October 10 kicks of a celebration of the work emergency nurses do with Emergency Nurses Week. In the past year and a half, emergency nurses have faced a pandemic and the overwhelming care needs of a staggering patient load. Frequently, emergency nurses are the initial care provider for people who have COVID-19 symptoms, and they have taken on a care caseload filled with some of the sickest patients these nurses have ever encountered.
Emergency nurses are needed more than ever. As pandemic cases continue to rise and fall and as patients who put off needed care are presenting with even more advanced needs, emergency nurses are in perpetual demand.
As the need for their skills rises, emergency nurses are especially prone to exhaustion and burnout. Taking care of themselves becomes a low priority when the demands of the job are so high, so continual, and so overwhelming. If running to the bathroom is considered a break, how can emergency nurses be expected to keep up the pace?
And while there’s no magic potion to improve the work balance (let alone a work-life balance), nurses can be aware of doing whatever they can to make life any easier right now. And remembering that eventually, this impossible time will pass.
With an unrelenting job, nurses need to let themselves take shortcuts when they can. Buying premade meals or getting groceries delivered saves time and effort that are in short supply. The shortcut doesn’t have to lead to unhealthy choices. Focus on foods that give you the biggest nutritional bang for the buck. Prepared salads, cooked veggies, chopped fruit, and grilled meats are great choices. And when you’re too tired to even think about eating, a comforting soup–pureed or hearty–with bread and cheese will fill you up and nourish you.
Asking for help is often a nurse’s Achilles heel. After giving so much care, nurses are reluctant to admit they need some help. Whether it’s childcare, elder care, transportation, or mental health care, a little assistance can make your life easier–and that can make the world of difference. Even connecting with other nurses through an organization like the Emergency Nurses Association can give you the support you’re seeking.
Find the Joy
For many nurses, there’s been less joy this year. As waves of patients remain high, the emotional toll on nurses and healthcare workers is evident. Keep yourself going by finding the small joys in your day. A great playlist, a funny podcast, a movie that lets you escape (even if it takes five sessions to watch because you keep falling asleep), or even the softest socks that soothe your aching feet at the end of the day are good choices. Bonus points if it requires no extra effort and double bonus points if it’s something you can look forward to.
During Emergency Nurses Week, honor those who work in this demanding specialty. And if you are an emergency nurse, thank you for all you are doing!
This week’s celebration of Pediatric Nurses Week (October 4-8) is a reminder of the specialized work these dedicated nurses offer to their young patients.
For anyone interested in a career as a pediatric nurse, it’s helpful to know the responsibilities of this job. Nurses who work with children are the biggest advocates for their young patients. From toddlers to teenagers, pediatric nurses will become familiar with, and fluent in, the issues facing these ages.
Nurses who work with children will have an understanding of everything from toilet training and toddler play habits to social media and adolescent decision making habits. Pediatric nurses will see children for well visits, minor illness like a stomach flu, and life-threatening diseases including cancer.
Because of the range of ages, potential conditions, and situations, pediatric nurses have to know myriad relevant medical information and also how any issues or concerns will impact the family. Working with so many different families while focusing on a young patient can be challenging for pediatric nurses. Families are also the best advocates for the child and so creating a good working relationship with families is especially helpful. Compassion and understanding go a long way, but calling attention to concerns is also a pediatric nurse’s responsibility.
The Society of Pediatric Nurses is an excellent resource for nurses who work with children and their families. It offers guidance on education, advocacy, and clinical information to cover the needs of just about any pediatric nurse.
Nurses in this specialty are in high demand and can find a satisfying career in one office or by changing the focus of their career. They can find work in a family practice, a specialty practice, a hospital, an outpatient or surgical clinic, schools, or even rehabilitation centers.
By taking the exam, nurses are proving they have the most updated knowledge on evidence-based practices and on treating their young patients. This helps them give the best care possible as this specialty changes rapidly. Nurses who become certified are also demonstrating a specific commitment to being the best nurses they can and to gaining the tools necessary to make that happen. For a career move, this extra level is frequently noticed by your peers, supervisors, and organization. Nurses who are certified and keep their certification current are the nurse leaders organizations look for and depend on.
Whether you are an experienced nurse practitioner with years of clinical practice already under your belt, or you’re a student preparing for a fulfilling career devoted to helping people, you’re likely to face some unexpected challenges and some exciting opportunities in the work you have chosen. The role of the nurse practitioner is rapidly evolving, responding both to changes in the health care industry and to the evolving needs of the communities you serve. This article explores some of the most significant trends nurse practitioners are facing today.
