Hospitals remain the top employers for nurses, but they are certainly not the only places where nurses can find a fulfilling career. Some may find that their true passion is in helping others outside the confines of an inpatient setting. And luckily, that is possible. There is a great need nowadays for compassionate and skilled nurses who can serve people in the community setting. Listed here are just a few examples of specialty areas in community health that nurses may want to consider.
Hospice and Palliative Care Nursing
Hospice nurses provide comfort-focused care to patients who have a life expectancy of six months or less. Palliative care, though sometimes used interchangeably with hospice, is slightly different in that patients do not necessarily have to be in the terminal phase of their disease process. Palliative care nurses care for seriously ill individuals who are dealing with discomfort as a result of chronic diseases or treatments used to manage these diseases. Regardless of the technical differences between them, both hospice and palliative care nurses specialize in symptom management. Rather than focusing on curing patients, hospice and palliative care nurses promoting comfort, which may involve managing chronic pain, respiratory distress, or nausea, among other things. While some hospice and palliative patients are cared for in hospitals, many also receive care in their homes.
If you are skilled with IVs, then you might consider working as an infusion nurse. Infusion nurses start and maintain various kinds of intravenous lines. Not only do they administer medications, but they also provide monitoring for their patients to make sure that treatments are effective and are not causing any adverse effects. Those who have had a lot of experience with IVs in the hospital setting might find this type of nursing appealing. Many companies, including home health agencies and pharmacies, are hiring skilled nurses who can provide infusions to patients in the community.
Wound Care Nursing
Wound care nursing is a specialty area for nurses who have a passion for helping patients afflicted with wounds, some of whom have chronic and debilitating injuries that put them at high risk for infections. Among the people who require the services of wound care nurses include bedbound patients, diabetics, patients with chronic circulation problems, and patients who have had accidents or surgeries. If you are interested in this kind of nursing, you may also want to consider getting some type of certification in wound care nursing. Your expertise will be valued by many organizations and you may see patients in their homes as a traveling consultant for durable medical equipment companies and healthcare agencies that specialize in wound treatment.
Worker’s Compensation Nursing
Getting injured at work can affect one’s life in many ways. Depending on its severity, workplace-related injuries may affect more than just one’s physical health. Losing the ability to work can also cause mental and financial strain. As a worker’s compensation nurse, you will have the opportunity to help these individuals get their life back on track. You will have the role of a case manager who will ensure that your patients get the high-quality treatment necessary to restore them to their highest level of function.
When you think of an educator, you may picture someone who is in a classroom, lecturing and scribbling notes on a chalkboard. While nurses do teach in academic settings, there are also nurse educators who work in the community. These are nurses who may work for pharmaceutical or medical equipment companies that are selling highly technical products. The job of nurse educators, in these cases, is to assist other health care providers in understanding how these products work so that they can be safely utilized in clinical settings.
Public Health Nursing
Public health nurses wear many hats. They may go out and educate communities about preventing the spread of certain types of diseases. They may go into clinics to provide vaccinations. Other times, public health nurses may visit people in their homes to ensure that they are living under humane and sanitary conditions. In some cases, they may also function as medical case managers for underserved individuals in the community. Whatever they do, the main role of public health nurses is to safeguard and promote the health and well-being of the communities they serve.
One of the beauties of the nursing profession is the sheer diversity of available opportunities. Inpatient settings, like hospitals, are just one of the many places where nurses can share their talents and make a difference. Nurses have a lot of freedom in shaping the course of their careers and if you are looking for a change of pace, now could be your chance to do so. Who knows, you just might find your calling as a community health nurse.
When Felicia Menefee, RN, NP, ACNS, recruited patients for the landmark African-American Heart Failure Trial (A-HeFT), little did she know that the study would yield such positive results for them—or future patients.
Since African Americans with advanced left ventricular heart failure do worse than Caucasians in all phases of this condition, scientists wanted to see if adding a potent nitrate-vasodilator-duo to their standard therapy would make a positive difference in their symptoms, hospitalizations, and daily activities. What was the target of this National Institutes of Health study? A fixed-dose combination of isosorbide dinitrate (ISDN) plus hydralazine (HYD).
