Do you dream of a nursing position that offers constant variety, instead of treating the same types of patients and medical conditions day in and day out? Do you long for a work environment where physicians regard you as a key player on the team, rather than making you feel subservient? Have you always wanted to work in a field where the patients come from so many different walks of life that a racially, ethnically and culturally diverse nursing staff is nothing short of an absolute necessity?
“I enjoy the variety,” enthuses Julie Moses, RN, a native of Trinidad who is a clinical resource nurse in the emergency department at Washington Hospital Center in Washington, D.C. “Any medical problem can turn up in the emergency room. You get to do so many different types of nursing—from med/surg, OB and orthopedic to cardiac care and ICU. You see it all, from birth to dying, and everything in between. I just love it!”
Thelma Kuska, BSN, RN, a Filipino-American CEN (Certified Emergency Nurse) who worked for 20 years in the ER at Christ Hospital in Oak Lawn, Ill., believes emergency nursing is an ideal career for minority nurses because it is so empowering. “I’ve worked in other areas, such as surgery and pediatrics,” she says, “but the ER is the most rewarding, because the doctors treat you as a colleague. They value your input. If you say, ‘I need you here in this room, NOW,’ they run. And they show you everything—they’ll say, ‘Come look at the x-ray!’ instead of treating you like someone who’s just there to follow orders.”
Because life-threatening emergencies cut across all categories of age, gender, race, ethnicity and socioeconomic status, emergency nursing is virtually synonymous with diversity. And because the nurse is usually the first person that patients encounter when they are brought into the ER, minority nurses can play a unique and highly visible role in providing culturally sensitive emergency care.
“We’re really right there on the front lines,” notes Cherrlyn Jones, MSN, RN, an African-American clinical resource nurse at Howard University Hospital in Washington, D.C., and president of the Metropolitan Washington Chapter of the Emergency Nurses Association (ENA). “The way the patients see us shapes the way they will view the rest of their treatment.”
“There’s always anxiety in the ER, because patients don’t come there unless something is really wrong,” adds emergency nurse practitioner Elda Ramirez, MSN, RN, CEN, FNP, who is also an assistant professor of clinical nursing at the University of Texas-Houston School of Nursing. “It’s important to give them some sense of relief and comfort. I think that when minority patients see a caregiver from their same culture, it gives them that relief. They think, ‘This person will understand me. They will know what my problem is.’”
Best of all, job opportunities for emergency nurses are everywhere, because the demand for these professionals has risen to unprecedented levels in recent years. While America is currently suffering from an acute nursing shortage in virtually every area of the profession, RNs with specialized emergency-care training, skills and experience have become particularly scarce.
Beyond “ER”
If your knowledge of emergency nursing is based on watching the TV show “ER,” it’s time to switch to the reality channel. “I think the words ‘ER’ may scare some potential nurses away,” Moses believes. “They say, ‘I don’t want to work [in an environment] like that!’ But emergency nursing is simply another type of nursing, another way to care for people. It’s not like the TV show, where everybody is constantly rushing around.”
In fact, the term “emergency room” no longer truly reflects reality. The Emergency Nurses Association, along with a growing number of hospitals, prefers the more all-encompassing term “emergency department (ED).” Today’s emergency nurses can be found practicing in an impressively wide array of settings beyond the traditional ER—from trauma centers, urgent care clinics and prehospital services to such enterprising new areas as in-flight nursing, forensics, amusement park nursing and emergency prevention education. The ENA’s membership ranges from staff nurses, ED nurse managers, administrators and clinical nurse specialists to prehospital coordinators, nurse practitioners and educators.
Kuska now works as an injury control and prevention educator for the National Highway Traffic Safety Administration, providing outreach to communities in a six-state region. She teaches the importance of seatbelt and airbag use, bicycle safety and drunk-driving prevention. “I did a lot of soul-searching about whether I was ready to give up ER nursing,” she says. “But I finally decided that with this position, I could use my expertise to make a much broader impact than I could treating just one patient at a time.”
Still other emergency nurses are expanding their careers into corporate settings. “Many big oil and gas companies now have teams of emergency medical technicians and nurses who are on call in case of accidents or disasters at their refineries,” Ramirez reports. “In fact, a lot of people who have done emergency care in the past end up becoming consultants for corporations in areas like disaster management. I even see emergency nurses going into the business field—there are a lot of companies that contract emergency services to hospitals and corporations.”
Gloria Salazar, MA, BSN, RN, CEN, a 20-year veteran of the ER who is now a trauma education and injury prevention manager at Thomason Hospital in El Paso, Texas, feels that “emergency nursing is a stepping stone. Most emergency nurses have plans to continue their education or their professional development, and they eventually move on to something else.”
Think Fast
Meanwhile, back in the ED, there’s no denying that the pace is fast. Because every emergency case is different and the volume of patients is high, emergency nurses must have a finely honed ability to quickly assess what’s wrong with the patient and take immediate action. Creativity, flexibility and being able to work under pressure are absolutely essential, as are top-notch problem-solving skills, sound judgment and the ability to prioritize which patients are the sickest.
“Critical thinking skills are very important,” says Jones. “You need to be knowledgeable in managing patients with life-threatening problems. You need to be up-to-date on current trends, such as new treatments for acute coronary syndrome. You need to read articles, so that you can explore new information with your colleagues and the physicians. And when you’re carrying out an order, it’s not enough to just do it—you need to understand why you’re carrying out that procedure.”
Because everything in the ED is based on verbal orders, Kuska adds, “you have to know your medicines and know exactly what things are for, so that you can make sure the doctors’ orders are correct. You have to be able to think, ‘Wait, I shouldn’t be giving Demerol to a head-injured patient,’ or ‘The potassium he ordered is too high for a two-hour drip.’ If you haven’t acquired that knowledge from prior experience in another area of nursing, you’re not ready for the ED.”
Ramirez adds one more essential quality to the list: the ability to be nonjudgmental when faced with emergencies that could have easily been prevented if the patient had used common sense. “We recently had a case where a mother was driving with her kids in the car and her little boy was not in a seatbelt,” she says. “She got into an accident and the child flew out the window. But I can only educate her—I cannot judge her. I have to be able to stay calm and say, ‘You know, it’s really important that you seatbelt your child; he could have died today.’ You have to be an exceptional teacher.”
Cultural Detectives
Being an emergency nurse is a lot like being a detective, according to ENA immediate past President Benjamin E. Marett, MSN, RN, CEN. Often, he explains, someone will come into the ED in crisis and neither you nor the patient will have any idea what’s wrong. It’s up to the nurse to sift through all the clues—the patient’s vital signs, their medical history, what they did and ate that day, diagnostic tests such as EKG, electrolytes and cardiac monitoring, etc.—and deduce what the problem is.
“All you may know from the vital signs is that something isn’t quite right,” says Marett. “You need to have a keen ‘sixth sense.’”
Ramirez believes this “Sherlock Holmes component of emergency nursing,” as she puts it, is another crucial area in which minority nurses can make a culturally competent difference when treating patients who share their same ethnic heritage: They are more likely to be attuned to “cultural clues” that would not be apparent to someone outside of that population.
“I think that’s one of the things that gives me an edge in treating Hispanic patients of Mexican descent and some Latin patients,” she relates. “I was born and raised with these people, so it’s like an innate cultural knowledge. When they come to the ED and they’re talking a certain way, they’re using certain terms, you think: ‘Wait a minute, I know what this person is saying.’
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“Last night I had a perfect example,” Ramirez continues. “A Hispanic woman came into the ED and she was using a Spanish phrase that, literally translated, means ‘I have tonsils.’ Immediately, I knew exactly what she was talking about. She didn’t have to tell me, ‘My throat hurts and I have fever.’ In my culture, when someone says ‘I have tonsils,’ it means that they’ve had a history of tonsillary problems and now it has come back.
“All I had to do was ask her, ‘What have they treated you with before?’ She told me, ‘The shot.’ I asked, ‘The one with penicillin?’ ‘Yes, that’s the one.’ ‘Does it help?’ ‘Immediately,’ she said. ‘It’s gone within two days.’ She could have said ‘I have tonsils’ to another nurse who wasn’t familiar with Hispanic culture and they would have had no clue. But to me, it made perfect sense.”