An Expanding Role
The global health care shortage is not news, but what is news, perhaps, is how significant and widespread it is. In fact, in the United States alone, it is estimated that the shortfall in the number of physicians needed by 2033 will approach 140,000.
And that reality is rapidly and dramatically expanding the role of and the demand for skilled nurse practitioners. Where nurse practitioners might have once worked primarily in collaboration with a physician, increasingly, nurse practitioners are taking the lead in patient care. In many states, this includes overseeing and implementing treatment plans and even coordinating end-of-life care.
In addition to operating more independently than ever before, nurse practitioners are also finding themselves drawing on an array of skills, resources, and knowledge to provide more comprehensive care.
For example, as demand and cost pressures on the system mount, health care providers and patients alike are seeking more holistic strategies to promote wellness and prevent disease. This often includes, for instance, an emphasis on fitness and nutrition, constituting a significant shift in standard medical practices.
Historically, health care providers have been dissuaded or even prohibited from offering nutritional advice, as it may have been considered outside of the clinician’s scope of practice.
In addition to cultivating specialized knowledge to provide higher quality and more comprehensive care, nurse practitioners are also increasingly being looked to as multigenerational health care providers. In such cases, nurse practitioners may provide many of the services of a primary care physician, general practitioner, or family physician.
For this reason, a large number of nursing schools are offering students the opportunity to train as family nurse practitioners (FNP), enabling them to offer optimal patient care across all stages of the lifespan, from birth to death. Licensure as an FNP can be a particularly attractive option for those who seek to develop long-term, trusting relationships not only with individual patients but with an entire family.
Serving At-Risk Communities
Disparities in access to consistent, affordable, and high-quality health care have long been known and lamented. However, health care systems are increasingly turning to nurse practitioners to stand in the breach, filling a desperate need for health care providers in underserved communities.
That means that nurse practitioners may routinely find themselves asked to serve in remote, rural communities or impoverished urban areas where the need for qualified health care providers is greatest. In fact, nurse practitioners who have pursued specializations in community or public health can find themselves in particularly great demand and may build rewarding careers as traveling nurse practitioners, serving communities in need for weeks or even months at a time before moving on to the next post.
When it comes to both training and practice, nurse practitioners have more options and opportunities than ever before. In addition to choosing specific areas of specialization, such as adult or pediatric care, nurse practitioners can also select from an array of subspecialties which will increase their marketability.
However, the degree of clinical autonomy nurse practitioners enjoy will vary from state to state. In some U.S. states, licensed nurse practitioners enjoy what is known as full-practice authority (FPA), meaning that they can prescribe medication, order tests, and define and implement patient care strategies without requiring a physician to sign off on the plan. In other states, though, nurse practitioners still need a physician’s authorization before a treatment plan can be implemented.
Nevertheless, the opportunities for nurse practitioners to earn FPA are growing. For instance, attaining an Advanced Practice Registered Nurse designation can give you full practice authority in many states, including some states where a physician’s sign-off would otherwise be required. Most exciting of all, organizations such as the American Association of Nurse Practitioners are working to establish a nationwide certification protocol to enable qualified nurse practitioners to enjoy full practice authority in all U.S. states and territories.
It is an exciting time to be a nurse practitioner, a time of high demand, increasing independence, and tremendous opportunity. Nevertheless, the challenges are significant, principally due to an ongoing labor shortage and continuing disparities in health care access. In a time when both the need and the reward are great, nurse practitioners are perfectly positioned to fill the gap.
In this feature, we profile a particular type of nursing so that others in the field can learn about what nurses do in this position, what they enjoy about it, and how others can get into it.
Kathleen Martinez, MSN, RN, CPN, President, American Academy of Ambulatory Care Nursing (AAACN), and an infection preventionist at Children’s Hospital Colorado, gave us information about ambulatory nurses.
What is ambulatory care nursing and what do they do?
Ambulatory care nursing is unique in that it treats an individual in this fuller context of community, family, and population. Ambulatory care considers the access and quality of health care, but also evaluates the influence of other social determinants of health: economic stability, neighborhood environment, social context, and access to quality education.
I was introduced to ambulatory care nursing when I accepted a position in Children’s Hospital Colorado Telephone Triage Center. In telephone triage, an RN uses the nursing process (assessment, diagnosis, plan, implementation, and evaluation) to determine the significance of symptoms during a phone call. Every call requires all your skills and creativity. Each encounter requires total focus and attention; interpreting and clarifying information, considering availability of resources, navigating barriers, ensuring that the family understands the care instructions, or that they have called 911, or that they have transportation available to get to the ED or clinic.
