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  1. Details have been changed to protect the patient and her family. The facts of this case are true. The ambulance page pierced the silence. Most nights it could barely be heard over the din of a busy ER, but tonight the snow had fallen in heavy layers and this seemed to keep people in their homes. The nurses, slouched at our stations, straightened to attention upon hearing the dispatcher's voice crack over the radio, "28-year-old female, difficulty breathing, conscious." The address was announced and everyone gave a concerned glance. The call was to a narrow, notoriously treacherous dirt road, high in the mountains on the west side of our small Colorado town. In good weather and broad daylight, it was a 30-minute response time. That night we had unforgiving snow, whipping winds, and a dark, moonless sky. The ambulance crew rounded the corner past the nurse's station, bundled in their coats, and headed out the door. Twenty-five minutes later, we heard the ambulance crew speaking with dispatch. They were hopelessly stuck in a snow drift- forcing dispatch to page another ambulance to the address. Thirty-five minutes later, it was stuck too. The woman was still having difficulty breathing, now admitting to the dispatcher that she had huffed two cans of commercial keyboard dusting spray just a few moments before her respiratory distress began. She stated her heart felt like it was racing. In our small Rocky Mountain community, we have a team of highly skilled volunteer fire and emergency medical services who had also been activated when the initial call came an hour earlier. One of these responders had managed to get his oversized pick-up truck near the cabin where the patient was waiting for help. His voice came over the radio, "Patient is pale, diaphoretic, tachypneic. Her heart rate is 140 beats per minute. She is having chest tightness." He measured her oxygen saturation at 90% on room air. She had no medical history other than occasional street drug use. As per the previous report, he confirmed that she had huffed a propellant just minutes before the start of her symptoms. He made a judgment call - this woman needed the ER right away, so he did a rather unconventional thing and hiked the woman through the thigh-high snow, bundled her into his truck, and began the unpredictable journey to the hospital. On the way, he encountered one of the stuck ambulances and was able to help them back onto the road. Over two hours had passed, but the patient was finally in the back of an ambulance and headed our way. The phone rang and the charge nurse took the ambulance report. The woman's heart rate and respiratory rate were still elevated, but supplementary oxygen had improved her condition. Her heart rate was 105 bpm and her respiratory rate 24 breaths per minute. On a simple mask at 8L, her oxygen saturation was 100%. The EMTs thought perhaps she was having a bit of a panic attack and that the delayed response had increased her anxiety, but they felt that she was relatively stable. We prepared our cardiac/respiratory room, just in case. Everyone was optimistic - this patient was young, relatively healthy, and she was already improving. This was no big deal. The patient arrived. The updated ambulance report was relatively the same. The patient was a slightly overweight Latina female with hot pink hair. Tattoos snaked her arms and calves. She was indeed pale. Smeared mascara was streaked all over her face - she'd been crying. Her initial vital signs were reassuring. Mild tachypnea was present and she was still slightly tachycardic, but otherwise she looked good. The ER doctor working that night was a gentle and highly skilled provider with over three decades of experience. He immediately evaluated the patient upon her arrival and told her he suspected a mild reaction to the inhalant she had huffed with a subsequent panic attack. Reaching for his hand with wide eyes, she said to him, "I feel so scared." He comforted her and ordered labs, an EKG, a small dose of IV Ativan, and a chest x-ray. He assured her we would do a thorough work-up and get her some medicine to help her stay calm. She nodded and appeared relieved. I left to obtain the Ativan, the charge nurse went to get the EKG machine, and a phlebotomist began to set up for labs. As I was preparing to administer the IV Ativan, the phlebotomist began to draw her blood. The patient's heart rate suddenly spiked to 110, then 120. I thought she was anxious about the needle stick, so I said to her, "Try to stay calm, take a deep breath." Eyes wide, she looked at me with pleading desperation and said something I'll never forget, "I'll never do it again. I am sorry. I am trying," she gasped. The monitor began screaming. HEART RATE 186. "SVT," I thought. Then it quickly converted to ventricular tachycardia. And before I could even blink, ventricular fibrillation. She was coding. I snapped into autopilot, a rush of adrenaline hit my body. I checked for a pulse, but it was obvious she had none. I rolled her onto a board and began compressions. The phlebotomist smacked the code blue button and our ER team streamed into the room. We ran the code for 55 minutes before the doctor announced that he was going to talk to her family, who had arrived in the waiting room 10 minutes before. We continued the code while he was gone. When he returned he informed us that the patient's mother, father, and 5-year-old son were in the waiting room. The room fell into a hush. "She has a child?" I asked. I felt totally deflated. There was no promising sign that she was going to make it. The only sound in the room was the rhythmic, mechanical thrusting of the LUCAS machine, an automated chest compression device we had placed on the patient 15 minutes after she coded, relieving the staff of the breath-taking work of chest compressions. The doctor nodded, then said, "Let's continue for another 15 minutes, and then I'll have to call time of death. Does anyone have any ideas? Anything at all?" No one in the room spoke. "Okay," he said, "another round of epi please." Fifteen minutes later, we called time of death - 0428 - almost four hours after she initially called for help. She was translucent, still, and mottled. I began post-mortem care. I cleaned her, changed her gown, wiped the mascara off her face, gently closed her lifeless eyes, and tried my best to smooth her hot pink locks, only able to guess which way she parted her hair. The doctor guided her mother and father into the room. Her mother wailed, screamed, her knees buckled. We had to hold her up so she could say goodbye to her daughter, her baby. The rest of the night is a blur of tears, tissues, crushing hugs from her mother and the reverberating question "why?" The young woman's body went to the morgue and I left for home. On my way, I saw her son, unaware of what had transpired, sitting on the lap of the grandmotherly woman who works registration. He was coloring and drinking apple juice - a picture of complete and blissful innocence. I hope someday he will know how hard we tried to save his mommy; how sorry she was for making the mistake to use drugs. But it is likely he will always wonder those things. I got in my car and the tears began. First, a hot stream down both cheeks, then a sob. I cried the whole way home. My 5-year-old daughter was awake when I walked into the house. "Mommy!" she laughed as I gave her a big squeeze. My heart was breaking, but I smiled at her. My husband rubbed my back, encouraging me to get some rest and go to bed. "No," I said, "Today, I am going to have breakfast with my baby." Author's note: You may be wondering about the more clinical aspects of this story. There are many different chemical compositions to propellant-based keyboard dusters. According to the pharmacist in the room during the code, this particular dusting compound is known to bind to cardiac muscle and deplete the body's stores of calcium. When the patient's initial labs resulted, approx. 30 minutes after she arrested, she was found to be profoundly hypocalcemic. Many efforts were made to restore her calcium levels during the code, but clearly, it was too late. I often wonder if the precious hours wasted getting the patient to the hospital would have allowed for us to correct her hypocalcemia before it led to cardiac arrest. We will never know.