Are You Experienced?
Even though the current shortage of emergency nursing specialists is forcing many emergency departments to hire nurses without prior ED training and experience, nurses who do possess solid emergency background and skills are in much greater demand. Moreover, because of its extremely serious and fast-paced nature, emergency nursing is definitely not a field for beginners.
“I would tell any nurse, minority or not, that before you can come to work in emergency nursing, you need a strong base in medical/surgical or another more general area of nursing,” Moses emphasizes. “If you jump right into the ER as soon as you graduate from nursing school, you’re only setting yourself up to be burnt out within a year. But if you get that base first, you’ll be able to function much better when you come to the ER.”
Let’s say you are currently a med/surg nurse who would like to make a career change to the more exciting field of emergency nursing. What specific education, experience and credentials will you need to add to your resume?
“Our hospital requires you to have taken the TNCC (Trauma Nurse Core Course), the ACLS (Advanced Cardiac Life Support) and PALS (Pediatric Advanced Life Support),” says Salazar. “There’s also a critical care course offered at our local university, and I advise the students I work with to take that. Most of the students who take those courses and then look for a job in emergency nursing are the ones that are hired right away.”
In addition, Moses advises potential ED nurses to obtain a strong grounding in technology skills by taking computer classes. “Nowadays, the whole ED is computerized,” she explains. “The patient’s x-rays, medication, everything is on the computer. For discharge planning, you press a key and you get discharge instructions; for patients’ lab work, you pull it up on the computer screen.”
One way today’s hospitals are trying to develop a larger pool of experienced emergency nurses is by increasing their investment in on-the-job training. Jones, who has earned a certificate for the ENPC (Emergency Nurses Pediatric Course) as well as the TNCC, ACLS and PALS, is a good example of a minority nurse who performs this crucial educational function within a hospital ED setting. “I precept most of the new staff that comes in, whether they are nursing students, nurse interns, ED technicians or newly hired RNs,” she says.
Jones created Howard University Hospital’s ED training and orientation program, which puts heavy emphasis on hands-on learning. In addition to classes on topics like pediatrics and critical thinking, preceptees closely shadow Jones and other ED nurses in their clinical settings. The training program also includes mock Code Yellows, mock traumas and other simulations that teach new staff members how to think and act quickly in unexpected emergency situations.
How important is the Certified Emergency Nurse credential, conferred by the Board of Certification for Emergency Nursing (BCEN)? Although the ENA endorses earning the CEN, board certification is not required to work in emergency nursing, and most of the nurses interviewed for this article agree that the CEN does not necessarily increase a nurse’s chance of being hired over a candidate without certification. Still, says Kuska, “I think that having to take the certification exam and keep up with the CEUs makes you a more well-rounded nurse. Having those letters after your name shows that you are truly committed to your specialty.”
Reaping the Rewards
Despite all the excitement, variety and respect that emergency nurses enjoy, this career is not for everybody. “You will see horrible, terrible things in the ED—gunshots, stabbings, burns, child abuse, car crash victims and more,” Marett cautions. “But it does have exceptional rewards that come when you make a real impact in saving someone’s life.”
Thelma Kuska couldn’t agree more. “It’s very rewarding, because you make decisions that really make a life-or-death difference,” she says. “If you’re an astute nurse who knows what to look for, you can really feel like, ‘Wow, I made a difference today!’
“For example, suppose a woman of child-bearing age comes in complaining of severe abdominal pain. Her blood pressure’s a little low; her pulse is a little fast. You ask when her last period was and she says, ‘Five or six weeks ago.’ So you put the pieces together and think, ‘Maybe it’s an ectopic pregnancy.’ You make the decision and tell the ER doctor, ‘I think we need an OB consult.’ There have been many times when I’ve picked up on something like that and the doctor told me, ‘Because of you, that patient went to the operating room right away. You saved a life today.’”
For More Information About Careers in Emergency Nursing
Emergency Nurses Association
915 Lee Street
Des Plaines, IL 60016-6569
Phone: (800) 900-9659
Fax: (847) 460-4001
Web site: www.ena.org
The ENA’s mission statement emphasizes that “respect for diversity of patients and colleagues is inherent to emergency nursing practice and emergency care.” According to George Velianoff, DNS, RN, CHE, the association’s deputy executive director of nursing, “We are very concerned about recruiting more nurses of color into the profession. There is a tremendous need for more minority emergency nurses.”
The ENA offers many resources for current and potential emergency nurses, including:
Access to the latest scientific research concerning emergency care
Networking opportunities with key governmental, academic and professional contacts
Educational programs, including an emergency nursing core curriculum and continuing education courses
The Journal of Emergency Nursing and other publications
An annual educational and networking meeting
Undergraduate and advanced educational scholarships
Chris Burchill, Ph.D., R.N., C.E.N., still remembers the evening he was attacked by a patient.
“I was on the phone with our social worker trying to help the patient obtain a ride home,” Burchill says. “Without any warning, he began pummeling me with his fists.”
Burchill, a clinical nurse in the emergency department (ED) at the Hospital of the University of Pennsylvania in Philadelphia, sustained facial lacerations and microfractures on his nose and near his eyes. He decided to press charges against the patient, and since the attack, which occurred last year, he has made it his mission to ensure that none of his nursing colleagues are attacked on the job.
“I put together an interdisciplinary group composed of nurses, doctors, ED techs, trauma surgeons, our COO, and director of human resources to look at how we can make the ED safer for staff,” Burchill says. “The hospital has put cameras in ED areas that previously weren’t covered by security cameras, and we also hope to secure training for staff on personal safety and de-escalation techniques.” The group is looking into personal communications badges that nurses and other staff can wear to alert security in the event of an emergency. “We’ve also trained staff to not enter a patient room alone if a patient isn’t acting rationally or is under the influence of drugs or alcohol,” he says.
Burchill is dedicated to improving nurse safety beyond his own hospital as well. He’s currently developing a survey on violence against nurses that he hopes will be approved for distribution at the UPenn Health System’s three hospitals, followed by distribution to the greater Delaware Valley, and ultimately made available to nurses on a national basis.
“Since I was attacked, I’ve learned that often nurses don’t report violence incidents to hospital administrators,” Burchill says. “But if violence isn’t reported, administrators aren’t aware of how pervasive the problem really is for nurses.”
The frequency with which hospital violence occurs is rather shocking. A 2010 study conducted by the Emergency Nurses Association (ENA) found that 8%–13% of emergency department nurses are victims of violence every week.
“I think people might have the misconception that violence goes hand-in-hand with working in the ED,” Burchill says. “Yet nowhere in a nurse’s job description does it say it’s okay to be assaulted.”
Taking action
Violent acts against nurses are increasing around the country, according to the ENA’s research. In October 2010, nurse Cynthia Palomata was attacked and killed by an inmate she was caring for while working at the Contra Costa County Main Jail in Martinez, California. Another nurse was shot by a patient at Danbury Hospital in Connecticut last year. In yet another instance, a patient’s family member shot a doctor at Johns Hopkins Hospital before turning the gun on the patient and himself. Nurses have also reported being spit on, kicked, punched, and verbally abused.
Although many cases of hospital violence occur in the emergency department, it isn’t limited to that unit, as Theresa Brown, R.N., an oncology nurse in Pittsburgh, Pennsylvania, discovered when she was attacked by the wife of a patient.
“The patient and his wife, who I later learned was drunk, had been fighting, and when she lunged at him, I instinctively grabbed for her, hoping to keep him safe. Instead, she attacked me. I had no self-defense skills and I struggled with her until a male nurse and security arrived,” says Brown, author of the new book Critical Care: A New Nurse Faces Death, Life, and Everything in Between (HarperOne, 2010). “The experience made me feel scared for quite awhile afterwards, and I kept replaying it in my mind wondering what I could have done differently.”