And all of this is done within an eight-minute phone call, with a family you may never have met before. I was hooked! It is incredibly empowering and humbling to walk with a family through a child’s illness.
All state Nurse Practice Acts define “Dependent Practice” in circumstances where RNs are carrying out the orders of another provider, such as an MD, Advanced Practice RN, or Physician Assistant; and “Independent Practice” in circumstances where RNs are using their knowledge, skills, and training to initiate and complete tasks within the scope of nursing. Ambulatory care lives much more in the “Independent Practice” realm.
As an ambulatory care nurse, what are your responsibilities?
Well, that depends on your role. If you have a role in Care Coordination and Transition Management (CCTM), you might be checking lab results for a patient, or adjusting their medications based on those results. You may visit a complex patient in an inpatient unit who is preparing to transition home or to an extended care facility. Maybe you are doing a home visit to ensure a family can properly deliver the medications and treatments their child requires.
If you work in a clinic that performs procedures, you may be teaching a preoperative class. Or completing a post-operative wound assessment. Or completing a procedure, such as a fecal microbiota transplant in a GI clinic, or phototherapy in a dermatology clinic. Or performing a prenatal exam or well child check in a Federally Qualified Health Center.
What many people don’t understand is that the acuity of care performed in the ambulatory care setting is similar to care delivered during an inpatient stay. In fact, more than 80% of all cancer care is delivered in ambulatory care settings, including high-dose chemotherapy, preparative regimens for bone marrow transplants, and radiation therapy.
According to the Center for Medicare and Medicaid Services (CMS) 70% of all surgeries occur in an ambulatory setting. Clinics perform complex procedures such as bronchoscopies, endoscopies, and dermatologic surgeries. In all of these settings, RNs use the nursing process to provide care, education, and support.
What are the biggest challenges in being an ambulatory care nurse?
One major challenge: Broadening the scope and job responsibilities to accurately reflect our education, training, and licensure.
Federally Qualified Health Centers and Rural Health Centers are role models in allowing nurses to work to the top of their license. Nurses perform well-child checks, routine pregnancy care, and Medicare Wellness visits. They perform screenings and manage medications with the use of Standing Orders. They teach classes on managing chronic illness. They coach, encourage, and engage individuals to take charge of their health and wellness.
Other ambulatory care settings are learning from these models and creating exciting and engaging roles for RNs.
Another major challenge: Reimbursement for services remains a frustration for nursing in all settings and is a primary focus of the American Nurses Association and the Future of Nursing 2020-2030.
What are the greatest rewards in being an ambulatory care nurse?
The promotion of health and prevention of disease occurs over a lifetime, not in a single episode of care. Ambulatory care nurses meet people where life is lived: in schools, community centers, clinics, and in their homes. We walk alongside individuals through a season or a lifetime as mentors, peers, and teachers.
Statistically, only a small percentage of people are hospitalized each year, yet greater than 90% of Americans seek health care services in ambulatory care settings. And we are there to meet them!
When I was performing telephone triage, one of the most impactful statements I could make was saying, “It sounds like you are doing a great job.” Or simply, “Your child is lucky to have you as her parent.”
Creating this space of honor and trust allows the family to interact truthfully, which allows us to provide better care. It also just feels amazing to hear the relief and gratitude in the voice of the caller when their efforts are recognized and appreciated.
If nurses want to pursue a career in ambulatory care, do they need any additional education and/or training?
A Baccalaureate Degree in Nursing provides much of the knowledge and skills needed for any nursing role, including ambulatory care nursing. A strong “Transition to Practice Program” fills in any gaps and focuses on additional training. Just as critical care nursing is a specialty, ambulatory care is a specialty, requiring ongoing education and training.
AAACN offers tools and resources to support orientation and we have developed a very popular ambulatory care nurse residency program. We also provide extensive support via education events, networking/special interest groups, and targeted publications for those interested in pursuing a career in ambulatory care nursing. I always advise nurses to join an association supporting their specialty to open career doors and bond with colleagues.
To further advance the specialty, AAACN is working with the American Association of Colleges of Nursing to ensure all prelicensure programs include adequate material and experience in the ambulatory care setting.
What kind of advice would you give to a nurse wanting to work in ambulatory care?
I have been in ambulatory care-specific or associated roles for 30 years. Every year the opportunities are expanding. The Affordable Care Act of 2010 was a game changer. After half a century of hospital-focused care, there was suddenly a shift to health maintenance, disease prevention, care coordination, patient-centered care, and looking at social determinants of health as a larger context of care.