  2. The Emergency Nurses Association's Annual Conference was held in Austin, Texas recently. With almost 200 presentations, the 3800 attendees had the opportunity to learn much and network among colleagues. One of the interesting presentations involved complications of the legalization of recreational marijuana. The presenter was Lisa Wolf, PhD, RN, CEN, FAEN, ENA's Director of Emergency Nursing Research. allnurses.com was able to interview Dr Wolf. First, we asked what types of complaints do you think will be more commonly seen in the ED due to legalization of recreational marijuana? Hyperemesis syndromes - one of these is cannabinoid hyperemesis syndrome (CHS) which according to Cedars-Sinai hospital is a condition that leads to repeated and severe bouts of vomiting. It is rare and only occurs in daily long-term users of marijuana Pediatric ingestions of edibles (brownies, cookies, and gummies) - According to a Journal of Pediatrics article, "Unintentional cannabis ingestion by children is a serious public health concern and is well-documented in numerous studies and case reports. Clinicians should consider cannabis toxicity in any child with sudden onset of lethargy or ataxia" Geriatric ingestions can also result in a myriad of issues; Acute asthma exacerbation Pneumomediastinum and pneumothorax suggested by tachypnea, chest pain, and subcutaneous emphysemas caused by deep inhalation with breathholding Occasionally angina and myocardial infarction We discussed the possible increase in MVAs associated with the legalization of recreational marijuana? Dr Wolf stated that this would be difficult to discern as "edibles have a delayed onset of effect, and people may misjudge." Drugged driving is being addressed by state legislatures; "Detection of marijuana in drivers involved in traffic crashes has become increasingly common. According to the National Highway Traffic Safety Administration, 12.6 percent of weekend nighttime drivers in 2013-2014 tested positive for tetrahydrocannabinol (THC), the component that gives marijuana its psychological effects, compared to 8.6 percent in 2007." Some of the first states to legalize recreational marijuana are on the forefront of developing tests to determine impairment: "In Colorado, the first state to legalize marijuana use, the Colorado State Patrol (CSP) includes specialized drug recognition officers. Any driver arrested after a trooper observes signs of impairment is given a blood test. “When driving a motor vehicle in Colorado, any driver has given their consent to submitting to a chemical test if they are presumed to be under the influence of drugs or alcohol,” Sgt. Rob Madden, a CSP representative, told Healthline. “Drivers can refuse a test, but that leads to an immediate revocation of their driving privileges.” Madden also noted that the CSP is entering the final phase of testing of new “oral fluid” devices. California, where the recreational use of pot became legal on January 1, also has specialized drug recognition officers and rules stipulating drivers arrested for driving under the influence are required to take a blood test if marijuana is the suspected intoxicant. That suspicion is formed during a 12-step roadside evaluation process that includes some familiar elements — walking in a straight line, standing on one foot, touching fingers to nose — as well as checking pulse rates at three different points in the process and checking pupil size in ambient light, near-total darkness, and direct light." We then shifted to what ED complaints are being seen in states where there is legalized recreational marijuana. Dr Wolf does live in a state, Massachusetts which has legalized recreational marijuana and she reports the most common complaint they see is hyperemesis. As more states move to the legalization of marijuana, I asked if she had any tips for those EDs in states where recreational marijuana will soon be legalized to prepare for this suspected onslaught? Her comments included these tips: Educate the ED staff Push for good community education in the same way we educate about alcohol Access protocols for managing cannabinoid hyperemesis (Colorado has some good ones) Thank you Dr Wolf and ENA for facilitating this interview. Has legalized recreational marijuana impacted your ED? Please share.