According to the U.S. Bureau of Labor Statistics, 46% of all violent acts in the workplace that necessitated time off were against RNs. And in the 2011 HealthLeaders Media Industry Survey, just 40% of the responding health care professionals said nurse leaders have “effectively addressed” workplace hostility.
“There are many reasons that precipitate violence,” says Sharon Canariato, M.S.N., M.B.A., R.N., Deputy Executive Director for the Illinois Nurses Association. “I also don’t believe that the current state of the economy has helped. We’re seeing patients that are sicker and more stressed.”
Rather than wait for hospitals and other health care employers to implement antiviolence programs, some states have sought legislative solutions including mandatory comprehensive prevention programs for health care employers, as well as increased penalties for those convicted of an act of violence against a nurse. Last November, New York State’s Violence Against Nurses law took effect, making it a felony to assault an on-duty RN or LPN. Following Palomata’s death, the California Nurses Association worked with California assembly member Mary Hayashi to introduce a bill, AB 30, that would assure RNs have adequate staffing and safety measures at work.
“Unfortunately, many hospitals don’t change their policies until an adverse event takes place,” Canariato says. “Hospitals are so extremely busy that the creation and implementation of a procedure that prevents a problem takes a back seat to immediate issues that need prompt resolution.”
That’s not to say nurses shouldn’t take action and push for workplace safety programs. “There’s a lot of information available on how to institute a zero tolerance program related to workplace violence,” Canariato says. “Nurses should also get involved with their state nurses’ association. These groups advocate for health care issues affecting nurses and the public through lobbying the state’s legislature and regulating bodies.” The Center for Occupational and Environmental Health of the American Nurses Association is currently working on a violence prevention-training module for nurses with the National Institute for Occupational Safety and Health (NIOSH).
Nurses also need to prepare themselves, taking steps to ensure their own safety on the job. “Never be alone with a potentially violent person. Always have an exit strategy,” Canariato says. “And always report violent occurrences to hospital administration. As nurses we tend not to make waves and will often dismiss or bury a problem.”
Shiphrah Williams-Evans, Ph.D., P.M.H.N.P., B.C., F.N.P., S.A.N.E.-A., an associate clinical professor at the University of South Alabama‘s College of Nursing in Mobile, says some of the red flags that precede violence among patients and their families include anger, hostility, paranoia, displaced aggression, and persistent voicing of unmet needs.
“I encourage all nurses to be vigilant, watch for warning signs of violence, and discuss with colleagues how to diffuse and prevent violent situations,” Williams-Evans says.
Programs that promote safety
Some hospitals have begun taking steps to ensure their staff’s safety. Detroit’s Henry Ford Hospital has had success with metal detectors, confiscating 33 handguns, 1,324 knives, and 97 cans of pepper spray in the first six months of implementation. The American College of Emergency Physicians has recommended other safety measures, including 24-hour security guards, coded ID badges, bulletproof glass, and “panic buttons” medical staff can push.
In the University of Wisconsin Hospitals and Clinics (UWHC) system, a new program utilizes a green-yellow-red color-coded alert system to show the current security status, with lights in strategic places in the department.
After having two employees injured in the ED in 2007, we put together a multidisciplinary team of physicians, nurses, and security to look at our current security processes and what we could do to improve safety,” says Tami Morin, an emergency department clinical nurse manager at UWHC. “We looked at past videos of incidents that had occurred and examined what we could do to prevent situations from escalating to the point of violence.”
UWHC nurses now go through a four-hour training program designed to teach them how to de-escalate situations and to protect themselves. If a situation starts to take a violent turn, nurses are encouraged to step back and call in a behavior response team, composed of ED techs and security trained to handle violent situations. Data shows the UWHC program, implemented last year, seems to be working. While there were several injuries reported by ED staff in the two-year period before the color-coded system, there was only one reported staff member injury and no injury-related staff absences after the safety program was introduced.
When incidents suggest a higher risk level for violence, such as patients exhibiting behavioral problems, the department’s status changes from green, business as usual, to yellow, potential for disruptive behavior. A red status signals the potential for loss of control in any part of the ED. During a “code red,” the ED restricts visitor access and goes into lockdown while security members cover all department entrances.
“The system helps staff to [be] better able to identify people at risk of individual violent behavior and know when to cue a potential change in security status,” Morin says. The hospital is now looking into personal communication badges that allow nurses to hit a button and obtain immediate assistance, and it is also examining the handling of verbal abuse in the ED.
“It’s not okay to walk into a school or a grocery store, or any other public place, and verbally assault the person who is helping you,” Morin says. “It’s not okay to do that in the hospital either, and we’d like to see a policy in place noting that if you verbally assault a hospital staff member that there will be consequences.”
Training and solutions
At Seattle Children’s Hospital in Seattle, nurses are taught how to assess potentially violent situations as part of their new-hire orientation.
“Nurses are encouraged to ask patients and their families how they are doing and how to recognize and intervene in potentially escalating situations,” says Ann Moore, R.N., M.S., director of the hospital’s inpatient psychiatric unit. “People who are stressed often don’t cope well and it can come off as angry or hostile. If our nurses encounter someone like this, the best intervention may be to call in a social worker or pastoral care who can better help the person manage their emotions.”
In Seattle Children’s ED, a “code purple” has been established to identify incidences of aggression or high-risk events. Psych nurses and social workers are on call to help resolve potential conflicts. “If a nurse senses that a situation may be getting out of hand, we encourage them to call on the psych nurse or social worker rather than to try and handle the situation themselves,” Moore says.
The training also emphasizes listening skills and how to read patients’ body language. “It’s often easy to forget that what is just another day at work for us is actually their worst day,” Moore says. Often, it’s the little things that make a big difference, like having nurses and other staff members introduce themselves and ask patients and their families, “What can I do to help you right now?”
“All too often we get busy with our own agendas,” Moore says. “Sometimes we just need to pause and ask a family member what they need at that moment. It could just be someone to sit with them while their child is undergoing testing, or for us to call another family member or friend to come and be with them.”
AnnMariePapa, D.N.P., R.N., C.E.N., N.E.-B.C., F.A.E.N., and President of the Emergency Nurses Association (ENA), says her organization’s new toolkit can help many nurses address on-the-job violence. (Visit www.ena.org/IENR and click on “Workplace Violence Toolkit” for more information.)
A recent ENA study found that over half of emergency department nurses experienced some form of verbal or physical abuse by patients or patients’ friends and relatives within the previous seven days. In three out of four cases, according to the survey, hospitals did not respond to nurses’ reports of violence.
“Our toolkit provides nurses with the resources to create a project plan that supports quality improvement in the ED through identification, evaluation, development, and implementation of a process towards decreasing and preventing workplace violence, thus working towards creating a safer environment for nurses and patients,” Papa says. “There are worksheets, sample forms, and more that help the nurse and the hospital develop an appropriate violence mitigation plan for their facility, and can be used in units other than the ED as well.”
Papa also cites MOAB Training International, Inc. (www.moabtraining.com) with teaching hospital staff to recognize, reduce, and manage violent and aggressive behavior. A cross-disciplinary corporate program, MOAB also trains workers in compassionate methods of dealing with aggressive people both in and out of the workplace.
“There are several different independent programs that can be brought in house for all staff training,” Papa says. “One of the key elements is partnering with the hospital security staff. Any training, in order to be effective, needs to complement the approach and mindset of the security personnel.”
Nurses should not be afraid to go to work. With a team-based approach to emergency preparedness, they won’t have to be.
Edwin Drummond, RN, never knows what kinds of cases he’ll see as a flight nurse. He might treat a young man who has lost his leg in a motorcycle accident or an elderly woman who fell down a flight of stairs or a child with severe burns. But as he straps on his helmet and steps aboard the whirring helicopter, there is one thing he does know: Someone’s life will depend on him.
With such widely varying challenges and tremendous life-and-death responsibility, a career in flight nursing or medical transport nursing isn’t for everybody. But for those nurses with the right training, experience and personality, the soaring rewards can’t be beat.
“When you fly to the scene [of an accident or other emergency], everyone’s waiting for you, and you get to intervene and save a life,” says Drummond, an African- American flight nurse for Washington Hospital Center’s MedSTAR Transport emergency medical helicopter service in Washington, D.C. “When it goes well, it makes you really feel good.”