When researchers discovered that patients on the drugs indeed functioned better clinically than previously (some even energized enough to exercise), they halted the blind study prematurely. In doing so, they also handed the US Food and Drug Administration (FDA) enough data to demonstrate that survival and quality of life indeed increased, while hospitalizations decreased, on the medications. The FDA approved ISDN/HYD in June 2005 for heart failure therapy in blacks.
A-HeFT is just one of a myriad of NIH- and industry-sponsored drug and device trials Menefee has participated in during her 17 years as a nurse practitioner with Kansas City-based St. Luke’s Cardiovascular Consultants. Staffed by 48 cardiologists, many of whom are tied to academia, the practice provides ample opportunity for her to participate in clinical studies.
“Research is extremely important in advancing medicine,” she says. “Without it, health care stagnates. But with drug and other studies we can improve care. Sometimes a trial’s results are negative; sometimes they’re positive. But we won’t know unless we do it.”
Primed for Drug Studies
Perhaps you have the same curiosity as Menefee in advancing new pharmaceuticals or expanding indications for existing ones. What role can you play to help develop the next cutting-edge prescription or the newest use for an over-the-counter standard?
Truth is that unless you’ve piggy backed your nursing experience onto another degree—perhaps pharmacy, biochemistry, or medicine—your contribution likely won’t be in a drug company (or academic center) laboratory. Pharmaceutical scientists involved in the discovery or refinement of new medications typically bring masters and PhDs in the hard sciences to a company’s research and development function.
But that doesn’t mean your experience isn’t valuable. Clinical knowledge, critical thinking skills, and caregiver intuition can be a perfect match for other positions directly impacting medications. In fact, by parlaying and building on your background, you can ensure that what scientists produce in the laboratory is both safe and efficacious in real people. Whether you’re coordinating clinical drug trials in a patient setting, fielding adverse events for a pharmaceutical company, or playing another role, you can find a rewarding frontline niche.
As Sherry Banez-Muth, RN, manager of coordinating services, Center for Clinical Studies, Washington University School of Medicine, St. Louis, observes: “It’s definitely satisfying when you see people taking a new treatment that may be life-changing. It’s a good feeling to say, ‘Wow, I contributed to this.’”
Coordinating for Results
The good news for nurses and nurse practitioners is that you don’t have to stray far from a patient setting to be part of the drug development process. Once scientists have tested their hypothesis to determine that a preparation developed in the lab may indeed help with a specific indication, the scene shifts to the FDA for a human study protocol approval. When the regulatory agency is on board, sponsors can enlist multiple clinical trial sites—health systems and large medical practices—for the Phase I to IV (and post-marketing) human studies.
Much of the work at those locales rests with nursing professionals, point people in the day-to-day operations of a drug trial. As clinical research or study coordinators, they juggle multiple tasks in making the protocol work. They not only train supporting cast members to find, screen, enroll, monitor, and collect data on participants, but they’re often on board from the onset, helping principal investigators prove that a health provider has what it takes—in experienced staff, adequate space, and access to the right patient demographics—to move a protocol forward.
As a director of clinical research for the Dallas-based Baylor Health Care System, Jennifer Thomas, RN, BSN, MS, CCRC, works side-by-side with investigators, first reviewing potential drug or device trials to ensure that they’re a good fit both financially and clinically for the institution. Thomas had her nursing skills tucked neatly under her belt when she earned a clinical research administration masters to even the negotiating playing field with sponsors over start-up costs and other numbers. “It helped me look at the bigger picture,” she says. “I’m better able to account for everything we need to do to go into a trial.”
Although Thomas no longer conducts individual studies, her imprint is widespread since she provides education and other resources to 40 professionals who manage from 70 to 100 investigational drug, device, and prevention studies, covering a multitude of conditions from diabetes to transplant research. She makes sure others are knowledgeable about a particular study and ready to conduct it according to regulations and good clinical practice.
That means becoming familiar with all aspects of the protocol, a regulatory document that can range from a mere 20 pages to a 500-page tome. It covers every possible nuance, from the hypothesis and research behind the drug to the goals, criteria, and requirements for participation. Whether the information is gleaned from principal investigator meetings, in-service tutorials, or other sources, mastering the fundamentals and logistics of a protocol is critical in running it correctly and consistently with other centers so results are valid.
