For Christmas, I buy a box of cards and candy canes for my tech and me to sign and give to our patients. If a patient is diabetic, I make sure to give him/her sugar-free candy canes.”–Dickie Smith, RN, IU Health West Hospital.
“Nurses often work over the holidays, sacrificing time with family and friends to serve patients and their families. The best way to keep patients in good spirits over the holidays is by making sure the patient care team is in good spirits. At IU Health West Hospital, we offer a complimentary meal to working team members and their families on major holidays to show our appreciation.”–Lisa Sparks, chief nursing officer, IU Health West Hospital.
“I try to make my presence known especially during this time of year, because it goes along way when someone is not able to be with their family. I always try to be a good listener and allow them to plan what they will do differently next year with new sober life, while keeping the thought of being in treatment positive.”–Theresa L. Brown, RN, Director of Nursing at Solutions Recovery Treatment Center.
“For the patients with us over the holidays, we plan a Skype visit with the patient’s family if they were out of the area and unable to visit. On the holiday, one or two members of our Alcathon meeting will deliver gifts to the patients and offer their support.”–Corinne Conlin, RN, Director of Nursing at Sunrise House Treatment Center.
“I find joy in making my patients smile and laugh during times when they may feel stuck in the hospital during the holiday season! Once you start laughing, the healing starts.”– Mertis Shearry, BSN, RN, Director of Nursing at Laguna Treatment Hospital.
“Sometimes the best language between a nurse and a patient is the language of the heart. It makes people feel more loved and have a sense of belonging and purpose. And remember, serenity is an inside job.”– Kimberly Knapp, RN, Staff Nurse at Laguna Treatment Hospital.
Angela Mitchell, BSN, NS, CNML, Center Director, St. Paul’s PACE AKALOA, gave these tips:
- Encourage involvement in care as much as possible–loved ones can include neighbors, friends, church members, etc.
- Keep familiar items in the room such as favorite blanket/throw from home, pictures of family, etc.
- Spend at least five minutes at the bedside, engaging in a “moment of caring.” Research shows that time spent sitting at the bedside promotes trust, which ultimately improves nurse satisfaction, patient satisfaction, and patient outcomes.
- Provide a small gift. Even something small shows you are thinking of them and can bring patients joy during the holidays if they are feeling lonely.
- Spread some holiday cheer. Pick an appropriate time of day to gather 3 – 4 team members to perform a bedside Christmas carol (20 – 30 seconds top). This can be done periodically throughout the morning and afternoon shifts.
Caroline Park, LVN, Staff Nurse at Laguna Treatment Hospital, likes to remind her patients that: “The best gift you can give to your loved ones this Christmas is YOU.”
Nursing can be stressful, no matter what area of the field you’re working in. But working in the Emergency Room (ER) or Emergency Department (ED) carries with it its own kind of stressors. Silver Powell, RN, at the University of Maryland Medical Center Midtown Campus Emergency Department, took to time answer our questions about what nurses regularly deal with in the ER/ED.
What follows is an edited version of our interview.
As a nurse in the ER/ED, what does your job entail? What do you do on a daily basis?
As an ED nurse, my duties tend to change. The majority of the time I circulate as either the charge nurse or the triage nurse. On a typical day as the charge nurse, the shift starts with taking reports from the night shift nurse on all the patients in the department, including the patients that are roomed as well as in the waiting area, and issuing assignments to the nurses circulating on the unit. From there, both charge nurses count the narcotics in the medication room and reconcile any pending discrepancies.
My next responsibility is to ensure that the nurses circulating have the support and supplies they need to properly care for the patients. This may include delegating tasks to other nurses or techs or being a liaison between the nurses and the physicians on the unit or the nurses on the other units. Responsibilities also include triaging patients that are brought in by ambulances and assigning rooms to all triaged patients. Often, the rooms fill quickly, yet it’s pertinent to initiate a work up on patients that are not roomed to eliminate any delays in process of the patient’s care.
In the meantime, I am also responsible for ensuring the cleanliness and the safety of the department.