Air medical transport dates back to 1870 when hot air balloons were used to evacuate wounded soldiers during the siege of Paris in the Franco-Prussian War, according to a history compiled by Washington Hospital Center. Later, the U.S. military’s use of planes and helicopters in World War II, the Korean conflict and Vietnam led to the development of air transportation systems for civilian medical needs. In 1972, St. Anthony’s Hospital in Denver, Colo., began “Flight for Life,” the first dedicated hospital-based air transport service. Today more than 300 such services in the United States help save people’s lives.
The standard flight crew on a medical transport helicopter or airplane typically includes a pilot, a paramedic and a nurse; additional crew can be added when necessary. A small percentage of air transport services employ doctors as part of their flight crews. The crews transport patients from one hospital to another as well as fly to scenes of accidents and disasters.
A Rising Demand
Resources for Learning MoreThe Air & Surface Transport Nurses Association (www.astna.org), also known as the National Flight Nurses Association, is a nonprofit organization of about 1,600 members dedicated to advancing the practice of transport nursing and enhancing the quality of patient care. It has two regional chapters plus special interest groups for nurses specializing in ground transport, fixed-wing (airplane) and rotor-wing (helicopter) flight nursing, military, pediatric, neonatal, and maternal/HROB (high-risk obstetrics). Among other things, the association’s Web site features information about flight nurse and transport nurse education, job openings and an excellent FAQs section with links to other resources. FlightWeb (www.flightweb.com) provides news, information and resources for air medical professionals around the world and maintains a list of job openings. The American Association of Critical-Care Nurses (www.aacn.org) and the Emergency Nurses Association (www.ena.org) provide a wealth of information about education, clinical practice and certification in these two specialties. Strong background and experience in these areas is usually considered a prerequisite to a career in flight nursing.
Demand for flight nurses is growing, says May Wykle, RN, PhD, FAAN, FGSA, dean of the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio, which in 2002 launched the nation’s first degreed program for training flight nurses. With the reorganization of the health care industry, fewer medical facilities offer critical care and trauma services, Wykle notes. As a result, more air medical personnel are needed to transport patients to centers that offer specialized care.
Today’s air transport services are more than just fast ambulances, says Professor John Clochesy, RN, PhD, FAAN, FCCM, one of the directors of the university’s National Flight Nurse Academy. Instead of just maintaining the patients during transport, advanced practice flight nurses make onsite diagnoses and treatment decisions, providing care before the patients get to the hospitals.
Adds Wykle: “The whole idea is to get treatment started as soon as possible.”
In this role, flight nurses have greater autonomy than hospital nurses. Working under protocols, they decide which medications to give, how fast to give them and what other treatment to provide.
“We don’t have a physician in the back of the helicopter telling us what to do,” says Robert Sanchez, RN, a flight nurse and outreach and education coordinator for AeroCare in Lubbock, Texas, a service owned by Covenant Health System. “We have to take our knowledge base and put that to use.”
This independence is a key drawing point, believes Ann Lystrup, RN, BSN, CFRN, CEN, CCRN, a flight nurse for the University of Utah Medical Center in Salt Lake City and president of the Air & Surface Transport Nurses Association (ASTNA).
In contrast to many specialties hit hard by the nursing shortage, flight nurse job openings attract lots of applicants. “It’s very competitive because it’s a dream job,” explains flight nurse Pauline “Butch” Ignacio, RN, BSN, MBA, CCRN, CFRN, NNP, perinatal and neonatal clinical coordinator for Guardian Air in Flagstaff, Arizona.
Getting Your Career Off the Ground
Flight Nursing 101To meet America’s growing demand for skilled flight nurses who can provide airborne critical care to victims of disasters and emergencies, Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, Ohio, has teamed up with the city’s MetroHealth Medical Center to establish the first-ever national degreed program for training nurses in air medical transport. Launched in October 2002, the National Flight Nurse Academy training is offered as a concentration in the nursing school’s Acute Care Nurse Practitioner program, a two-year program that is part of the Master of Science in Nursing degree. Students take courses in professional development, scientific inquiry and advanced practice, as well as clinical courses in acute care nursing. They also complete research projects to further the knowledge base about treating critical patients in transport. And they get hands-on experience during an annual summer training camp and an advanced internship in flight nursing at MetroHealth. During the internship, students accompany flight nurses on missions with Metro Life Flight, a service that has transported more than 50,000 patients since 1982. This year’s summer camp will be held August 9-14 at the university’s Squire Valleevue Farm in Hunting Valley, Ohio, about 10 miles east of the University Circle campus. In addition to flight nursing students, the camp is open to experienced flight nurses, physicians, pilots, firefighters and paramedics. For more information about Case Western Reserve University’s National Flight Nurse Academy, visit http://flightnurse.case.edu.
Most flight nursing programs require a license as a registered nurse, at least two to three years of critical care experience and/or an Advanced Cardiac Life Support certificate and Pediatric Advanced Life Support certificate, according to ASTNA. In addition, the association says, some flight services may require completion of a neonatal resuscitation program, a nationally recognized trauma program and certification as a Critical Care Registered Nurse (CCRN), Certified Emergency Nurse (CEN) or Certified Flight Registered Nurse (CFRN). Some states also require flight nurses to be certified as Emergency Medical Technicians (EMTs) or paramedics.
“The more well-rounded you are, the better,” Ignacio agrees. She is a certified paramedic, a neonatal nurse practitioner and has experience working as a critical care nurse in the ICU and with coronary patients. She also earned an MBA to get a solid business background for management.
MedSTAR Chief Flight Nurse Allen Wolfe, RN, CFRN, TNATC, advises nurses interested in air medical transport to get ICU experience in larger hospitals, where there are more opportunities to work with sicker patients and better technology than in small hospitals. ICU settings provide broader experience than emergency rooms, he adds.
Flight services themselves train their staffs in how to work aboard helicopters and planes. But conferences also offer hands-on training, such as the Critical Care Transport Medicine Conference in the spring and the Air Medical Transport Conference in the fall. Case Western Reserve University, meanwhile, offers a summer training camp through its National Flight Nurse Academy. Open to nurses, physicians, pilots, firefighters and paramedics, the camp provides training exercises to prepare teams for treating critical patients in unstructured environments, such as those following disasters.
It takes more than the right training and experience, though, to thrive in flight nursing. Nurses must also have the confidence to carry out and live with their decisions. Afterward, it’s OK for nurses to question themselves as long as that questioning is productive, Lystrup says. They can’t let that self-questioning eat them alive.
Sanchez believes most flight nurses are Type A personalities. They are driven high-achievers who relish the challenges that come from never knowing what the next case will bring.
They must also be able to work well as a team with their colleagues. “The attitude of ‘I’m the nurse, so we’ll do it my way’ can be disastrous,” says Wolfe, who oversees 16 paramedics and 24 nurses at MedSTAR.
In addition, flight nurses must be able to comfort patients and families under stressful conditions–a skill that requires quick thinking, excellent communication and empathy. Drummond recalls arriving at an accident scene involving a mother and her two-year-old son. Their injuries were mostly superficial, but the mother was upset and the boy was inconsolable. Knowing the child needed to be close to his mom, Drummond had the two of them placed on the same stretcher and the boy calmed down. “As a father of four, I knew what that child needed,” he recalls.
Leaving Your Comfort Zone
Even for nurses who have what it takes to thrive in flight nursing, the sheer responsibility can be daunting at first. Wolfe recalls his first flight 13 years ago: “I was so nervous I put my helmet on backward.”
Drummond remembers being “petrified” on his first flight. But all the training and his years of experience in the ICU enabled him to make the right decisions for his patient, he adds.
Wolfe says it takes most flight nurses about a year to get comfortable with flying. But that comfort must never turn to complacency, he warns. Safety is paramount, and the entire crew must stay on guard against danger. Nurses and paramedics on board, for instance, help the pilots look for any obstructions to be avoided when landing at accident or disaster scenes.