“If there are too many variations, the sponsor can’t tell what’s causing a problem,” says Lynn Fukushima, RN, MSN, FNP, MBA, CCRC, nurse coordinator for the Keck Medical Center of the University of Southern California. “Is it the proposed medication itself or something else? We have to be very meticulous in our record-keeping so there’s no doubt.”
Fukushima wears many research hats in navigating drug studies related to cystic fibrosis and other pulmonary or lung diseases. For starters, she also helps her physician-colleagues determine if a clinical drug trial is appropriate by submitting information to the institutional review board for an up-or-down decision. Because her job includes budgetary tasks, she earned a health care administration MBA to better grasp the financial implications of a study.
In terms of each protocol, Fukushima sometimes works alone, organizing all aspects of a study, while other times, she’s coordinating with staffers. Whatever the case, her patient involvement changes with each trial stage. Phases I and II, for instance, can be intense since researchers are looking closely at efficacy and safety. She may see subjects weekly, daily, or even several times a day for blood draws and other procedures. During phases III, IV, and post-marketing, the individual interaction diminishes since sponsors are no longer tracking efficacy, but safety in an expanded universe of patients.
Whatever the stage, the paper chase with a clinical drug trial demands the kind of attention to detail and familiarity with medical jargon and charts that usually fit nursing professionals to a T. The skills you’ve likely established in training and honed in practice can provide an important cornerstone for managing the administrative and patient-contact components of any given study. But it’s also the ability to stay up-to-speed, think outside the box, and respond with on-the-spot analysis or critical thinking that’s important. Each protocol is replete with guidelines, but you still need to accommodate new information and unexpected turns-of-events.
In managing a support service unit for principal investigators throughout Washington University School of Medicine, St. Louis, Banez-Muth is used to the structured training and continuing education necessary to get a trial up, running, and producing valid results.
Of the 35 to 40 active NIH- and industry-sponsored studies she and her seven coordinators target at any given time, the phase II to IV drug trials represent a spectrum of urological and gastrointestinal targets. Whether Banez-Muth is personally managing a trial for a principal investigator or overseeing the work of others, she not only has to be organized but nimble on her feet. “As black-and-white as you would like things to run, it’s never that way. There’s always one patient who falls outside the box,” she says. “When that happens you want to make sure that you’re doing what you can to keep this person safe during the protocol.”
From Tuskegee to Transparency
Indeed, beyond data integrity, the primary task of nursing professionals involved in a clinical drug trial is to protect the subjects they seek, find, vet, enroll, and follow. From the moment coordinators scan medical records, tap health care providers, or reach into the community to find subjects, their focus has to be on complete honesty and concern about someone’s health and well-being.
That wasn’t always the case, given this country’s sometimes chilling research history, especially in regards to minorities. The infamous Tuskegee syphilis experiment, for instance, may have started in 1932 to chart the progression of an untreated sexually transmitted disease in black sharecroppers. Yet, by the time it ended in 1972, it had put hundreds of them at medical risk because US public health scientists and their local physician-partners withheld what had become standard-of-care treatment: penicillin. Even decades after whistleblowers shut it down, Tuskegee has left an indelible mark, particularly among African Americans.
Thankfully, clinical trials today are light years from Tuskegee, not just in terms of bioethical standards but also in practical safeguards. Study coordinators can point to a drug process so rigorous and regulated by the sponsor, the FDA, institutional review boards, and other agencies that safety rules at every turn. Patients are monitored so closely with high-tech imaging and other services that care often exceeds what they receive nominally from their personal physicians. “The wonderful thing about research is that you get excellent follow-up care,” says Menefee. “It can be a very special opportunity for participants.”
But nurses must be both transparent and on their toes in engaging candidates with a medical history that matches a given protocol. Informed consent is the primary tool they hold in their quiver to ensure that every enrollee understands every relevant specific—possible risks, benefits, and commitments—of a given study. But in outlining the parameters, they also target their rights. Distilling the caveats is important for every clinical trial, especially those that demand much of a participant, perhaps even an invasive procedure, with no guarantee of positive results.
