Every workplace has its challenges. But, on the flip side, each has its advantages as well. We asked Beverly A. Ely, APRN, FNP-C, who works as a Family Nurse Practitioner in Harrogate, Tennessee, about what it’s like to see patients in a rural area.
Beverly A. Ely, APRN, FNP-C
What kind of work do you do?
I currently am a Family Nurse Practitioner and work with Lincoln Memorial University/DeBusk College of Osteopathic Medicine. We have 2 clinic locations that serve the University and the public. In the clinic, I see patients of all age groups from newborns to the elderly.
Working in a rural area is quite different from what most nurses do. Have you worked in a more urban or suburban area before this? If so, how does working in a rural area differ from those places?
My career spans over many decades and regions. I began a career in nursing in the late ‘80s. I graduated from Lincoln Memorial University with a degree as an Associate Nurse. I chose to begin my nursing career in Knoxville, TN and commute back and forth. Working in a suburban area, I encountered larger volumes of patients in which needs were very different than those in an urban location.
The urban area is different than the area where I first began my career. Coming back to it was a different experience, but one that has proven to be the most rewarding. I help them meet the simplest of everyday needs and assist them with coping skills to understand a diagnosis—this is rewarding. That is what I cherish about rural health and the people of the Appalachian area. I can now say that I can give back and serve the people that have given me so much.
Why did you choose to work in a rural setting? What kinds of patients do you tend to see? How are they different from those you saw in a more urban setting?
I chose to work and serve in the rural area of Appalachia because the needs are so great. I completed 29 years as a suburban nurse and saw many different classes for people. The common denominator for both is survival.
What have you learned from working as a nurse in a rural area?
I have learned to be patient and compassionate. I have learned that there is very little that we truly need in order to survive.
What are the biggest challenges of working in a rural setting?
The biggest challenge is compliance and understanding of their illness.
What are the greatest rewards?
Seeing people feel better and the smiles on their faces.
What would you say to someone considering moving to work in a rural area? What do they need to be willing to do or deal with?
I would voice that rural health is the most rewarding field that you can chose. It requires you to have compassion and patience.
Is there anything else about working in a rural area that is important for people to know?
Yes. Do I plan to continue here? The answer would be YES. It is the most rewarding of my 30 years as a nurse that I could have ever imagined. I’m compassionate and love the people of Appalachian and desire to see them live life to the fullest.
Being a nurse is a great career! Whether you’re caring for patients, assisting physicians, or talking with families, no day is ever the same. We polled nurses on why it’s a great time to consider a career in nursing in 2018, and here’s what they had to say.
“At the end of every day, I know I made a difference in someone’s life—every single day. I love being a nurse practitioner.”
—Yudelka Garcia, MS, RN, FNP-BC, Clinical Instructor, Columbia Doctors Primary Care Nurse Practitioner Group
“I love being able to help people recover or maintain their health while still being able to apply critical thinking skills and a knowledge of medicine. It’s always gratifying to have patients express their appreciation to me for taking care of them.”
—Paul Wohletz, BSN, RN, CCRN
“The health of the American nursing profession is as strong as ever in 2018. As an African American male nurse functioning in the role as a Nurse Practitioner, I stand on the shoulders of African American giants in nursing such as Beverly Malone, Elizabeth Carnegie, Mary Mahoney, Sojourner Truth, and Harriet Tubman, to name a few. It’s an amazing time to be a nurse and NP in 2018 because the profession and roles are making positive gains and are ever evolving and expanding. The nursing profession is so dynamic, and nurses along with their patients and stakeholders are moving at light speed to eliminate artificial barriers to create a more inclusive, collaborative, collegial work environment without professional constraints or perceived glass ceilings.
Nurses and Nurse Practitioners are not only serving as Chief Nurse Officers, but are also serving with pride and distinction in other capacities including: Chief Executive Officers, Chief Operating Officers, Nurse Scientists, Deputy Surgeon General of the United States Public Health Service, Chief Medical Officers, and many more.
The Gallup survey reports nursing as the “most trusted” professionals in the U.S. because of very high honesty and ethical standards. It is our time, right here, right now!”
—Captain James Dickens, DNP, RN, FNP-BC, FAANP, AANP Board Member-Elect, Manager of the Office of Minority Health, U.S. Department of Health and Human Services
“It is great to be a nurse because I get the privilege [of] caring for people in their most vulnerable times…and I get to wear pajamas (scrubs) to work!”
—Jordan Kaczor, RN, BSN, PCCN, University of Kansas Health System
“You have the opportunity to help others who are in need.”
—Moonja Shin, RN, High Focus Centers, Ambulatory Detox, Paramus
“Now more than ever before, nurses are proving to be forces of change in the health care industry. Traditionally, the nurses’ role was limited to the four walls of the hospital. Now, nurses are taking their role as patient advocates to the next level by letting their voices be heard across multiple disciplines. Nurses are increasingly participating at the legislative level through federal lobbying, as well as getting involved in industries including technology, pharmaceuticals, education, and law. Nurses are even playing a larger role in fashion by designing scrubs, and in architecture by helping to design hospital units. It’s an exciting time for nurses as they expand their responsibilities both within the hospital and in their communities, working to affect lasting change in health care. It’s critical our nurses are able to apply their valuable firsthand experience as caregivers and feel empowered to influence leadership.”