And nurses must never believe they know it all. There’s always more to learn, Lystrup stresses, and continuing education is a top priority. When they are not flying, flight nurses spend time updating and expanding their skills through lab work, courses and conferences. They also teach other local medical professionals at smaller medical facilities, fire departments and ambulance services, and they instruct police and fire officials on how to help prepare emergency sites for helicopter landings.
Professionalism is critical, not just in how flight nurses treat their patients and co-workers, but in how they interact with everyone they encounter–from police officers to hospital emergency room doctors. Flight services compete with one another for business and they are judged by the conduct of their crews. “When you’re a flight nurse, you’re a walking advertisement for your program,” Ignacio says.
Diversity in the Skies
Statistics on the number of racial and ethnic minority nurses employed as flight nurses are difficult to find, but minority nurses who work in the field say the percentage is tiny. Wolfe says he knows of only three African-American male flight nurses, himself included, and they all work for MedSTAR.
The low numbers may be related to the fact that there are relatively few nurses of color in critical care nursing, where most flight nurses work before taking to the skies, Sanchez points out.
As in other nursing specialties, achieving more racial and cultural diversity in the flight nursing workforce will greatly enhance the profession’s ability to serve patients from a wide range of backgrounds. Sanchez says his Spanish speaking skills are helpful because his service flies to a lot of U.S./Mexican border towns where patients often don’t speak English. “It’s a lot easier to put people at ease when you’re able to converse with them and they know you understand and you’re not just guessing at what they’re saying,” he comments.
Ignacio, who is of Filipino descent, advises nurses considering a possible career in flight nursing to learn as much as possible about the field to decide whether it’s right for them. “Don’t just get stars in your eyes,” she cautions. “Don’t do it just for the flight suit and for the glamour.”
Nurses should make sure they’re prepared to deal with the stress of never knowing what might happen next, and that their families can accept the risks. Despite the industry’s keen attention to safety, accidents can happen. “I have lost friends,” Ignacio says. When evaluating potential employers, she emphasizes, be sure to check flight services’ safety track records and consider the financial viability of the programs.
During her orientation as an emergency nurse at Kaiser Permanente Hospital in Hollywood, Calif., Katherine Bolden, MSN, RN, helped care for a man who had come to the ER after falling and hitting his head. The medical staff suspected that he had suffered a serious injury, and the doctor ordered tests. A CT scan revealed a brain bleed. The medical team rushed him to the operating room, and he underwent emergency surgery.
“We saved him,” Bolden says. “Later I heard he recovered and walked out of there.
” Bolden’s life was changed forever, too. From that day forward, she was hooked on emergency nursing.
Minority nurses can make a profound impact in emergency care—the front lines of today’s health care system. Emergency nurses treat an unusually diverse variety of patients and conditions, from infants with colds to elderly heart attack patients to victims of stabbings and shootings. They care for people from every walk of life and cultural background, including patients from the most vulnerable and underserved populations, many of whom come to the emergency department because they have no other access to health care services.
Emergency nurses thrive on unpredictability and variety. They don’t call themselves “adrenaline junkies” for nothing. Yet the rewards of this career come as much from comforting a patient’s family members as from saving a car accident victim.
“You’re [providing care to] patients at the worst times of their lives, when they need it the most,” says William Briggs, MSN, RN, CEN, FAEN, trauma program manager at Tufts Medical Center in Boston and president of the Emergency Nurses Association (ENA).
Briggs, who coordinates services for injured adult patients at Tufts, has been interested in emergency medicine since high school, when he taught first aid and became an emergency medical technician at 17.
“I was always kind of [drawn to] the emergency room,” he recalls. “I like taking an unsolved problem and solving it, creating order out of chaos.”
No Shortage of Opportunities
The nursing shortage hasn’t hit emergency care as hard as some other specialties, Briggs says. But career opportunities for current and prospective emergency nurses still abound. Hospital emergency departments employ clinical nurse specialists, pediatric and psychiatric nurses, transport team nurses and case managers.
Demand is also growing for emergency nurse practitioners (see sidebar), who provide care in a variety of settings, including large urban emergency departments, rural and military hospitals, ICUs, adult internal medicine units and even walk-in clinics.
Katherine Bolden, MSN, RN
One of the primary reasons why emergency nurses are in such demand is that hospitals throughout the country are struggling to keep up with patient loads in emergency rooms. While emergency visits have risen by 36% since 1996, 5% of the nation’s emergency departments have closed, according to statistics from the Centers for Disease Control and Prevention (CDC).
Overcrowding is the biggest challenge emergency nurses face today, says Briggs. On busy days, patients may lie on stretchers in crowded corridors, waiting hours and hours for beds.
“It’s a national crisis right now,” he declares. “Every [emergency department] is busier [than it used to be].”
Five years ago, Massachusetts General Hospital in Boston saw 180 to 200 patients a day in its emergency department. Now it sees 260 a day, says Maryfran Hughes, MSN, RN, nursing director of the hospital’s ED/observation unit. A variety of factors are causing this surge in emergency room use: an aging population, a shortage of primary care physicians and a growing number of uninsured patients who lack access to other sources of health care.
This favorable supply/demand equation also makes emergency nursing an attractive option for career-changing nurses who are looking for a more challenging, exciting specialty. Bolden, for example, became an emergency nurse after working for more than eight years as a health educator.
“It was almost like being a new grad again,” she remembers.
“It was a little scary at first. I wondered, ‘Am I going to be able to handle everything that comes in?’ In the first six weeks I lost 15 pounds, because I went from working in an office to what I now call ‘real nursing.’”
She asked lots of questions and found support and camaraderie among her fellow emergency nurses and physicians, who trusted and consulted one another. A collegial relationship with doctors and other members of the health care team is one of the biggest benefits of the emergency nursing specialty, where nurses often have greater autonomy and more say in patients’ care than they would in other parts of the hospital.
“There’s no way you could do it alone,” says Linda M. Redd, RN, an emergency nurse at Massachusetts General. “Patients are overflowing into hallways and are constantly being moved. It would be easy to lose track of people if you weren’t working as a close-knit team.”
The Culturally Competent ED
In its position statement on diversity in emergency care, the ENA emphasizes that a diverse and culturally competent nursing staff is essential to meeting the needs of today’s multicultural patient base. The specialty has a great need for more minority nurses who can help break down cultural and linguistic barriers to provide better quality care in emergency settings.
“When [emergency] patients come in and are very anxious, it’s important for them to be in an environment where they know they’ll be comfortable and will be able to bond with someone,” says Hughes.
She cites the example of an elderly Muslim woman who came to the ED complaining of stomach pain. The doctor ordered an MRI, and the woman became upset at the idea of having to remove her headscarf. The medical staff only wanted to ensure that her clothing contained no metal fasteners, which would pose a safety hazard and ruin the images because of the machine’s powerful magnetic field. A nurse whose grandmother was Muslim talked with the patient, letting her know she understood her concerns, and explaining the procedure and safety precautions. Because she shared the woman’s cultural background, the nurse was able to make a personal connection with the patient. Together with the staff, they worked through the issue and the woman successfully underwent the MRI examination.
The Emergency Nurses Association on Diversity In 1997, the Emergency Nurses Association (ENA) published a position statement on diversity in emergency care that makes a powerful case for why more nurses of color should consider pursuing careers in this specialty. Here’s a brief excerpt: “Diversity is particularly significant in emergency settings as care is inherently episodic, discontinuous, and represents the point of entry to health care services for many cultural groups. “Ethnocentrism, prejudice, bias, stereotypes and ignorance of cultural differences pose a negative impact on emergency care provision and outcomes. Cultural differences affect patient assessment, teaching and compliance with plan of care. Furthermore, lack of culturally congruent and culturally competent emergency care is associated with costly, ineffective care characterized by multiple patient visits to the emergency department requiring unnecessary diagnostic and treatment procedures. Lack of cultural competence is a barrier to effective communication with patients and their families and among professional caregivers with consequent impact on practitionerpatient relationships and collaborative interdisciplinary team relationships… “It is the basic human right of all people to access culturally congruent and culturally competent emergency care.” For more information about the Emergency Nurses visit www.ena.org.