In fact, making promises that someone will receive an active ingredient or that it will work with no side effects, is a trial taboo. The only guarantees nursing professionals should be sharing with their enrollees are that they’ll be good patient advocates, pursuing everything possible to ensure a safe experience. That includes collecting vital signs and good data with each office visit, addressing any side effects or adverse events, and keeping everyone, including a patient’s personal physician, apprised of important changes. As one coordinator notes: “You’re asking people to participate in a clinical trial from which they may or may not derive any benefit. So establishing trust and rapport is important.”
Whatever the specifics, vetting presents a great opportunity for minority nursing professionals to convince fellow patients of color that their participation in a study is critical. Given your own sensitivity to the cultural mores and concerns of a community, you can be a key link in dispelling any myths about drug research while bringing volunteers into the fold.
In engaging her enrollees, Thomas, for instance, makes sure they know that they’ll never be asked to sign on to a Baylor study without someone reviewing every paragraph of the consent form with them. More importantly, if it’s not a good fit, they can leave at any time. “I understand the sensitivity among African Americans enrolling in research studies,” she says. “Hopefully I can educate them so they have a good understanding and they’re willing to say, ‘OK, I will participate in this.’”
Similarly, when Judith A. Rivera, MSN, recruits subjects for both NIH- and pharma-sponsored memory trials, her goal is to find an ethnically diverse pool of people when the study merits it. As a Latino nurse practitioner and principal study coordinator for the University of California-San Diego’s Comprehensive Alzheimer’s Program, Rivera is well aware that dementia is a serious health issue among minority, as well as majority, Americans. Unfortunately, in some ethnic communities memory loss is often dismissed as simple aging rather than a potentially serious disease.
But by targeting culturally and racially diverse subjects for a slew of drug and other studies related to memory, researchers at her institution are giving vital information to pharmaceutical companies about all of the people, not just Caucasians, who might need their products. More importantly, they’re also raising awareness among enrollees about the potential pharmaceuticals—albeit under study—that might help them remain active and functioning. “We want them to be as independent as possible for as long as possible.”
Monitoring for Safe Outcomes
Making sure that a participant isn’t compromised during a drug trial is an important part of realizing any positive results. From phase I to post-marketing, nursing professionals are not only helping patients navigate the terrain of a protocol, but they’re also gathering information about a drug’s safety and effectiveness.
Detecting and forwarding potential problems to a sponsor is a natural for nursing coordinators since their training and frequent interactions often give them a pulse on what people are experiencing. “Some nurses have a sixth sense about how a patient is doing,” Fukushima says. “If they see a frown on a face or hear unusually short answers, they may be a little more aggressive in investigating the cause.”
But overseeing a clinical trial isn’t the only way to determine if a drug is working well or not so well in a patient. In fact, many nurses are finding satisfying ways to use their critical thinking and detail skills in other research-related venues. From pharmaceutical companies to clinical research organizations (CROs) and other patient service firms, prospects abound for managing and monitoring trials as well as educating and tracking subjects. Besides sales and marketing functions to promote approved products further down the line, the activity usually centers on making sure medications aren’t hurting users.
As a clinical safety specialist for GlaxoSmithKline’s (GSK) Global Clinical Safety and Pharmacovigilance Division, Shannon Hart Anderson, BSN, RN, JD, also manages adverse event reports—unexpected and potentially harmful reactions—for a bevy of pharmaceuticals bearing the GSK imprimatur. From over-the-counter remedies to prescriptive medications, her potential targets include therapies for a wide spectrum of benign and serious diseases. “We’re like the safety police,” she says, “We have to make sure that our products aren’t harming the public.”
From her berth in GSK’s US headquarters located in Research Triangle Park, North Carolina, Anderson processes initial complaints from consumers, health professionals, sales reps, and even the FDA. She then collects follow-up information, which is entered into a safety database that serves as grist for further investigation as well as the regulatory agency reports she also must prepare. To capture the most accurate information possible, Anderson routinely relies on the logical reasoning, problem-solving, and even communication and advocacy skills she’s honed as both a nurse and an attorney.