  3. Football season is upon us! We all like to dress warmly and go out on Friday or Saturday evening to cheer on our local high school team or bundle up to go to the ice rink to watch our teams. Some of the highest concussion rates among athletes under the age of 18 are ice hockey and football. According to the Brain Injury Research Institute: "The condition known as mild traumatic brain injury is more commonly referred to by the term concussion. While a severe concussion will normally be referred to as a traumatic brain injury or TBI, normal concussions are referred to as being mild traumatic brain injuries (MTBI) due to the fact that a single injury of this type will not typically cause any serious long term health consequences. Several repeated mild traumatic brain injuries, however, may lead to the life-changing and potentially debilitating condition known as chronic traumatic encephalopathy (CTE)." The Emergency Nurses Association emphasize the important role that emergency department (ED) nurses play in the education of these patients and their families/caretakers. One of their upcoming presentations will feature Georgia ENA State Council President Jack Rodgers, MBA, BSN, RN, CEN, NREMT-P. He states, "Parents, teachers, coaches and medical professionals all have the same priority to preserve the safety and well-being of our students.” Rodgers is a clinical educator, paramedic and emergency department nurse based in Columbus, Georgia. “In the emergency department, nurses are regularly the first person to see a patient for triage and the last to see them before being discharged. It is imperative that nurses can identify obscure symptoms and recognize severe cases to expedite treatment when necessary, to prevent long-term effects. But it’s equally important for our emergency nurses to discuss the seriousness of recovery protocols with students and parents upon discharge; emphasizing the Return to Learn protocol to decrease Second Impact Injury possibilities and promote a healthy and safe return to regular activities.” How Prevalent are Concussions? In 2017, the Centers for Disease Control and Prevention estimated that 2.5 million high school students sustained at least one concussion related to sports or physical activity. An estimated one million students reported having two or more concussions, with students that play on a sports team placed at higher risk. Even more threatening is Second Impact Syndrome, a second head injury before complete recovery from an initial head injury, which can be fatal. What About Recovery? Just as important as diagnosing a concussion, prescribing the right path to recovery is of growing prominence. The protocols of concussion recovery have dramatically changed over the decades. This isn’t the age of “rub some dirt on it” and get back on the field or in the classroom. The Centers for Disease Control (CDC) have an expected timeline for symptom resolution: 1. Rest - Your child should take it easy the first few days after the injury when symptoms are more severe. Early on, limit physical and thinking/remembering activities to avoid symptoms getting worse. Avoid activities that put your child at risk for another injury to the head and brain. Get a good night’s sleep and take naps during the day as needed. 2. Light Activity - As your child starts to feel better, gradually return to regular (non-strenuous) activities. Find relaxing activities at home. Avoid activities that put your child at risk for another injury to the head and brain. Return to school gradually. If symptoms do not worsen during an activity, then this activity is OK for your child. If symptoms worsen, cut back on that activity until it is tolerated. Get maximum nighttime sleep. (Avoid screen time and loud music before bed, sleep in a dark room, and keep to a fixed bedtime and wake up schedule.) Reduce daytime naps or return to a regular daytime nap schedule (as appropriate for their age). 3. Moderate Activity - When symptoms are mild and nearly gone, your child can return to most regular activities. Help your child take breaks only if concussion symptoms worsen. Return to a regular school schedule. 4. Back to Regular Activity - Recovery from a concussion is when your child is able to do all of their regular activities without experiencing any symptoms. ENA Adds Some Tips The first phase of the Return to Learn plan calls for total cognitive and physical rest that should last three days once the student is symptom-free for 24 hours. According to the Brain Injury Association of America, “it requires staying away from thinking, learning, memorizing, and even things like reading, texting, computer time, and watching TV for the first day or two following an injury” and includes physical rest. The second phase calls for light thinking activities, listening to calm and relaxing music or playing familiar games for a day or two followed by a return to school part-time or half days. “Provided conditions don’t worsen, a gradual return to activities, both on the field and off, has proved to be the best approach,” said Rodgers. “Parents can help by making sure their child gets both cognitive and physical rest, followed by a gradual return to activity. Obviously, parents should be in communication with their health care provider throughout the process.” ENA has annually offered training on traumatic head injury prevention and treatment while proactively educating members on the latest research and head trauma recovery methods. Emergency Nursing 2019 is another avenue for keeping members up to date on the latest clinical trends and techniques. “With more and more concussion-related research becoming available, our goal is to empower emergency nurses with the tools they require to provide the highest level of care for head injury patients,” said ENA President Patti Kunz Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN. “This information allows nurses to step outside the emergency department to engage their communities, enabling them to serve as medical volunteers at community sporting events, discuss preventative and diagnostic measures with their local schools or to share their education with coaches, parents and students to help patients during their road to recovery.” The Emergency Nurses Association offers many opportunities to further your skills, education, and career.