The Future of Nursing 2020-2030 calls for an increased focus on the role and value of the RN as a member of the health care team. During the 2019 Future of Nursing 2020-2030 Town Hall meetings, the focus was almost entirely on elements central to ambulatory care: environment, community, access to health and education resources, management of chronic diseases, and wearable technology. In addition, it’s important that patients are cared for in a comfortable and familiar environment. Use of telehealth specialty care decreases the burden and cost of travel. Telephone triage and telehealth visits allow sick persons to remain at home in comfort while accessing high-quality and reliable care. In some states, use of Standing Orders greatly expands the care that can be provided by the RN.
This year’s celebration of Neonatal Nurses Week continues a tradition that began 21 years ago. In 2000, the National Association of Neonatal Nurses (NANN) launched a day to honor neonatal nurses and expanded that time to a week two years ago to commemorate nurses in this distinct nursing specialty.
Neonatal nurses care for the smallest patients and work closely with a larger team of specialists as they advocate for babies in their care. Nurses care for babies who are often critically ill and are born with various health issues ranging from low birth weight, heart problems, birth defects, infections, and possible drug dependence or exposure. Neonatal babies may need care for recovery from surgery or may have been born prematurely.
Generally, the newborn age is considered neonatal, but neonatal nurses care for these babies until they leave the hospital. Some nurses may continue to care for babies with particular health issues until they are toddlers, although this is less frequent. As a neonatal nurse, you can expect to care for this age range as part of your specialty.
Nurses in this role support and advocate for the families of babies in their care. Families of infants in intensive care are frequently scared, exhausted, and need information on their baby’s health. Keeping them in the loop by giving them information in a way they can understand and take action on is especially important.
As your tiny patients leave your care, families depend on neonatal nurses to help them transition to the next phase where families assume a larger role of the care or care coordination of their baby. As you work with the families and caregivers of these special babies, healthcare education becomes a top task. You’ll help pass along often-complicated information on how to care for an infant who may need various equipment, special medications, or specialized feeding plans that even experienced parents may not know anything about.
As a neonatal nurse, improving your skills and continuous learning must be a professional and personal commitment. Treating and advocating for the tiniest patients who are not able to advocate for themselves makes your knowledge essential.
Becoming certified as a RNC Certification for Neonatal Intensive Care Nursing (RNC-NIC®) confirms your commitment to the best patient care and gives you invaluable expertise. As with other certification paths, nurses who want to achieve certification should plan to have at least two years of work in a specialty area like a NICU so they are able to gain hands-on, real-world skills. Once you have your certification, you’ll need to renew your credentials every three years.
Student nurses who are considering neonatal nursing as a career path can look into a student membership of NANN, which will give them the tools they need and help them establish a network of nurses in similar paths. Professional organizations are excellent resources for nurses who want to stay current on the latest evidence-based practices, recent developments in treating neonatal patients, and exciting research that may lead to improved care.
Neonatal nursing is a rewarding and challenging career path. Self-care for nurses is important as the intensity of the NICU includes elation and grief and every emotion in between. If you are a neonatal nurse, try to find some activities that help you manage the intensity of your work and give you a balance with your work and home life. Some days it will be impossible as it’s all too easy to bring your worries about your patients with you when you leave work. It’s important to recognize when that happens, honor the critical work you are doing, and have some plans to get back on track.
As medical technology continues to advance, in some areas with rapid speed, the babies in NICU have an increasingly better outlook. And for neonatal nurses, the small victories make the biggest differences.
There’s a nursing shortage that is not only affecting the United States, but the entire world. And research is showing that it could to get worse.
That’s why it’s crucial for nurses to stay happy and not completely burnout. And it’s not only up to them to stay that way, but for their employers to keep them pleased and working as well.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Health Learning, Research & Practice at Wolters Kluwer, an acute care/critical care nurse practitioner at Penn Medicine, Chester County Hospital; a clinical adjunct faculty member in the graduate nursing program at Drexel University, and author of COVID-19: Transforming the Nursing Workforce in the New Paradigm of Care took the time to answer our questions.
What could the current nursing shortage mean for hospital care quality?
The nursing shortage is actually a global issue. According to the latest research, it is estimated that the world will need an additional 13 million nurses by 2030; in the U.S., the need is projected to be 1.1 million (International Council of Nurses). There are several reasons for the nursing shortage. As the population of the world increases and Baby Boomers continue to age, the need for care will increase. This is compounded by the fact that nursing schools around the country are struggling to meet the rising demand for nursing education due to limited faculty, resources, and clinical sites; they turn away an estimated 80,000 qualified applicants each year in the U.S. due to this supply and demand issue (American Association of Colleges of Nursing). A large portion of the nursing workforce was set to retire in the next 10 years. However, the pandemic has accelerated this event, and nurses are leaving sooner than expected due to widespread burnout and exhaustion.