Bolden recalls an African American couple who took offense at a security guard’s instructions in the emergency room where she works. She intervened and talked with the couple to clear up the misunderstanding. “It helps to have a person from the same culture to smooth things over,” she says.
Redd agrees that minority patients are likely to experience less stress in the emergency care setting if there are nurses and doctors who look and talk like them. What’s more, she adds, a pool of culturally diverse nurses can help one another learn to provide better care to patients who are different from themselves.
“We teach each other,” she explains. “I’ve learned so much culturally from watching other nurses work with patients.”
Language differences can create enormous barriers. Briggs says more bilingual emergency nurses are urgently needed to bridge communication gaps with patients who speak little or no English. “If you have to find an interpreter every time you have to speak to the patient, you’re going to lose a lot of [time and] communication,” he emphasizes.
According to a study by Sharon M. Jones, MSN, RN, published in the June 2008 issue of the Journal of Emergency Nursing, five Caucasian, non-Hispanic nurses at a Midwest hospital reported that the language barrier impacted all aspects of care when they attempted to treat Mexican American patients. Only one of the nurses spoke a little Spanish, and she was the only one who described being able to establish a nurse-patient relationship.
Jones concluded that interpreter services should be available 24 hours a day and that emergency nurses should receive training to learn basic Spanish and to gain an understanding of Hispanic cultural considerations that can impact nursing care.
Ready for Anything
What does it take to be successful in emergency nursing? Nurses interviewed for this article stress that critical thinking skills and confidence are paramount.
“You’re kind of like a detective, and you have to be quick [in assessing what’s wrong with the patient], because if you dilly-dally patients can die,” says Thelma Kuska, BSN, RN, CEN, FAEN, who worked for 20 years in hospital emergency departments, including Christ Medical Center in Oak Lawn, Ill., 13 miles from downtown Chicago. “You have to be sure of yourself and be able to stand up for yourself [so you can advocate for the patient]. You need to be knowledgeable to make sure you are giving the correct care to the patient.”
She recalls a 22-year-old newlywed woman who came to the ER with belly pain. Kuska had a hunch, and after questioning the patient she quickly summoned an emergency physician, who ordered an ultrasound. It revealed that the woman had an ectopic pregnancy. Within 30 minutes, the patient was undergoing surgery. Later, when the young woman was recovering from the successful operation, the doctor pointed to Kuska and told the patient, “This nurse saved your life.”
Kuska received her nursing education in the Philippines and immigrated to the U.S. at age 20 to begin her career. Before finding her niche in emergency care, she originally worked as a surgical nurse, in an environment that was worlds away from the fast pace of the ED.
“[In surgery,] everything was laid out, you knew what the patient was coming in for, the instruments had been chosen the day before and the physician was there the whole time,” she explains. “In an emergency department, you never know what will present. It could be a heart attack patient, a car crash victim or a child with a fever. Our doors are always open, the ambulances come in, the patients come in and we treat them.”
There is no such thing as a routine day. “The emergency department is such a busy, busy place. It’s like being bombarded on all sides,” says Redd. “Emergency nursing [brings it all together] for me. I really have the chance to call my entire knowledge base into play.”
The variety can be as challenging as it is stimulating. “There are shifts where one minute you’re holding the hand of a family member whose mother has just died, and then you walk into the next room and you’re blowing bubbles with a four-year-old who’s having his chin sutured,” says Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the emergency nurse practitioner program at Vanderbilt University School of Nursing in Nashville.
What Recruiters Look For
At least a year or two of inpatient experience is recommended for nurses who want to work in the emergency setting. However, because of the high demand, some hospitals are now hiring new RN graduates and offering internship programs in the emergency department.
When hiring emergency nurses, Briggs says, he wants to see passion. “The worst thing an applicant can say is: ‘I want to work in the emergency room because you have the hours I like.’”
Hughes says she looks for nurses who have good clinical knowledge and decision-making skills, as well as the ability to work as a team with other clinicians. Above all, she wants nurses who know how to appreciate the patient as an individual.
“Sometimes [emergency nurses] have just a few seconds to establish a relationship with somebody before we have to give bad news and ask the patient to trust us,” she notes. “You really have to be able to reach the hearts and souls of patients and connect with them immediately.”
The ability to establish bonds with patients’ family members is important, too. Redd recalls an elderly patient with urinary problems, whose wife brought him in to the emergency room.
The man was ill and mentally confused, and his wife was clearly beside herself. Redd took the time to have a heart-to-heart talk with her and helped her come up with an emergency plan so that when the couple went home, the wife would know who to call and when.
Opportunities Beyond the ED
Emergency nurses can also play life-saving roles outside the traditional emergency care setting. After caring for numerous young victims of car accidents, Kuska wanted to do something to help prevent more youths from ending up in the hospital. She volunteered for the Emergency Nurses CARE (EN CARE) injury prevention program.
Two emergency nurses from the University of Massachusetts Medical Center in Worcester, Mass., started EN CARE out of frustration and heartbreak from seeing young lives shattered or ended because of drunk driving. They began presenting alcohol awareness programs to high schools, based on the cold, hard facts of their emergency department experience. The program spread nationwide and became an affiliate of the ENA in 1995, as part of the association’s Injury Prevention Institute. EN CARE has now expanded to include other injury prevention initiatives, such as gun safety and bicycle safety.
By presenting alcohol awareness programs at elementary, junior and senior high schools, Kuska has made a difference in countless young lives. One mother told her that after seeing Kuska’s presentation, her children hid the car keys when their dad planned to go out after drinking. A high school girl who had heard one of Kuska’s talks later told her she had refused to get in the car with her prom date because he had been drinking. She found another way home from the dance.
After working as an injury prevention volunteer for several years, Kuska began doing contract work for the National Highway Traffic Safety Administration’s Region 5 office in Chicago, where she now works full time as regional program manager.
“It’s another face of the emergency nurse that I never knew existed,” she says. “When I worked in the ED, I was saving one patient at a time. Now I’m saving lives [on a much larger scale].”
Emergency Nurse Practitioner: An Emerging Opportunity
Nurse practitioners have been providing emergency care to patients for decades. But only recently have nursing schools begun to offer degree programs designed to train advanced practice nurses specifically for the emergency setting.
Currently, seven graduate schools of nursing around the country offer emergency nurse practitioner (ENP) programs, which incorporate emergency nursing courses and clinical experience into traditional family or acute care nurse practitioner programs.
The University of Texas started the first ENP program more than a decade ago, after a study showed a need for nurse practitioners with broader emergency training. Acute care nurse practitioner programs provided emergency care training but did not cover caring for pediatric patients. Family nurse practitioner programs did not include enough emphasis on emergency care.
Now, besides the programs at the University of Texas-Houston and the University of Texas-Arlington, there are emergency nurse practitioner programs at Emory University in Atlanta, Loyola University in Chicago, the University of Florida in Jacksonville, the University of South Alabama in Mobile and Vanderbilt University in Nashville. While the structure of the programs varies from school to school, the ENP schools stay in close contact to make sure their curricula are aligned with one another.
At Emory University’s Nell Hodgson Woodruff School of Nursing, ENP students take family nurse practitioner courses along with four additional classes in emergency care. They must also do clinicals in primary, urgent and emergency care. Vanderbilt School of Nursing’s program is unique because it prepares emergency nurse practitioner students for dual certification as both family and acute care nurse practitioners. “This allows them to not only care for patients across the lifespan, but also across the acuity spectrum,” explains Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the ENP program.
The majority of emergency nurse practitioner graduates find work in hospital emergency departments. But Michelle Mott, MSN, APRN-BC, FNP, an instructor and interim program director for Emory’s ENP program, says her students have also found jobs in prisons, specialty practices and retail clinics. One graduate now works for a primary/urgent care clinic on a remote Alaskan island. “I’ve never had a student who has had trouble finding work,” Mott adds.