  4. The night my daughter told me she wanted to kill herself was not an easy night. I drove her to the Emergency room that I used to work in, thinking they would care for her best. What I found was not true, and as a nurse and Nurse Practitioner, I'm going to tell my story in hopes of making a change to the world I thought I loved, the world of nursing. I now want to leave the only thing I've ever known because I don't want to be associated with cold, judgmental nursing with cold punishing eyes. I didn't ask for my daughter to be so depressed that she couldn't find another solution. The cold look in your eyes at me and my daughter spoke volumes. I hope you never are faced with this fear or with the overwhelming feeling of failure that I felt as a mother that night. Your job wasn't to pass judgement or to be so cold-hearted that my skin crawled. Your job, my sister, was to look at me and feel empathy and understanding. Your job, my fellow nurse, was to accept that I was in crisis and going through my routine was the glue holding me together. That included bringing my meals with me because, besides nursing, my life in fitness was the only thing that made sense to me and filled me with the same passion nursing used to. Your cursing under your breath at the TV showed that you didn't see nursing as an art. To you, it was just a job that paid the bills. Your lack of compassion and not introducing yourself before you drew my daughter's blood showed me you thought my daughter was weak; while in my eyes, she is very strong because she reached out to me so she was able to get the help she needed. And to you the nurse who said it looked like we were camping out. Did you consider not everyone lives the same lifestyle and some of us may need food because of our way of life? Did you notice I kept everything neat and then cleaned up before we left? Did you consider that I needed that food and water to keep me from falling apart? How do you know that it wasn't for my daughter who has food allergies? As far as my daughter's belongings we had hoped she was coming home with me and she did. But you made us put them in my car and she walked out in the lovely paper scrubs provided for her. You didn't touch a life that night. Your lasting impression left me cold and disheartened for nursing. You left me embarrassed to tell others of the profession that I so dearly loved for so many years. If it's true nurses eat their young, it's also true that the nurse of today is not doing what the nurses of yesterday set out to do. Yes, I realize that my daughter may have been your tenth suicidal patient of that particular shift or week. I also realize she may have been your first. Either way, she deserved understanding and gentleness in your care, not detachment and cursing and rude comments passed. I deserved professional courtesy and maybe a distracting conversation. Again I pray that no one in your families suffers from such depression that they see no other way out. I hope that they go on to live beautiful productive lives. As my daughter will not because a nurse in the Emergency Department touched her life and changed it for the better but because her mother, also a nurse, never stopped looking at nursing as an art.
  5. About 5 days after our daughter was born, she stopped breathing during a bath. I had been a cardiac critical care nurse for a number of years at that time. You would think that I would know exactly what to do. I will tell you exactly what I did...I ran around crying in a very tight circle while my husband who is a doctor did CPR. After what seemed like forever, EMS and Paramedics came with a NICU team to take her to our local hospital (where both my husband and I worked). As a nurse, I have always been awestruck by what Emergency Nurses do each day, but I will say that I have never been more so than I was that day. I rode with our baby girl and her NICU nurse in the ambulance. I found myself waiting on the nurses every word for reassurance. Watching her care for my sweet girl was a surreal experience as I knew exactly what she was doing and why, yet I was helpless and trusted her literally with my everything. We arrived in the Emergency room where we were greeted by familiar faces of friends and colleges. I needed them to cry with, to calm me, to help me think clearly as my husband was finding someone to watch our 17 month old son. Pediatrics is not my thing, so heart rate monitors alarming with rates outside of adult parameters sent me into a panic. I had dealt with these nurses with adult critical care patients and knew their skill set. I was thankful to know those skills did not depend on the age of their patients. We were transferred to a tertiary care hospital by another NICU transfer team. Exhausted both emotionally and physically (I was just 5 days postpartum), I was able to sleep in the ambulance...another testament to the confidence I felt with the transport team. We spent a few more days at the hospital for what was thankfully just reflux. I have never been able to forget all of the "feels" that went along with that day. Each Emergency nurse that worked with my daughter also worked with me as a mom, a patient, and a nurse. Our family will forever be grateful. Fast forward several years to my new routine of picking up my oldest from kindergarten. As I was driving to get him, I witness a head on, high speed collision. I see the car fly at least 50 feet in the air and watch the driver eject from the car and land a few feet in front of my van. I slam on the brakes and get out to help. The young man is not breathing. I am in shock and trying to sort out what I am supposed to do. I have my kids in the van, the man is not breathing and bleeding from everywhere, and there is drug paraphernalia that flew from his car all over the road. (This makes me think harder on what to do...what if he has infections related to IV drug use). As I go back to my car to get gloves and CPR barrier, I hear voices start to approach the scene. Like a golden angelic glow...I see 3 faces of Emergency room nurses that I work with coming to help! It just so happened that at that very moment 3 nurses who were all ER trained were in that exact spot! They were calm and collected. They surveyed the scene, gave instructions, worked together, told me how to help...all until EMS arrived. That man lived despite so many life-threatening injuries thanks to those nurses. When you come upon an accident, you don't have to stop to help. You are either a person who jumps in head first or shys back knowing someone trained is on the way. Emergency nurses are the engrained to stop and help no matter the situation, lifestyle of the person in need, race, color, religious preference, age etc. Emergency nurses have one of the broadest and all-encompassing roles in nursing. They care for newborns, temperamental toddlers, children, teens, adults and elderly. They educate and nurture pregnant mothers, the frightened parents of children, and concerned loved ones. They provide end of life support to the patient and family members who sometimes anticipated this time and others who are thrust into it by life circumstances. They provide critical care at a moments notice for however long is needed to get the patient to the next level or care. During any given shift, Emergency nurses may be responsible for an inmate with an armed guard at bedside, a gang member who has been shot or stabbed in a street fight, a teen in a car wreck with parents on the way, a toddler having seizures with a fever over 104F, a 50 something year old man with new onset rapid afib and rising troponins with EKG changes, an intoxicated addict, a kid with a broken arm during a football game, and on top of that, a stream of people who visit the ER for ear aches, stomach bugs and pink eye. They are cursed at by families wanting quicker care. They take the attitude of those of us ICU and floor nurses whose units are already full to capacity as they are trying to transfer their care. They have to remember that radiology has not yet picked up the patient for their CXR to rule out pneumonia and that the lab needs the second set of blood cultures. They need to read cardiac monitors, bandage wounds, start IVs, monitor chest tubes, airways, run a code, and monitor sedated patients. Without even a thought, Emergency nurses seamlessly navigate from patient to patient, family to family and room to room, working with different doctors and orders along the way. They have one of the toughest, most exhausting yet rewarding and heroic roles in our community and healthcare today. Thank you so much from this fellow nurse, mom, wife, family member and friend. You are appreciated!