But the most important roadmap may be the positions she’s held previously with CROs, outside firms hired by a pharmaceutical company to provide a wide range of support services. That may include managing the day-to-day operations of a drug study or even serving as an outside monitor, making sure that each site follows a protocol correctly and meets FDA standards. In honing the pharmacovigilance skills she now uses at GSK, Anderson mastered the nuances of adverse event reporting and the importance of being detail-oriented as a drug safety scientist. “We need to know the ins and outs of what happens,” she says, “so that we can look for trends that may prompt us to change our label or even our product.”
Likewise, as a diabetes-musculoskeletal medical professional for Indianapolis-based Eli Lilly and Company, Marla Neal, RN, BSN, MHCA, educates health professionals about drugs and devices that may help their patients. When physicians and other practitioners pose questions of the sales force, she’s tapped to provide the definitive answer. Neal accesses every possible database and medical professional to respond to each request. She also updates sales members about current clinical trials while helping them understand how each Lilly product impacts a disease process.
But it’s her other priorities—capturing accurate information about unexpected side effects and product complaints—that really tap her nursing skills. “Oftentimes patients don’t even realize that they’re having an adverse event,” she says. “So I’m very diligent about asking the direct questions and picking through the subtle conversation for clues. It’s critical for making sure that our drugs are really improving the lives of our customers.”
Adds Shannon Bradley, RN, a telehealth nurse educator and team lead for The Lash Group, a Charlotte, North Carolina-based patient services support company: “When you’re speaking to someone on the phone, you need to ask the right questions because people don’t always come forth with information on their own. You have to help them identify what’s important.”
Bradley is the nursing voice on the other end of the line when patients, pharmacists, and other health care professionals make contact with her company’s Dallas office, usually by dialing the “800” reporting number on a medication’s packaging. Using her clinical intuition, honed as a hospital neonatal intensive care unit and trauma nurse, she collects and reports adverse events linked to medications manufactured by one of her firm’s pharmaceutical company clients. It’s a varied list, from digestive and fertility drugs to oncology and neurology medications.
But her primary role is often to educate and support patients in staying the course with their medication. For no matter how many drugs move from clinical trial to market, they aren’t effective if they’re not taken according to directions. “We want them to understand,” she says, “the significant impact medication compliance has on their therapy outcome.”
Reaping Rewards:Better Health and Other Benefits
Besides bedside nursing, there may not be a better way to use your skills and intuition than in drug development. You might not be the academic researcher or laboratory scientist behind a preparation, but you can help bring a drug the final distance via other roles. Truth is, by participating in the process once it involves ordinary people, you’re witnessing cutting-edge medications making dramatic differences in the quality of real lives. A grandmother who couldn’t comb her hair or walk without a cane before an arthritis drug trial, for instance, performs both tasks eight months into it. A grandfather who couldn’t play with his grandchildren now travels across country to romp with them.
As to Menefee, the landmark A-HeFT trial left her with many good feelings about being a co-investigator in the drug improvement process. Even though she didn’t place many African Americans in the trial, the protocol has worked so well since that now whenever a black heart failure patient in her practice meets the medical criteria, she prescribes ISDN/HYD to optimize their other meds. She hasn’t been disappointed yet.
The medication duo not only gives her more options in extending quality of life, but also serves as proof that research works. Every trial success, as well as every study failure, just reinforces her belief in the benefits of being part of the process. “Before a drug is even approved, I already know something about it,” she says. “So when it’s brought to market, I don’t need a sales rep to tell me how great it is. I know because I’ve already been involved with it. I’ve seen it work!” MN
Running the Gauntlet
The lengthy and complicated process of moving a drug to market is broken down into various phases. After a pre-clinical development stage during which animal and other laboratory tests have proven that a product is initially safe, the emphasis shifts to human or clinical trials. Although most drugs never reach that stage, the ones that do undergo a rigorous process in winning FDA-approval.
• Phase I: A drug is tested on 20 to 80 healthy volunteers not only to see if it’s initially safe but also to determine the most frequent side effects.
• Phase II: If the drug hasn’t produced unacceptable levels of toxicity during the first phase, it’s tested in a few dozen to 300 subjects with the condition or disease to obtain preliminary data on how well it’s working.
• Phase III: If a drug demonstrates a good level of effectiveness, it’s tested in an expanded pool of subjects, from several hundred to about 3,000, to see how it works with different dosages, populations, and in combination with other drugs.