As the triage nurse, my responsibilities start with checking the functionality and presence of the emergency equipment. The next priority is to triage all patients that come through the main ED waiting area. The charge nurse relies heavily on the triage nurse for support; therefore, I am responsible for aiding the charge nurse with all duties whenever possible.
Why did you choose to work in the ER/ED? How long have you worked there? What prepared you to be able to work in such a stressful environment?
While in nursing school, I applied for a student nurse position here in the ED at Midtown and fell in love with the excitement of the department. I immediately connected with the staff and felt honored when I was offered a position right after graduation. I gladly accepted and have been working here at Midtown in the ED for 5 years. Although working in the ED is very stressful at times, my student nurse position prepared me well. I made a strong connection between what I was learning in school in my critical care course and put it into action.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Many times, after having a stressful day, some of the other staff and I get together after the shift and have a debriefing. This allows us to express what we think contributed to the stress of the day and discuss what we could do differently in the future—so we can possibly alleviate having to face some of the same stress repeatedly.
What are the biggest challenges of your job?
With so much autonomy as an ED nurse, one of the biggest challenges of the job is being able to recognize the priority problem for each patient and being able to meet their needs. With the population that we serve, patients often are experiencing multiple priority problems, which at times can make it difficult to meet all of their needs.
What are the greatest rewards of working in the ER/ED?
The greatest reward of my job is to know that I have helped someone, no matter how large or small their problem may be.
What would you say to someone considering this type of nursing work? What kind of training or background should he or she get?
I would tell anyone that is considering working in an ER/ED that although stressful, it is a very rewarding job. Each day is different, and there are so many things to see and to learn. In my opinion, there is no definitive training that completely prepares one for life in the ED, yet taking as many critical care courses in as many different areas as possible is always a plus.
Working in an ED entails working closely with many people from so many different areas of the health care spectrum; team work is incredibly important. We rely on others from all specialties to aid us in the care of patients to ensure optimal patient outcomes.
There have always been challenges facing nursing students. What are the biggest ones today, and how can students deal with and overcome them? Some experts weigh in.
Frederick Richardson, a BSN student and the Breakthrough to Nursing director for the National Student Nurses’ Association, had no doubt about how much of his time would be taken up when he began attending nursing school. Yet, he says, this seems to be one of the toughest aspects of attending nursing school that students struggle with.
“One of the biggest issues that nursing students face is time—making time for everything,” explains Richardson. “Nursing school is very demanding, and when you add in the coursework, reading for homework, and the clinical work, there usually isn’t time for anything else.”
Richardson says that he was fortunate enough to learn about this before choosing to attend nursing school. His older brother had attended nursing school, and Richardson saw firsthand how often he didn’t see his brother during that time. “He would be at the library studying, at class, or at clinicals,” recalls Richardson. “When I’d see him, it would be late at night. And he would be out of the door first thing in the morning. At the time, I recognized that when I would get to nursing school, I would probably have a similar schedule, and sure enough, it’s been exactly the same way.”
To overcome this, Richardson says that students need to have perspective and be realistic regarding what they can accomplish in their lives while attending such vigorous programs. “Our schedules can get really hectic. But I think that when you get into nursing school, you have to recognize that you’re going to devote the majority of your time to your nursing program. A lot of students don’t realize that,” he says.
Students need to set their priorities straight and decide how they are going to organize their time. Richardson, for example, says that he had to learn how to plan his time, organize his life and tasks on a calendar, and then follow that calendar every single day. From his perspective, quite a lot of students expect to attend nursing school and still have an active social life and do everything they did before, like watch all their favorite television shows.
“I think that the trouble students run into is they believe they can have everything—do well in nursing school, have an active social life, et cetera. If they go in with that kind of view, I don’t think they’re going to survive nursing school,” says Richardson. “They’re going to have to sacrifice a lot of that time, but once you get into it, it gets a bit easier.”
Martha A. Dawson, DNP, MSN, FACHE, assistant professor and coordinator of Nursing and Health Systems Administration at the University of Alabama at Birmingham School of Nursing, as well as the current historian for the National Black Nurses Association, agrees that having enough time can be an issue for nursing students. Traditional nursing students still face challenges that relate to study time, finances, and part-time work. In addition to the challenges of traditional students, however, second degree nursing students, such as those in a BSN to MSN bridge or other accelerated degree program, may also have immediate family obligations, explains Dawson. For instance, some may be primary caregivers for older parents. “Many students in these new and emerging programs are older, and these added life demands can lead to both high stress and exhaustion,” she adds.