  6. The ALTO program (alternatives to opioids) in the ED. Last year the Colorado Hospital Association (CHA) pioneered the ALTO program. Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)! Colorado, as well as the US, is in the grips of an opioid epidemic, as I'm sure you are aware. We have the 12th highest rate of abuse of prescription opioids in the US (CHA, 2017). According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor". This effort is to reduce the unnecessary use of opioids, and thus one of the pathways to abuse and addiction. The key to the program was creating treatment algorithms based on pain pathways. The idea that all pain can and should be treated with narcotics is not true. All pain is not created equal. So the Colorado ACEP (American College of Emergency Physicians) developed Opioid Prescribing and Treatment Guidelines. (This can be found on the CHA web site.) This method treats pain by targeting the pathway that causes it. They identified the following; Headache/ Migraine Musculoskeletal Pain Renal Colic Chronic Abdominal Pain Extremity Fracture/ Joint Dislocation For each source of pain, they prescribe a set of drugs or treatments, always starting with non-narcotics, progressing to opioids as the last resort. As previously stated, a major reduction in opioid use resulted, with no reduction in patient satisfaction scores! The medications that are used are familiar to us, but not necessarily as pain medication. Topical as well as IV lidocaine, low dose Ketamine, Toradol, Tylenol, nitrous oxide, Haldol, Benadryl, and a number of antiemetics were all used with good results. Trigger point injection is also an intervention, in which lidocaine is injected directly into a nerve bundle, or muscle fascia. It can relieve muscle tension and spasm, and works well for the release of scalp tension headaches and other muscle pain. As a nurse who was involved in the pilot, I can tell you this works. Not only are patients looking for alternatives, but we are providing better care with less risk. Patient satisfaction scores did not go down overall. Hopefully as providers get more experienced in using these protocols, satisfaction will go up. Preparing a hospital for the ALTO program is a huge project. Pharmacy, purchasing, IT, and physicians and nurses all have to be on the same page. New standing orders needed to be written, new order sets generated, new dosing guideline for smart pumps, and new products, such as lidocaine patches had to be ordered. The Colorado ENA (Emergency Nurses Association) provided nursing education that included scripting in how to explain the program to patients. Nurses explained that we are looking to make patients more comfortable, or reduce their pain. Complete pain relief is not always a realistic goal, as we know. It is also realistic to discuss with patients the risks of narcotics, and the risk of abuse and dangers of having narcotics in the home. It will be exciting to see how far we can go. There were many lessons learned that will only serve to improve this model and how it is delivered. References: CHA (2018), Colorado Hospital Association, Colorado Opioid Safety Pilot Results Report, retrieved from Opioid Safety | Colorado Hospital Association CHA (2017), Colorado Hospital Association, Colorado Opioid Safety Collaborative
  7. ED nurses are a special breed. They are highly skilled, compassionate folk who work well as a team. They are open to experience, and agreeable. Here are some more traits common to most ED nurses. Game On ED is a noisy, fast paced environment with stimulus coming from every direction. There is no normal in the ED. It's noisy and chaotic. ED Nurses Thrive In Chaos Unlike their neatnik ICU sisters and brothers, ED nurses don't require a controlled, structured environment. They adapt quickly to rapidly changing conditions. They tolerate ambivalence and prefer change to structure. Emotional Intelligence ED nurses are high in emotional intelligence. They can establish a rapport with an elderly woman desperately grasping her husband's hand as he is being rushed to surgery, and seconds later, elicit a giggle from the feverish two-year old in the next room. They can smoothly manage both the wife and girlfriend showing up at the same time situation. They can approach the busy doctor and get him/her to order the pain med they need for their patient...now. ED nurses may cry inside, but not on the job. They're not seen as overly emotive types. They remain calm while projecting an attentive demeanor. They have the ability to put highly anxious family members at ease while listening for the vent alarm in the next room over. Breadth Over Depth They prefer broad to deep. An ED nurse will not study H&Ps from previous encounters to delve deeply into patient history. They don't get bogged down in the details and are not interested in non-presenting patient complaints. They aren't there to study; they're there to stabilize. But they are comfortable with babies to toddlers to middle-agers to seniors. Heart rhythms are either normal, too slow or too fast. If it's too slow, speed it up. If too fast, slow it down. Done. Treat 'em and street 'em and.... next, please! Fast on Their Feet ED nurses make instant decisions, react quickly, and think fast on their feet. Often they do this with minimal information. Should they see the 58-year-old male clutching his chest or the 24-year-old doubling over with cramps or the 18-year-old with hand wrapped