• Phase IV and other post-marketing studies: Conducted after the FDA has approved a given drug, these trials are used to gather additional information about safety, efficacy, and even other uses.
For incoming freshmen, attending college can feel like entering a maze. But for first-generation students, that maze can have added twists and turns, as they may not have a role model or rule book to follow when starting out as a first-year student.
In turn, while parents are proud of their college-bound daughter or son, they too are unfamiliar with the road they are about to travel. Yet, parents can still offer ample support for students just by showing up at family orientation events, asking questions from the program staff, and seeking out other parents to share information, guidance, and direction.
In the Rutgers College of Nursing Educational Opportunity Fund (EOF) Program, parents are strongly encouraged to be a support base to their students. The EOF program has a Family Orientation Day where not only parents, but the entire family is invited to attend. Family Orientation Day provides an overview of what students are expected to do in the intensive six-week Summer Readiness Program. The College of Nursing has the only EOF program exclusively for nursing students in the state of New Jersey.
In 2011, parents were given a firsthand account from a parent whose daughter completed the summer program the previous year. She and her daughter spoke to the audience and answered questions. Additionally, the mother stayed through the entire day to privately speak to parents, many of whom indicated this was especially appreciated. Having a parent whose child went through the program offered them a sense of relief and comfort, making it easier to leave their daughter or son on campus.
At the end of the Summer Readiness Program, the students “graduate” to become members of the College of Nursing (Class of 2015). The students participate in a celebration entitled “Culture Kitchen,” where students and/or parents prepare a dish from their culture. It is truly a feast! Students represent many countries, and sampling the cultural cuisine is a cherished memory of the Summer Readiness Program. This past year’s program was especially gratifying because one parent insisted on being a part of the team in setting up the buffet table and working with the students and staff! It was important for her to become actively involved and not sit on the sidelines.
Perhaps the most moving part of the Culture Kitchen program is watching the students reflecting on their summer experience and seeing the proud faces of their parents. Students benefit from their parents’ support and involvement, and parents are encouraged to be a part of the students’ college experience. The EOF Program wants parents to feel welcomed; we understand the daunting process of wanting their child to be educated along with the difficulty of “letting go” so their daughter or son can progress into adulthood and become a distinguished nurse.
In the 25 years I have been a bedside nurse and the 15 simultaneous years as a nursing faculty member, I have seen plenty of changes in how health care is delivered and how nursing is taught. What has not changed much is human nature—both of the nurse and the patient. Our patients’ fundamental needs, such as food, warmth, compassion, and alleviation of suffering, have remained constant. Nurses have responded to these basic needs much in the same way since the dawn of science, although the means to meet them may have changed. The foundation of the innate capacity of nurses to respond to these needs were perhaps already in them even before they entered the profession. In nursing school, this vitality is awakened through countless lectures, nursing care plans, evidence-based papers, and process recording. Nurses are “increasingly called on to perform highly skilled technical-scientific and relational work.” Therefore the motivation to cultivate virtue (compassionate practice) and virtuosity (technical skills) amongst nurses stems from the need to practice safely and accurately in less-than-optimal circumstances.1
What’s a nursing virtue?
A philosophical definition of virtue tells us it is “a force that has or can have an effect.” For example, the virtue of a medication is to cure. Essentially, a “virtue is a capacity or power and always a specific one.”2 The virtue of nursing—the power to heal the sick—is one of the critical elements of its professional value with its unique excellence in the records of the healing arts, as a distinct and effective form of treatment and wellness modality. An effective nurse is one who excels in nursing, either independently or collaboratively. In a virtuous nurse, life-saving skills and virtue converge at every patient care interface anywhere in the health care systems. Often, these virtues and values “remain unspoken, and perhaps unrecognized, but nevertheless profoundly influence what they attend to in a particular situation, the options they consider in taking action, and ultimately, what they decide” to do in response to the patient’s needs.3
A nurse is a “force” that has the power to heal or promote positive changes in the patient. And if this force is coupled with the great virtues of politeness, prudence, generosity, mercy, courage, gratitude, humility, honesty, tolerance, and gentleness, our potential for healing is unimaginable, if not already irreplaceable. The opposite is also true. The lack of these virtues in a nurse is a threat to patient safety and quality, and may lead to incivility and practice breakdown.4 The Quality and Safety Education for Nurses (QSEN) initiative proposed competencies for the new nursing graduate to “value” patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.5 Attaining safety and quality in nursing requires not only the skillful application of evidence-based knowledge, but also relies on the cultivation of values and virtue education in nursing in order to develop a competent and respected nurse.