Money, Money, Money
Richardson and Dawson agree that financial issues can also be a big challenge for nursing students. Dawson says that with the varying nursing programs and the older student population in them, these students may have greater financial obligations besides school, like a mortgage. “The current economic climate is making it more difficult for students to gain access to scholarships, trainee grants, and other forms of funding without going further into debt,” says Dawson.
In addition to taking out loans to attend nursing school, Richardson says that there are a number of scholarships available for students. Believe it or not, though, not a lot of students are applying for them. “There are a good number of scholarships available,” says Richardson. “After speaking with some people who have scholarships or who fund scholarships for students, I’ve discovered that they’re not getting a lot of applications. One reason is because of the time. A lot of students don’t know that the scholarships exist, and a lot who know they exist feel like they don’t have the time to fill out the applications because of the high demand of nursing school.”
The reality, Richardson says, is that studying takes up so much of the students’ days that many don’t think they could take the time to do what some scholarships may require in their applications—like get a letter of recommendation, write three essays, get transcripts, and the like.
Recently, Richardson had a heart-to-heart talk with a student who was frustrated because of going to school, clinicals, and a part-time job. “I said, ‘If you took about three hours applying for a scholarship, you would get more money to help you out with your school fees,’” says Richardson. He continued to explain to the student that he was working twice as hard and putting in twice as many hours at his part-time job to make the same amount of money that he could get if he applied for a scholarship—which would ultimately free up more of his time. “It would help the student more in the long run,” says Richardson.
Along with not getting enough financial support, some nursing students don’t have as much family support, says Rebecca Harris-Smith, EdD, MSN, BA, dean of Nursing and Allied Health at South Louisiana Community College. “Nursing classrooms across the nation are filled with an intergenerational, multicultural group of students that range from millennials to baby boomers,” explains Harris-Smith. “This nontraditional classroom of students has many that are parents who frequently do not have siblings, parents, or other relatives to assist them with child care. The expense of child care, transportation, and after-hours coverage often impacts the nursing student’s classroom, clinical, and study time.”
Richardson says that family support and encouragement is often needed, but not every student has it. “I noticed immediately that I needed a lot of support,” says Richardson.
“In my personal experience, soft skills as they relate to interpersonal people skills have become an issue for nursing students. The ability to communicate both verbally and in writing appears to be a challenge,” says Harris-Smith. She says that because Gen Xers and millennials have grown up with a lot of technology, they have spent a lot of their early years communicating that way.
“Basic socialization has changed in that the younger generations would prefer to text over having a verbal conversation. The lack of appropriate communication skills has an impact on the students’ ability to work collaboratively with physicians, fellow nurses, and other members of the health care team,” explains Harris-Smith.
“Effective communication is essential due to the intra- and interprofessional team collaboration essential in the health care arena,” Harris-Smith explains. “Additionally, nursing students must learn flexibility, professionalism, and a strong work ethic—which are essential to the development of the new nurse graduate. Being able to adapt to an ever-changing environment is important as health care facilities have staffing issues often requiring nurses to work beyond their shifts.”
Challenges for Minority Students
Although the challenges for nursing students are often the same for students of color and those who aren’t, “students from underrepresented groups in the nursing profession and in society . . . have them on a much larger scale,” says Dawson. “There are barriers and biases that these students experience such as academic skills, perceived perceptions about their abilities, lack of faculty role models, limited peer support, and major financial issues that ‘majority’ students do not have to deal with on a daily basis. Many minority students also struggle with the very basics of housing and food.”
An additional burden that minority students face, says Harris-Smith, is that of access and equity in education. “A selective admission process is used by schools of nursing across the nation, and this very process can serve as a barrier for students of color. Academic profiling of students ensures admission of the most academically prepared students that rank highest among their peers, but students from underrepresented populations are often the first-generation college students that struggle with the issues of being the first in the family to attend college. This situation places a heavy burden on the student because s/he may be dealing with the pressure of being the ‘savior’ for the family. These students are generally not savvy enough to apply for multiple college programs, have difficulty completing financial aid forms, and generally come to college with limited resources,” says Harris-Smith.