with dripping bloody gauze first? They can sniff out sepsis and spot an impending code. They make rapid assessments in under 30 seconds and can manage several emergent patient situations at once. ED nurses have excellent time management skills because they RACE from pod to pod, and front to back. They efficiently discharge, admit, transfer, treat and triage in record speed. Adrenaline Junkies Self-proclaimed junkies, ED nurses love the rush they get from true emergencies; a trauma, a pulseless John Doe...and never knowing what's rolling in next! They thrive on change, and preferably change with an element of risk or harm. ED nurses need high stimulation, charged action, and immediate results. Esprit d'Corps: High Fivers ED staff are often tight knit, team oriented, and socialize across job titles. They value their team identity and count on each other to survive. They form close ties to their work friends. They are highly social, known for having a wicked sense of humor, and are witty and sarcastic. They are friends with the EMTs, paramedics, policemen, and prison guards. Breakfast after your shift? They're in. Volleyball challenge from Respiratory Therapy? Accepted. Game on. Physical/Kinesthetic They're physical, always moving, have stamina, and cannot tolerate sitting for a shift. They can rig up practically anything and are creative at dressings. Always ready to spring into action, they dislike paper work and routine, repetitive tasks. Street Smart ED nurses score high in common sense and street smarts. They are down to earth and sensible. They are not easily conned, and they can spot maligners a mile away. Does this sound like you? Did you read this and keep thinking, "That's me! That's so me!" If so, you may be an ED nurse at heart. I hope this helps you find your nursing niche. Nurse Beth Are-You-Cut-Out-to-be-an-ED-Nurse.pdf
  8. A new practice improvement initiative and study indicates active shooter training and simulations are vital to ensuring staff is equipped to respond effectively should their emergency department ever become a target for such an act of violence. The goal was to develop and successfully implement a safety strategy that increased the ability of a large pediatric emergency department staff to effectively respond to an active shooter in their hospital. The corresponding survey results, set to be published online in the Journal of Emergency Nursing, show that out of 202 emergency nurses and ancillary staff members who participated in active shooter training, 92 percent felt better prepared to respond if a shooting occurred at their facility. Additionally, 70 percent of participants reported an increase in knowledge and readiness. "We are in the infancy stage of this conversation," study co-author and Emergency Nurses Association member Mary Baker, BSN, RN, said of active shooter training in hospitals. "As emergency nurses, we practice our ACLS and PALS a lot. We've gotten very proficient at it because it's always top of mind. But when it comes to preparing for a catastrophe such as an active shooter in our own emergency department, most nurses have no idea how we'd react because we aren't preparing for it." Active shooter situations and mass casualty incidents have become an unfortunate and increasing reality in society today. That has put emergency nurses on the front line of caring for victims of mass casualty incidents, but also on alert for the possibility their facility could become part of a large-scale disaster or tragedy. Due to the complexity and potential devastation of such an incident, it is critical for emergency nurses to be prepared. ENA knows it is vital for emergency nurses to regularly engage in active shooter training and mass casualty preparedness. To further prepare emergency nurses for their role in those scenarios, ENA is offering multiple opportunities for emergency nurses to participate in readiness courses and activities at Emergency Nursing 2018 - ENA's annual national conference dedicated to the emergency nursing profession occurring Sept. 26-29 in Pittsburgh, Pennsylvania. Mass casualty readiness educational sessions and activities at ENA18 include: MCI Escape Room Participants work as emergency nurses in a small community hospital emergency department with limited resources. After a brief description of the disaster, attendees will be broken into groups of five to quickly go through stations, solve clues and demonstrate skills needed for a variety of patient scenarios in a mass casualty incident or other disasters. "Game of Thrones" Attendees can compare make-believe traumatic injuries from the hit HBO series "Game of Thrones" to real-life traumatic injuries caused by modern threats to provide today's emergency nurse an opportunity to correctly identify these injuries and learn the proper course of treatment. DisastER Check out the 35-foot helicopter at the center of the exhibit hall and listen to ongoing presentations from Air and Surface Transport Nurses Association on topics such as transport after a mass casualty. State of Emergency - How We Prepared for Richard Spencer: Wendy A. Swan, director of emergency services at the University of Florida Health, describes how a Level I Trauma Center and emergency department prepared for a radical speaker, and the potential influx of thousands of associated supporters and counter-protesters. For more information on these mass casualty readiness activities, register for Emergency Nursing 2018.