It is beyond the scope of this article to discuss the treatise of these virtues. Often they are vaguely alluded to in the mission statements of schools and health care institutions. It is recognized that all virtues evolve over time and can be learned through experience.2 Nurses have the unique opportunity to get to know their patients over time. This allows them to “experience” their patients with greater intensity. This lasting interchange influences the formation of values in the nurse. Over time the nurse is expected to develop an ethical appreciation of the patient, not merely as a problem to be solved, but as an individual to be cared for. According to Benner, “the dominant ethic found in stories of everyday practice is one of care and responsibility.” Therefore, the development of virtuous practice is closely linked with the “development of skillful moral comportment that is derived from experience.6 Moral comportment results from reflection-on-action on the virtue of nursing during the span of a nurse’s career.3
According to Gallup’s annual survey of professions, nursing has been voted the most trusted profession in America for their honesty and ethical standards for the 11th consecutive year.7 Perhaps this reflects the collective ethical comportment that nurses manifest in practice.1 If we are to remain faithful to this public trust, nursing education must provide evidence-based clinical encounters that cultivate virtue development and growth.
The virtues already in place
Long before a student enters the nursing program, the foundations of these virtues were perhaps already laid down through their relationships with families, peers, their community, and the world at large. A study by Benner, Tanner, and Chesla showed that nurses come to clinical situations with a fundamental disposition toward what is good and right or what can be considered as virtues.8 The nursing faculty then accelerates the application of these virtues in the healing arts. It is with humility, both intellectual and experiential, that a faculty member may acknowledge the academic and clinical success of today’s graduates. This is partly the result of the richness of experiences, traditions, and cultures that students bring to the nursing program. Through carefully designed experiential learning activities, we can sustain our students’ innate and acquired virtues to be incorporated into their professional practice.
Strategies for virtue-inclusion in nursing education
Self-reflection is an essential component in value education. Benner et al. advocate for educators to “foster opportunities for students to learn how to reflect on their practice.”1 When provided with a safe climate for critical reflection, students can examine the virtues of nursing in the context of its success and practice breakdown. Integration of virtue education can easily be incorporated into classroom, simulation, and clinical activities. An essential first step would be to conduct a comprehensive curriculum review to identify gaps in moral or value education content and offer recommendations. Specific teaching strategies are offered below:
Enrich courses by integrating dilemma-based ethics and bioethics with attention to everyday notions of good practice and relational ethics.1
Organize small-group, student-led ethics committees and sponsor “brown-bag” discussions on similar topics.
Integrate current events dealing with bioethics in health care, education, and politics into clinical topics as appropriate.
Offer elective courses on ethics and value education. Collaborate with other schools within the university that may already have a course offered on the subject.
Require reflection papers and journal entries on ethics and values, exploring their impact on quality, safety, and patient satisfaction.
Conduct small in-class surveys or opinion pools on ethical dilemmas using interactive or online programs.
Infuse unfolding medical-surgical case studies with ethical questions and offer guide questions for self-reflection.
Use questioning to engage students in clinical thinking.1,9 Choose questions that allow learners to make decisions and defend their choices.10
Sponsor informal activities, such as a movie night, for students to watch ethics-themed films, followed by a panel discussion.
Create simulation scenarios with built-in ethical dilemmas.
Infuse simulation exercises with inter-professional collaboration that uses the multi-disciplinary approach in dealing with ethical issues.
Use the standardized “patient” in clinical simulation of ethical issues. Standardized patients (SP) are individuals who are trained to portray a patient with a specific condition in a realistic, standardized, and repeatable way.11 The use of SP will enhance virtue development because it allows for “nuances such as stance, touch, and orientation fused with physical presence and action” that cannot be replicated with a static manikin.6
Encourage student to attend ethics committee meetings in the hospital, school, or community.