In addition to her academic responsibilities, Mott also works in the emergency department at Grady Hospital in Atlanta. Advanced education in the emergency nursing specialty, she says, gives minority nurse practitioners a greater opportunity to improve health care for medically underserved populations. “You’re able to provide those skills that are the foundation of the philosophy of nursing, but you’re also able to provide management and bridge some of the gaps to provide greater access to care. It’s just a wonderful career path. It uses everything you learn in all of your schooling.”
While emergency RNs can earn such certifications as CEN (Certified Emergency Nurse) and CPEN (Certified Pediatric Emergency Nurse), there is no certification yet for emergency nurse practitioners. For now, these NPs hold either FNP or ACNP certifications, or both.
Wilbeck says more emergency nurse practitioner programs are needed. She believes the number of nursing schools offering ENP programs will grow as the nursing profession increasingly recognizes the value of these practitioners and begins to formalize standards for educating and certifying ENPs. Current ENP programs, she adds, are also looking at expanding and offering distance-learning courses.
Amidst the profound loss and grief that rocked the nation on September 11, the heroic efforts of police officers, firefighters and volunteers have helped renew our faith in the American spirit. But at Ground Zero and beyond, nurses responded to the terrorist attacks with equally inspiring acts of courage and compassion.
From mobilizing on-site assistance for rescue workers to caring for victims from the World Trade Center and the Pentagon to consoling families who searched for missing loved ones to quelling fears about anthrax and bioterrorism, nurses played a critical role in healing the nation’s wounds—not only in the immediate wake of the attacks but in the traumatic weeks that followed.
The nurses who banded together to tackle this unprecedented national emergency came from a variety of backgrounds, regions and organizations, including hospitals, visiting nurses’ associations, the Red Cross and the military. As one New York nurse put it, “I was just doing my job, but it was a life-changing experience.” Here are the stories of four minority nurses who can now add the title of “hero” to their professional credentials.
“Nothing Can Prepare You for This”
Lucille Yip, RN, BSN, an Asian-American nurse who works at St. Vincent’s Catholic Medical Center in Manhattan, lives on the 44th floor of a high-rise building in New York’s Chinatown. On September 11 she awoke at 3 a.m. and for some unknown reason felt compelled to gaze out her window at the breathtaking skyline. She never suspected that the view–and her life–would change forever within hours.
Yip re-awoke to the sound of an explosion and sirens. When she looked out the window again, she saw the Twin Towers burning. After calling family members to make sure they were safe and to reassure them of her own safety, her next impulse was to get as quickly as possible down to her post at the ER.
No subways or cabs were moving and ambulances were racing to the scene, but she spotted a sanitation truck stopping to give a police officer a lift and flagged it down in time to convince the crew to drop her off at St. Vincent’s. “Never would I have thought that I would hitchhike in New York, but it was total chaos in the city,” she recalls.
For the next two days, Yip worked grueling 13-hour shifts in the triage unit. The pain and grief she encountered in her patients during that time was worse than anything she had ever experienced before. “Nothing can prepare you for something like this. Nothing,” she says. In the face of such devastation, the usual humor that the staff typically relies on to help cope with life in the ER no longer seemed appropriate.
“Probably my most memorable patient was a young firefighter,” Yip remembers. “They said it was a crush injury to the chest. He was sitting up and talking, but he looked ashen and gray. In my heart I thought, ‘He’s OK, he’s going to make it,’ but in my head I knew there was no way that a person who had suffered this kind of injury was going to make it. I heard later that he died on the operating table.”
But her most heart-wrenching memories aren’t of patients but of families who had hurried to the hospital in hopes of finding their loved ones there, only to have their hope turn to despair when their search remained fruitless. A woman who worked in one of the Trade Center towers was looking for her husband, who had worked in the other tower. One family rushed into the ER after seeing a false report on the Internet that their son was there.
“They were hoping I could give them some kind of positive news, like ‘Yes, he was here,’” Yip says. “Not being able to help them really affected me. By the second day, I broke down and cried. I’ve never felt that sense of helplessness before. I’ve always been in control, no matter how chaotic it is in the ER. But this time, I just felt like, ‘There’s nothing I can do.’”
By the end of her shift on the second day, she was compelled to visit Ground Zero. “A lot of people asked me why I would want to go,” Yip recalls. But, she explains, working in the ER without any windows or TV or radio made her feel out of touch with what was going on, like being insulated in a sort of Noah’s Ark. “Firefighters, police officers…we were taking care of them and then sending them right back out there. I just wanted to see it for myself, to make a surreal experience real.”
She convinced a police officer to take her to the site. Although she had long been familiar with the area—it had been a favorite shopping destination of hers—she says that when she saw the devastation, she didn’t even know where she was. “I had to hold on to his arm. He asked if I was going to be OK and I said, ‘Yeah, yeah, I’ll be fine. You go on ahead.’ But of course I wasn’t fine. I stood there for half an hour. I felt literally numb.”
On her walk back home, the nurse encountered a seminary student who consoled her and led her to a church across the street from the towers that, amazingly, had remained unharmed. “I just sat there in the church and wept,” she says. “I wept for the firefighter who died, I wept for my sister who thought she was going to die on the smoke-filled train, I wept for the families I was unable to help. I wept for all those bodies that are still buried there.”
Although colleagues had marveled at Yip’s composure in the ER, she broke down at home. She couldn’t sleep more than a few hours each night for that next week, she couldn’t eat and she started losing weight. Her husband, a New York restaurateur, finally took her away for the weekend to visit family in New Hampshire. Only after going to church there did she start to recover.
Looking back on her unforgettable experience in the ER on September 11 and 12, Yip feels more than ever before that she made the right choice when she decided to become a nurse. “I’m hoping that I did make some impact on the families,” she says. “It’s so rewarding to touch a person’s life, whether it’s by healing them or just saying something comforting. I don’t believe you have to be a nurse to do that, but it’s at the heart of what our profession is all about.”
As for the impact on her own life, “I never took life for granted,” she states. “But [the events of September 11] have sort of made the colors in life a little brighter. I’m more introspective now, more thoughtful and I am even more thankful for what I have.”
Coming Together in a Crisis
Just a year ago, nurses at Washington Hospital Center in Washington, D.C. walked off the job as part of a bitter labor dispute over working conditions and staff shortages. When the strike was settled six weeks later, some of these nurses did not to return to the facility. Yet when the Pentagon was attacked on September 11, many of them put aside their differences and returned to the hospital to pitch in.
“They knew they were needed and that they had a valuable skill that not many people have, so they came in to help us in whatever way they could,” remembers Melissa Velazquez, RN, a nurse in the hospital’s Burn Intensive Care Unit who had been on the union’s negotiating team during the strike.
To Velazquez, who had testified on nursing shortages before the House Committee on Education and the Workforce just two weeks after the terrorist attacks, her former colleagues’ loyalty underscores the dedication and sacrifice that characterizes the nursing profession as a whole.
“It made me very proud to be among people of that caliber,” she says. “It was so gratifying to know that when people are faced with adversity and crisis, they can put away whatever negative feelings they might have and simply do the task at hand.”
Velazquez, who is of Puerto Rican descent, was not scheduled to work on September 11. But when she learned that the Pentagon had been hit, she made arrangements for someone to watch her seven-year-old daughter and drove the 40 miles from her home to the hospital, which was the nearest regional burn center to the site.
Her help was urgently needed. The 10-bed burn and surgical unit, which already was full, took in six new burn patients that first day. “That may not seem like a lot in terms of numbers. But in terms of intensity, acuity and the amount of time it takes to care for those patients, it’s a huge number,” she explains. The least severe patient had endured burns to 40% of his body.
Three or four nurses working for half an hour are needed just to get one burn patient bathed and to apply dressings. Then the patient needs to be resuscitated and IV fluids must be administered. “Not only is it mentally overwhelming, it’s also extremely labor-intensive,” Velazquez says. She ended up working 12-hour shifts for the next two days.
One patient she cared for during those days only started talking again months later. “It was the first day he ate food—pizza–and [the nursing staff] were all cheering and screaming,” she smiles. “It’s just little things like that, the turning points we can get patients to, that just tickle us to no end. Those moments are what makes it all worthwhile.”