  9. The annual Emergency Nurses Association conference is dedicated to the emergency nursing profession and it will be held in the City of Bridges at the David L. Lawrence Convention Center (Pittsburgh, Pa.), Sept. 26 - 29, 2018. "Emergency Nursing 2018" will bring attendees unique opportunities for hands-on education, access to cutting-edge research and renowned experts in emergency medicine as well as opportunities to network with nurses from around the world. There are numerous ways to take advantage of the education and networking opportunities at the conference this year. Attendees can earn over 29 contact hours and choose from more than 160 sessions ranging from pediatrics and geriatrics, to leadership, trauma, advanced practice and forensics. All attendees have the opportunity to build their own personal agenda by pre-registering for their desired sessions, including hands on cadaver and ultrasound labs. This year, there will be more advanced practice content available too. In partnership with the American Academy of Emergency Nurse Practitioners (AAENP),ENA has created a full day Advanced Practice Procedural Skills Lab that allows attendees to participate in hands-on practice elements, two interactive simulations to promote clinical reasoning skills, a basic suturing workshop and more. This experience can be further enhanced by an advanced practice ten-course track designed to dive deep into common advanced practice emergency nursing skills and address the risks, benefits and possible complications that become considerations practitioners should be versed in. The conference offers several interactive experiences in the Exhibit Hall including: ENA Learning Lab: Discover clinical education sessions on the exhibit floor and earn CERPs - topics include IV infiltration, intubation, obstetrics in the ED and more. Career Wellness Center: Access professional services like headshots, make use of private interview spaces and unwind in the ENA sponsored relaxation station. DisastER: Visit the flight medical helicopter and tent to learn more about transport nursing. Presentation topics will focus on how to become a transport nurse, how to transport intubated patients and more: SIM Wars: 16 teams of four will compete in a two-day emergency simulation competition on two separate stages complete with bracket style playoffs, ending in a championship round. AdvancED: Step into the future of emergency nursing. This fully-equipped, mock, four- bed ED provides nurses at any stage of their career with progressive clinical information allowing groups of six to eight to participate in hands-on clinical simulations. EDTalks/SMACC Talks: Listen while colleagues, ENA representatives and valued partners share short presentations focused on successful ideas, trends, equipment, supplies, services, research studies, practical problem-solving efforts and expertise that are optimizingEDs around the country. Early bird rates are available through July 31, 2018. For more information or to register for the conference, visit Emergency Nursing 2018. Register When: September 26 - 29, 2018 Where: David L. Lawrence Convention Center in Pittsburgh, PA Primary Spokesperson: ENA President Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, FAAN Conference Website For additional information regarding ENA, please contact Tim Mucha at tim.mucha@ena.org, 847.460.4022 Rates Registration Type Early Bird Deadline July 31, 2018 Advanced Registration After July 31, 2018 Member - Full Conference $520 $750 Member - Two Day $350 $500 Member - One Day $185 $285 Non-Member - Full Conference $620 $850 Non-member - Two Day $450 $600 Non-member - One Day $285 $385 General Assembly - Full Conference $520 $520 General Assembly - Two Day $350 $350 General Assembly - Thursday Only $185 $185 Student Nurses* - Full Conference $250 $250 Student Nurses* - One Day $100 $100 Faculty Discounted Rate** $250 $250 *Student rate applies to both member and non-member students, based on ENA Student Membership requirements. **Must be approved for discounted rate. Please contact education@ena.org for details. Hotel Information: ENA has negotiated travel discounts and secured a limited number of reduced-rate hotel rooms to make your trip to Pittsburgh affordable. Through the travel experts at onPeak, rooms at the group rate are limited and available on a first come, first served basis. Please login into the registration dashboard to book your hotel. You must have an active Emergency Nursing 2018 registration in order to reserve a hotel room in the official hotel block. Reservations without active registration records will be canceled and a cancellation confirmation will be sent. Please note: You may book up to 3 rooms per registrant. If you require more than three rooms, please email your request to ena@onpeak.com. Official ENA Hotels The Westin Convention Center Pittsburgh - Headquarter Hotel Starting at $209/night Courtyard by Marriott Pittsburgh Downtown Starting at $199/night Doubletree by Hilton & Suites Pittsburgh Downtown Starting at $199/night Embassy Suites by Hilton Pittsburgh Downtown Starting at $189/night Hampton Inn & Suites Pittsburgh Downtown Starting at $184/night Kimpton Hotel Monaco Pittsburgh Starting at $234/night Omni William Penn Hotel Starting at $205/night Renaissance Pittsburgh Hotel Starting at $189/night
  10. Pixie.RN

    Trauma Nursing

    What is Trauma Nursing? Trauma nurses specialize in caring for patients injured through trauma, be it accidental or intentional. Trauma nurses must be well versed in stabilizing patients and rapidly recognizing impending life threats. Patients will range in age from neonates to centenarians. Care of these patients can range from short-term in the emergency department (ED) or dedicated trauma unit to long-term in ICUs and rehabilitation units. When these patients enter the system, they don't necessarily arrive with an obvious diagnosis and can benefit from the clinical acumen of experienced trauma nurses. This specialty also requires close coordination and communication with members of the treatment team, ancillary services, and family members. Education Requirements Trauma nurses comes in many flavors, including LPNs, ADN-prepared RNs, BSN-prepared RNs, MSN-prepared RNs, and Nurse Practitioners in mid-level provider roles. Not all types of nurses will be present in all trauma units as hiring preferences vary by location. Additional certifications that trauma nurses may be required to obtain or might pursue include: Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), Trauma Nursing Core Course (TNCC), Emergency Nursing Pediatric Course (ENPC), and Advanced Burn Life Support (ABLS). Additional courses may be required by or available at other locations; this list is not all-inclusive. Board Certification Two emergency-related board certifications that Trauma RNs may have or seek to obtain are the Certified Emergency Nurse (CEN) credential and the Certified Pediatric Emergency Nurse (CPEN) credential. To qualify for the CEN, one must be an RN with an unrestricted license in the US or its territories, and there is no minimum practice requirement, though two years is recommended. To qualify for the CPEN, a candidate must hold a current unrestricted RN license in the United States or Canada and have practiced at least 1,000 hours in pediatric emergency nursing practice as an RN in the preceding 24 months. Links to the Board of Certification for Emergency Nursing (BCEN) exams are available in the "Resources" section below. A newer trauma-specific board certification is the BCEN's Trauma Certified Registered Nurse (TCRN) credential. To sit for the exam, one must hold a current unrestricted RN