“Nursing programs tend to address diversity in their mission statements but fail to explain how this is accomplished. Merely placing the statement in the mission statement does not explain how the school of nursing addresses the issue. To ensure transparency, each school of nursing could better address this issue by providing information on the way in which this mission is accomplished,” says Harris-Smith. For example, she says, schools could use a statement that’s more explanatory: This school of nursing addresses diversity via academic profiling of students but is careful to admit a diverse student body that resembles the demographics of the community in which we live.
“There is a need for schools of nursing to restructure their admission process to address the lack of the underrepresented students in attendance at their colleges and universities,” Harris-Smith adds.
Richardson says that’s why he is a part of the Breakthrough to Nursing committee because its goal is to increase diversity in the nursing profession. Another challenge he’s seen is that some minority students don’t last in nursing school because they have different ways of learning. “Culturally, students from different backgrounds learn differently. I’m a kinesthetic learner. If you show me how to start an IV, I will know how to start an IV more efficiently than reading three chapters about how to start an IV,” Richardson explains. “A lot of nursing school is geared toward your textbook. But a lot of students are visual, auditory, and kinesthetic learners.”
He says that there are also students from various cultural backgrounds who don’t know how to study. “For students who come from the other side of the world to America to learn, their views are different from yours, and when you have a different perspective, you’re able to become more aware. You’re able to see a different view. It actually makes us stronger and allows us to become smarter to look at the way that other people do things,” suggests Richardson.
“With diversity, we need to recognize and communicate to understand what the other person’s thinking is and allow them to realize that though their culture is different, it’s not a bad thing,” says Richardson. “It’s just a different view and perspective for them.”
According to the Centers for Disease Control, more than 100 million Americans have diabetes or pre-diabetes, making it the seventh leading cause of death in the U.S. as of 2015. As a result, a number of nurses work with patients who have this disease.
Joyce M. Knestrick, PhD, APRN, CFNP, FAANP, president of the American Association of Nurse Practitioners (AANP), says that one of the most alarming and interesting factors is that many patients who come to see their nurse practitioners (NP) have no idea that they have the disease. “Roughly a third of Americans with the disease do not know it, and every 21 seconds, another person is diagnosed. And it is for this reason that diabetes is called the ‘silent killer,’” explains Knestrick.
What can nurses do to help these patients? “As NPs, we discuss things like obesity, poor eating, and bad exercise habits as risk factors that drastically increase patients’ chances of becoming pre-diabetic or diabetic. That’s really what we do on a daily basis—examine patients for warning signs; get to know them by discussing their history, their lifestyles, and their families; and, if need be, order various tests to help us gain more information that allows us to put patients on a proper track towards better health,” explains Knestrick. “As NPs, the key is threefold: active listening to your patients, adaptability to each patient’s unique set of needs, and the flexibility to lead or assist a care team all the way through the patient’s care continuum. So it is really NPs who are on the front lines, so to speak, with the patients battling this disease, and we work very closely with organizations who are working hard to raise awareness about diabetes and how it can be prevented, mitigated, and treated.”
Diabetes, Knestrick says, has devastating effects on patients’ bodies. “NPs have a daily responsibility to understand the risk factors and work with patients to mitigate those risks before they become diabetic. Like with so many diseases, NPs help patients focus intensely on prevention efforts and ways to take better control of their daily health,” she says.
In addition to what diabetes can do to people’s bodies and affect their overall health, Knestrick also points out that there are also astronomical economic costs associated with this disease. “A lack of overall awareness had led to over $322 billion spent annually treating diabetes. This means that health care costs are almost two-and-a-half times higher for someone with diabetes, and that is largely because of additional and devastating complications that result,” she says. “That is why we cannot emphasize enough that it is not just about people with diabetes, but that everyone has a responsibility to elevate awareness so we can avoid the human and economic costs of this terrible disease.”