Velazquez says her pride for what she and her colleagues accomplished in the aftermath of the attacks is bittersweet. While the heroism of police and firefighters has received national recognition, the equally heroic efforts of nurses still remain largely unsung.
“Nurses are very much a group among themselves that really has to rely on each other for support and accolades and things of that nature,” she points out. “Sometimes it seems like the public really doesn’t understand how much work we do and how much heart and soul we put into that work.”
What will she remember most? “The way everyone came together to just do what needed to be done,” Velazquez replies. “We kicked some butt! I will always remember that–the teamwork, the camaraderie, the individual moments with patients. Those are the things that are going to stick with me for the rest of my life.”
A Muslim Nurse’s Perspective: “We Are Americans, Too”
At the cue to carry the American flag across the stage at the opening ceremony of the Transcultural Nursing Society’s 2001 conference in October, a nurse from Pittsburgh did the honors.
Only this was no simple act of patriotism. Kawkab “Kay” Shishani, MSN, a PhD student at the University of Pittsburgh School of Nursing who had come to the U.S. from Jordan just 10 months earlier with her husband and four children, was hoping to send a strong post-9/11 message to her colleagues, fellow students and friends.
“I wanted all the people at the conference to know that the flag means the same thing to me as it does to them,” explains Shishani, who drew thunderous applause as she strode to the stage in traditional Muslim dress. “There’s a general feeling [in the U.S.] that Muslim people are barbarians, people who hate America and like to die. That’s not true.”
Her voice breaks with emotion and she struggles for composure as she talks about the biased stares and vicious comments her family and other people of Middle Eastern descent who attend the mosque in her neighborhood have endured in Pittsburgh’s streets and shopping centers since Osama bin Laden became a household word.
“We are people like everybody else,” she says. “We love to live. We have children. We care for ourselves, we care for others. By carrying the flag, I hoped that people would see someone like me presenting these American values and realize that the stereotypes about Muslims that they see on TV are not right.”
Like everyone else in the world on September 11, Shishani and her family were glued to the television screen in horror as the Twin Towers collapsed and survivors fled through the wreckage. For her, these images were not only tragic but a painful déjà vu of her own experience during the Gulf War and the ongoing tensions and violence that still flare across the Jordanian borders in Iraq and the West Bank.
“[As nurses in Jordan,] we saw many horrible things—many, many patients who came from both sides [of the conflict],” she remembers. “We saw severely injured children and many kinds of cancers and amputations.” Never had she imagined when she temporarily left her teaching position at Hashmite University outside of Amman to study in the United States that she’d be witness to the same kinds of events.
“Since September 11, all my past memories are intensified,” says Shishani, who points out that some of the World Trade Center employees who died that day were Muslim. “My family was watching the TV and we saw the families who had lost loved ones and were in pain. We wanted to help them bear their pain and grief. We wanted to do something.”
Her first impulse was to join the relief efforts and fly immediately to New York. “My husband was very encouraging. He said, ‘OK, I’ll take care of the kids and you go.’”
But as revenge-inspired acts of violence against Arab-American communities began to erupt in many parts of the country, Muslim women were being encouraged to remain indoors to avoid retaliation, since their traditional dress was easily distinguishable. So Shishani stayed at home for a week, suspending her class study and keeping a close eye on her children, who were having difficulty coping with the confusing messages on TV and at the public schools they attended.
“My kids were so traumatized by this,” she says. “They know that Muslim beliefs do not advocate violence, and yet they were hearing something completely different on the TV, people saying that Muslims are killers and terrorists…It was like they were being attacked too, because of their beliefs.”
So instead of flying out to Ground Zero, the Jordanian nurse responded to the crisis with a different mode of healing. She and other Muslim parents who attend her mosque formed a support group for their children to let them vent the emotions they were feeling. They held one session every few weeks for about 15 children ranging in age from seven to 14.
“Our main goal was to let them express their feelings of anger, frustration and depression,” says Shishani. “We also wanted to reassure them that they should not feel ashamed of who they are or what they believe in, and that they should always stand up for themselves.”
In contrast to the angry reactions she and her family encountered in parts of the city, Shishani says other nurses have been especially warm and welcoming to her in the wake of the terrorist attacks. When she didn’t go to classes, she received many calls from professors and classmates offering to help her with shopping or getting to the campus. “They were highly supportive,” she emphasizes, “and I think that without that support I would never have been able to go back to school.”
Like the message she hoped her flag-bearing role at the nursing conference conveyed, she believes that Muslim nurses in the aftermath of September 11 have an important opportunity through their work to help the nation heal its wounds—including those caused by prejudice and stereotypes.
“Nurses work with a wide range of people in public and community settings,” she notes. “Muslim nurses go can out and talk about their religion and represent [our people] for who we really are. I think that people will listen and that perceptions can be changed.”
Next Stop: Anthrax Education
As a nurse educator, Peter Allar, RN, says he’s always trying to figure out the most effective way to provide public health training. But in the days following the World Trade Center attack, he discovered an unlikely podium: the New York City subway.
It was Allar’s job as the clinical nurse instructor for the ER at St. Vincent’s Catholic Medical Center in Manhattan to help teach the medical staff and patients about how to deal with the risks of different forms of bioterrorism, particularly as reports of anthrax cases suddenly started to surface in Florida, New York and elsewhere.
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Since cyanide antidotes and plutonium decontamination are more the stuff of science fiction novels than nursing school textbooks, he had to teach himself about the subject–and quickly. For days he pored over medical journals, the Internet and books from the Defense Department.
Surprisingly, though, his message transcended the hospital walls. On the subway ride home one night, Allar (who is Caucasian but is considered a minority in the nursing profession because he is male) noticed that he had attracted the attention of a captive audience as he was rattling off information to a group of nursing graduate students about the best strategies for fleeing a chemical attack.
“In New York, everybody listens to what everybody else has to say,” he explains. “So other passengers around us started saying, ‘You know, that’s a really good idea’ and ‘You mean I’m in the safest spot right here?’”
Allar seized the moment. “We had mini-lessons right there in the subway,” he recalls with a laugh. For instance, he told his fellow riders that the safest place to stand in a crowded train is next to an emergency exit, rather than in the middle of the car, so that it’s easier to get out fast if the train is infiltrated by chemical agents.
He also demonstrated how to stand on top of the seats if you can’t get out, since chemicals are usually denser than air and will sink. “If you act fast and act smart and keep your wits about you, you can not only keep yourself alive but help other people escape, too,” he notes.
Despite their surreal quality, Allar’s words were welcomed. “A lot of people were saying, ‘We really appreciate that you’re telling us these things. You’re calm about it and you’re really focusing on the positive things we can do to handle the situation.’”
Allar had played a similar role in providing a sense of calm amidst the madness around him during the ER’s two 17-hour shifts immediately following the World Trade Center attacks. “Every single person who came in to the unit was falling apart,” he remembers. “Everybody’s idea of stability was wiped out.”
There was the veteran firefighter and batallion chief who told him, “I saw my entire crew die before my eyes.” Or the young rookie who rescued his partner from one of the burning towers only to find outside that the body he was carrying had no head.
“What can you possibly do for people like that?” Allar says with a sigh. The answer he settled on: “You just kind of console them, try to make them feel OK and safe, and give them time to verbalize their feelings.”
He believes the ER staff, notorious as “the wild bunch” of the hospital, gained a newfound respect that week. Cardiac surgeons readily took orders from ER nurses to search the hospital for more burn ointment and tetanus shots. People from the community visited the ER, bringing with them not just injuries and fears, but plates of food and other offers of help.
“They were saying–and they still say—‘I don’t know how you people do what you do down there,’” Allar relates. “I was really proud of us, actually, for the job we did. You’re never really totally prepared [to deal with such a huge crisis] and you’re always looking for what’s going to come next. You just kind of hope and pray that it’s nothing too terrible.”
Does he consider himself a hero? “No. But I feel good about the contribution I made. I feel it’s made me stronger as a person and also stronger as an American. I feel like if something terrible happens to my country or my community, I know I’ll be able to deal with it and respond in a good way.”