—Aparna Bala, MSHI, BSN, RN, Clinical Transformation Consultant, AirStrip
“Nursing is the most fantastic career opportunity of which I am aware. With multiple entry points and endless possibilities ranging from the daily heroism of bedside nursing care to amazing research opportunities, leadership roles, management roles, and my personal favorite: academic nursing. A career in nursing means being surrounded by brilliant, caring people engaged in endlessly fascinating pursuits.”
—Robert Muster, PhD, RN, Regional Dean of Nursing Rasmussen College
The stress of nursing can take quite a toll on nurses emotionally and psychologically. Learn to recognize the signs, what to do, and when to seek help.
Abbegail Eason, RN, remembers some of the most devastating moments she’s witnessed as a nurse: a teenage girl learning she would never walk again after being shot by a gang member, a mom who gave birth but then died from a cerebral aneurysm just days later, and a baby who was left in a store’s parking lot and ended up dying.
“In these types of situations, it’s almost impossible not to be affected after your shift is over,” says Eason, a holistic coach at Abbegail Eason, LLC.
“Every nurse is susceptible to suffering from emotional distress,” explains Lucia M. Thornton, RN, MSN, AHN-BC, a consultant, educator, and author of Whole Person Caring: An Interprofessional Model for Healing and Wellness. Thornton and other sources we interviewed say that while all nurses can be affected emotionally, those in particular specialties may be more apt to experience this kind of issue. Some of the areas where nurses are especially at risk: emergency departments and trauma, intensive care unit (ICU), hospice, oncology, pediatrics, HIV clinics, homeless medicine, high-risk pregnancy clinics, palliative care, and neonatal intensive care unit (NICU), among many others.
“Anyone who is empathetic and works in a caregiving role—including nurses and certified nursing assistants—are at risk for developing compassion fatigue and increased caregiver stress, which affects emotional health,” explains Karen Whitehead, MS, LMSW, DCC, CCFP, who provides counseling in the greater Atlanta area and at TurningPoint Breast Cancer Rehabilitation. “Nurses who over-identify with patients and blur boundaries, as well as nurses with personal trauma histories, poor social support, isolated working conditions, or a previous history of unmanaged anxiety are at greater risk. Feeling a lack of control about your work environment—including schedule, lack of recognition, or sense of community—can also contribute to caregiver stress.”
“Working in these areas with these types of patients triggers the sympathetic nervous system and keeps the body in fight or flight mode. This heightened stress reaction can, over time, lead to compassion fatigue and ongoing emotional distress,” she adds.
It can also be especially difficult for nurses because they are on the frontline of patient care, says Carl J. Sheperis, PhD, NCC, CCMHC, MAC, ACS, LPC. “Aside from the ongoing stressors of variable schedules, budget cuts, and constant technology changes, nurses are faced with a broad range of emotions experienced by patients,” explains Sheperis, a licensed professional counselor as well as the program dean for the College of Social Sciences at the University of Phoenix. “According to the American Nurses Association 2011 Health and Safety Survey, over 56% of participating nurses had experienced some type of threat or verbal abuse from patients. All of these stressors compound and result in high incidences of compassion fatigue and burnout for nurses.”
Compassion Fatigue, Moral Resilience, and Burnout
Mary Bylone, RN, MSM, CNML, president of Leaders Within, LLC, and a former board member of the American Association of Critical-Care Nurses (AACN) often lectures and writes about the AACN’s healthy work environment standards. Bylone says that while compassion fatigue, moral resilience, and burnout are terms often used interchangeably because they do have a lot of overlap, they also have some differences.
“Burnout is best used to describe a situation in which an individual feels overwhelmed and exhausted. It can be seen when people sacrifice themselves for work or become overwhelmed with the feeling that the work is never done. Compassion fatigue refers to the weariness that develops from caring for individuals when the caregiver feels saddened that they cannot change the situation and give of themselves in the hope of relieving pain or suffering in the patient,” explains Bylone. “Moral resilience refers to the aspect of an individual’s character to rise above situations creating moral distress, such as being asked to provide futile care or care against a patient’s wishes. Resilience comes when the nurse is able to restore and maintain their integrity by challenging or pushing back when asked to do things they do not feel are right. It involves using one’s bold voice to speak up when others would remain silent—to ensure that the morally right thing is done.”
For the past decade, the AACN has addressed all these issues. Its National Teaching Institute recently held a special interactive session during which more than 300 nurses spent an afternoon sharing the types of experiences that would cause these feelings and sharing their solutions with their colleagues as well. “The AACN puts a lot of energy into hope and resilience rather than dwelling on the negative,” says Bylone.
Recognizing the Signs
“Experiencing emotional reactions is human and appropriate,” says Sheperis. “The key is recognizing when the emotional reactions are out of proportion to a situation or when they have a negative impact on you or others around you. Nurses are often good at compartmentalizing emotional reactions, but sometimes the compartments become full, and the emotions spill out.”