If nursing staff are feeling overworked and undervalued, they will more readily leave their institution, and perhaps the nursing profession altogether. This, in turn, increases the current nurse shortage, and the problem continues to worsen. Hospital care quality suffers if nurses are burnt out and overwhelmed, just as it suffers if nurses are missing. Patient wait times increase, and bedside care suffers. For hospital care quality to improve, there needs to be a concentrated effort to fix the supply and demand issue in nursing education, and there needs to be a concentrated effort on workforce well-being and fostering resilience—that is the bottom line.
What can hospitals/medical centers do to increase resilience among their existing nursing staff, while making sure that they don’t burnout and leave?
To foster resilience among the workforce, organizations need to acknowledge there is an issue and focus on workforce well-being. This means providing a safe environment in which to practice and provide patient care. Providing adequate staffing based on acuity/severity of illness and competency not just on numbers is the first step. Building up float pools that are cross-trained to work across adjacent specialties and move from one area to another is essential. While nurses do not like to float outside of their units, in an emergency or disaster situation, having the staff cross-trained to work in adjacent specialties helps to create an agile, efficient workforce.
Health care institutions need to invest in their workforce. Providing adequate breaks, healthy meals, self-scheduling, shorter shifts, and being able to take time off is crucial to preventing burnout. Nurses want to feel valued—providing continuing professional development activities and having the ability to meet career goals with lateral or vertical moves can make the difference between keeping the talent and losing it.
Health care systems must recognize when burnout and moral distress are occurring. That means having trained personnel up on the units evaluating what is really happening and then providing mental health support through employee assistance programs. Often nurses are worried about their families; health care institutions need to provide alternative child or family care or even financial planning. Burnout can be prevented or at least minimized if health care institutions are actively on the lookout for it, address the issues that cause it and invest in their workforce well-being.
How can nurses prevent their own burnout? Especially when hospitals, etc. are understaffed?
Preventing burnout is no small task, but nurses can certainly take steps to reduce their stress and prioritize self-care when they feel overwhelmed in the workplace. It’s important for nurses to know how to evaluate their own well-being, recognize their limitations, and be able to advocate for themselves when something is beyond their bandwidth.
Learn to be comfortable with saying, “No.”
Saying no is one of the hardest things for nurses to do; we are a caring profession and we often sacrifice our own self-care to care for others. We need to understand that if we don’t care for ourselves and find our own inner peace, there will be no one left to care for others.
Personally, I recharge by finding my inner peace and joy by reading, enjoying the outdoors, and sitting by water. Reclaiming “me time” within my day to recharge allows me to show up fully ready for my next day of work.
What are some proven strategies for creating a more agile workforce that both addresses the nursing shortage as well as avoids reliance on traveling or temp nurses?
The agile care model is based on patient acuity, competency of the workforce, and alternative care delivery models. It provides agility that allows hospitals to move their nursing workforce when and where they are needed and uses other members of the health care team to support patient care such as unlicensed assistive personnel, licensed practical nurses, and others. It also switches the care delivery model from a primary nurse model to a hybrid team model of care as needed.
The backbone of this model is cross-training the float pool to work across adjacent specialty areas and as a backup, having the full-time staff cross-trained to work across adjacent specialties in an emergency situation. This interdisciplinary team-based approach facilitates the rapid deployment of staff to areas most in need in a crisis, such as what we’ve experienced with COVID-19, and provides better care for a greater number of patients.
This addresses the nursing shortage by improving the quality-of-life nurses experience at their workplaces. With more nurses trained to work in adjacent areas, staff will be able to take time off and recharge. When nurses feel practice-ready, confident, and able, they are less likely to burn out because they will experience less overall stress at work. Health care institutions must also be on the lookout for early signs of burnout and encourage their nurses to take time off when it is needed.
What are the biggest mistakes that hospitals/medical centers can make with their current staff that could lead faster to burnout and them leaving?
Health care organizations need to understand that their biggest asset is their workforce. Without nurses and other medical professionals, hospitals and medical centers cease to function. Nurses need to be recognized for their value—their workplaces should support them by looking out for signs of burnout, offering mental health support, offering family/childcare support, and encouraging a healthy work-life integration. Without these basic acknowledgements, it is no surprise the burnout and shortage levels are what we are seeing today.
Nurses’ mental health matters! Nurses need to talk to their organization and be vocal about how they can better support their nursing teams. Whether that is more frequent review of their workforce policies, more transparency in the workplace, or more vacation time, nurses shouldn’t be afraid to speak up and stand up for themselves and for their fellow nurses.