Encourage students to ask a moral or ethical question during pre-and post-conferences.
Conduct bedside rounds as an alternative to post-conference. This allows for personal interaction between the students and the patient. This will help cultivate empathy, honesty, and politeness.
This list of teaching activities is by no means exhaustive. It is important to consider that even brief but specific endeavors can be used to integrate virtue education and facilitate discussion and reflection. Ongoing faculty development activities on virtue education will also be needed in order to elevate the quality and effectiveness of these educational strategies.1
If virtue can be taught, as I believe it can be, it is not through books so much as by example.2 A student who responded to the Carnegie National Student Nurses’ Association survey said the biggest challenge in nursing education she faced was “being lectured on caring and building trust by instructors who don’t practice what they preach.” 1 As clinical faculty, we have the moral imperative to model the virtues we want our students to emulate. We provide plenty of skills practice for bed, bath, and invasive procedures, both in real-time and in simulation, but there are very limited or non-existent “skill labs” for students to practice empathy, compassion, gentleness, humor, and the highest of all virtues: love. It is time to return virtue and value education back into the nursing curriculum.
P. Benner, M. Sutphen, V. Leonard, and L. Day, Educating Nurses: A Call for Radical Transformation.San Francisco, CA: Jossey-Bass, 2010.
A. Compte-Sponville. A Small Treatise on the Great Virtues: The uses of philosophy in everyday life. New York: Metropolitan Books, 2001.
C. Tanner, “Thinking like a nurse: A research-based model of clinical judgment in nursing,” Journal of Nursing Education, 45 (2006), 204-211.
S. Luparell, “Incivility in Nursing: the connection between academia and clinical settings.” Critical Care Nurse, 31(2), (2011) 92-95.
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Two of California’s most distinguished minority nurses, both of whom have devoted much of their careers to mentoring, teaching and developing training programs for students from underserved communities entering health care professions, were honored this summer by The California Wellness Foundation (TCWF) as the inaugural winners of its Champion of Health Professions Diversity Award. At an awards ceremony in Los Angeles, Linda Burnes Bolton, RN, DrPH, FAAN, and Pilar De La Cruz-Reyes, RN, MSN, each received a $25,000 grant in recognition of their pioneering achievements.
“Each of these champions has developed innovative and effective practices that promote diversity in California’s health workforce,” says Alicia Procello, TCWF program director for the Diversity in Health Professions Priority Area. “As a result of their efforts, many more health professionals are working in traditionally underserved communities, helping to decrease the well-documented disparities in health for people of color in our state.”
Both of the winners are high-ranking nurse executives who overcame significant barriers to rise to the top of their profession. Burnes Bolton, who made history as the first African American to graduate from the Arizona State School of Nursing, is vice president and chief nursing officer at Cedars-Sinai Medical Center and Research Institute in Los Angeles, where she instituted a cultural competence training program for all staff.
As a faculty member at both UCLA and the University of California, San Francisco, Burnes Bolton actively recruits and supports minority applicants for admission into the graduate nursing program and has mentored eight doctoral students from communities of color in the UC system. She also promotes equal opportunity by serving on the California Strategic Planning for Nursing Committee on Diversity and on the editorial board of Hispanic Health Care International, the journal of the National Association of Hispanic Nurses. In addition, she advised on the formation of the Asian American/Pacific Islander Nurses Association.
Pilar De La Cruz-Reyes grew up in a migrant worker family, laboring in the fields by day and studying at night. After earning her BSN and MSN degrees from California State University, Dominguez Hills, she began her career at Community Medical Centers (CMC) in Fresno as a staff nurse. Working her way up through the management ranks, she progressed from frontline manager of acute critical care to director of nursing services to executive director of the Community University and education development services. She is currently chief nurse executive at the Fresno Heart Hospital.
De La Cruz Reyes, who has personally mentored over 35 young people who sought health care careers, has initiated many programs that championed the needs of underserved communities. At CMC she established the hospital’s first Cultural Competency Task Force. In collaboration with Fresno City College, she developed the Nursing Paradigm Program, which provides training for hospital employees to enter the nursing profession. She also developed the Community Job Institute, which provides opportunities for low-income minority parents in the local community to get work experience and training at the hospital.