Some of the signs that a nurse is experiencing negative effects from emotional overload are: using a greater number of sick days and/or dreading going to work; feeling exhausted; problems sleeping; using drugs or alcohol to sleep; having work-related dreams, nightmares, or intrusive thoughts; being angry a lot either at work or home; yelling at patients or families; changes in mood or behavior at work; crying all the time; feeling angry at supervisors or coworkers; developing fears about the safety of friends or family; feeling less engaged in their personal and/or professional life; the inability to think clearly; headaches; gastrointestinal problems; irregular breathing patterns, feeling devalued, and losing the capacity to care about themselves, their patients, their family members, or really anyone.
This doesn’t even touch on the signs of clinical depression, which nurses may also experience. The point is that if nurses notice vast changes in themselves or in their coworkers, they may need to seek or suggest help.
The first action that nurses can take to keep their emotional health intact is to set boundaries, says Gail Trauco, RN, BSN-OCN, a grief mediator, owner of Front Porch Therapy, and author of Conquering Grief from Your Own Front Porch. Nurses can do small things to make themselves happy. “Be sure you have things that you visually see which create an immediate ‘happy sensation,’” suggests Trauco. “This can be a favorite coffee mug, bright-colored scrubs, flowers on your desk, or even a funny stethoscope cover.”
One of the biggest problems nurses have is that they tend to put everyone else’s care above their own, says Jill Howell, MA, ATR-C, LPC, a board-certified registered art therapist, professional counselor, and author of Color, Draw, Collage: Create Your Way to a Less Stressful Life. While she works at Pocono Psychiatric Associates, Howell worked with many nurses at the Pocono Medical Center. “It’s all about self-care—nurses will, of course, react by saying that they don’t have time,” says Howell. “Please remember what they say on the airplane—put your oxygen mask on first before you try to help others.”
When working with nurses, Howell would check in with them to see how they were dealing with work, give them an opportunity to vent, and make small self-care suggestions. She would also do quick guided meditations with them, teach a relaxation technique, or set up large sheets of mural paper and have them draw out their frustrations.
“I have found that most nurses, while they can care for others continuously, have a very difficult time in caring for themselves,” says Thornton. “Self-compassion is an important and useful practice for nurses to develop.”
“Nurses are givers. We go into the field because we are caretakers,” says Eason. “Many of us feel we are at our best when taking care of others.” She says that it’s important, though, for nurses to understand that they have to take care of themselves first. “Ensure you are getting adequate, quality sleep. You are eating a well-balanced meal. You are getting adequate exercise. You are spending time cultivating a life that is meaningful, rich, and deep outside of work,” says Eason.
After a particularly stressful experience at work, Lisa Radesi, DNP, CNS, RN, academic dean at the School of Nursing, College of Health Professions, University of Phoenix, says that nurses and other staff should have a debriefing session and remember that, despite all of the “bad” that occurs in their jobs, the “good” is the most rewarding part of what they do.
“Nurses should work together to ensure that they are okay after an incident. If a nurse notices a coworker is not doing well, they should talk with the coworker and bring it to the attention of the supervisor or manager,” says Radesi. “Above all, nurses should feel comfortable seeking treatment and communicating about emotional issues they may experience. Keeping this information bottled up can lead to issues and stress that have long-lasting effects. Know that it is not weakness, but strength, to acknowledge emotional disturbances and respond to them accordingly.”
If you see a coworker in distress, you can do something as simple as strike up a conversation with her or him, advises Bylone. “Use open-ended questions to find out how they are doing. Sometimes hearing the other person’s story really puts things into perspective. Let them know you care, and you are there to help, if only to listen. Please do not watch them suffer alone. Left unattended, these feelings only deepen and create lasting impact, often causing them to leave the profession,” she says.
Seeking Professional Help
Let’s face it: there are times when a spa day, time out with friends, or a bubble bath just won’t cut it in alleviating emotional problems. That’s when nurses need to seek professional help.
“If you are experiencing distressing symptoms over an extended period of time, it’s a good idea to check in with a professional therapist or counselor,” says Whitehead. “Whether it is distress from work or something related to your life outside of work, connecting with a professional can help you be a more effective caregiver and build your own resilience to mitigate the effects of your chosen population at work.”
If you need professional help, first see if your workplace has a program for staff members. If not, Sheperis says that the National Board for Certified Counselors has a directory of board-certified counselors across the United States (visit nbcc.org for more info). PsychologyToday.com also has a therapist directory that includes profiles of providers who can help.
There’s no shame in seeking help to get better. Sheperis says, though, that all nurses should do whatever they can to prevent their emotional stress from getting to this level. “Most people only seek professional help after something in their life had caused significant distress. While it is important to seek help if you are reaching a level of burnout or compassion fatigue, it is much better to take proactive steps and to work with a counselor to build resilience prior to hitting an emotional wall,” he says.
Sheperis also suggests that nurses focus on wellness practices at the onset of their careers. “It is easy to become engrained in a high-pressure system and to become emotionally overwhelmed if you don’t have a set of wellness practices in place.”
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.”