license in the United States or its Territories, and a nursing certificate that is equivalent to a US RN is also acceptable. Two years of trauma experience is recommended with 1,000 hours per year across the trauma continuum, and 20-30 hours of trauma-specific coursework. A link to more information about the TCRN is below. In the critical care/Trauma ICU arena, trauma nurses may have or wish to pursue the CCRN certification for critical care. To qualify to take the CCRN exam, RNs and APRNs must have a current, unencumbered license in the United States. Exam candidates must also meet one of two clinical practice requirement options: 1) practice as an RN or APRN for 1,750 hours in direct care of acutely/critically ill patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application; or 2) practice as an RN or APRN for at least five years with a minimum of 2,000 hours in direct care of acutely/critically ill patients, with 144 of those hours accrued in the most recent year preceding application. The exam is available for three populations of care: adults, pediatrics, and neonates. Practice hours are those spent caring for a single patient population (adult, pediatric or neonatal) matching the exam for which you are applying. Applicants must include the contact information of a professional reference who can verify clinical practice. A link to CCRN information is available in the "Resources" section below. Work Environment Trauma nurses often work in the hospital-based ED setting, though some facilities have dedicated trauma units that receive only trauma cases meeting certain criteria. Typically a trauma nurse can expect to have unlicensed assistive personnel resident in the department, such as unit secretaries, registration associates, and Patient Care Technicians (PCTs). The broader interdisciplinary team also includes radiology techs, lab techs, respiratory therapists, and other specialists who participate in caring for trauma patients. The entire team, including providers, works closely to stabilize and care for patients. Some facilities also have Trauma ICUs (TICUs). These units are typically staffed with similar assistive personnel and also include a broad interdisciplinary team with the goal of moving the patient toward recovery and eventually a step-down unit or rehabilitation facility. Skills/Qualities Trauma nurses should possess excellent assessment skills to identify and reverse potential life threats. Often trauma nurses are the first to see trauma patients; as such, rapid recognition and identification of issues is essential. The environment is fast-paced and constantly changing, and a trauma nurse must be able to thrive in the chaos of trauma resuscitation. As trauma resuscitation methods are constantly changing and improving through research, trauma nurses should constantly seek new evidence-based information via professional journals and online networking. Job Outlook Though the downturn in hiring has certainly affected nursing across the board, this is a specialty that has been relatively stable for experienced nurses. New graduate nurses may have more difficulty with direct entry into trauma nursing practice, but because emergency nursing opportunities remain available and desirable, that specialty could serve as a gateway to a trauma nursing role. Salary Salary will vary by education and location. Trauma nurses typically work in shifts, which results in shift differential and other benefits. Resources Society of Trauma Nurses Board of Certification for Emergency Nursing - Trauma Certified Registered Nurse (TCRN) Board of Certification for Emergency Nursing - Certified Emergency Nurse (CEN) Board of Certification for Emergency Nursing - Certified Pediatric Emergency Nurse (CPEN) AACN: CCRN Certification
  11. Abstract According to the Institute of Medicine, as many as 98,000 patient deaths occur each year in U.S. health facilities. One primary limitation of current research of nurses' use of research-based knowledge in practice is that the vast majority of studies, which have described barriers and facilitators of evidence-based practice have been qualitative or quasi-experimental designs. There is a paucity of research related to studies about the acquisition and implementation of research-based knowledge in nursing practice in the context of real-time problems that must be solved with on the spot reflective practice. This study examined the effect of a 3-part evidence-based-practice exercise on capability beliefs of RNs to access and implement research-based knowledge into practice. Bandura's Social Cognitive Theory guided the study. Confidence levels were measured using the Evidence-Based Practice Capability Belief Scale post-intervention. For inferential findings, data was analyzed using Independent T-tests, and Mann-Whitley U. Descriptive statistics and p-values compared the two randomly assigned groups on the demographic variables. Chi-square statistics were used to report these findings. Introduction Purpose. The purpose of this study is to promote evidence-based practice behaviors in RNs who provide direct patient care in an Emergency Department setting on a number of important indicators. Also, this study will aim to redirect incorrect self-beliefs and habits of thinking that EBP behaviors cannot be regularly used in nursing practice. Background. There is a need to understand nurses thought processes in situations that require them to acquire new knowledge. Despite efforts to move research knowledge into regular nursing practice, the scholarship of research remains primarily in academia. Many problems nurses face must be solved by on the spot reflection and actions must be undertaken with time constraints that further add to the complexity of patient care. It is not reasonable to expect nurses to take time to form research questions and perform statistical designs while caring for patients. Furthermore, it is not reasonable to expect nurses to possess all knowledge available to solve every problem they may face on a typical day. Nurses should be confident that they can access and implement research-based knowledge into their practice and there should be user-friendly ways to do so. Evidence suggests that research knowledge integrated into nursing practice makes patient care safer, more economical and increases patient satisfaction (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). However, nurses do not routinely participate in the acquisition and implementation of current research (Brown et al., 2009; Fink et al., 2005; &Kaplan et al., 2014). Although nurses agree that implementation of research knowledge would improve patient care, nurses do not see the relevance of research in their own practice (Aboshaiqah, Qasim, Abashaireth, & Patalagsa, 2014; Estabrooks, 1998), nor do they consider it part of their professional responsibility (Majid et al., 2011; Wallen, et al., 2010). Researchers have attempted to bridge the gap between research and practice. Numerous studies identify personal and environmental barriers as well as facilitators to implementation of research knowledge into practice. In one such study, researchers aimed to link scientific evidence to nursing practice, by providing a cadre of research mentors, who were knowledgeable in research implementation and made the mentors available to staff nurses. The mentors assisted nurses in formulating answerable clinical questions supported by sound research evidence. Other researchers aiming to stimulate scientific curiosity in nurses introduced research concepts in easily understood terms, such as whether sugar-free chocolate chip cookies taste better than regular ones (Walden, Cephus, Gordon, & Johnson-Hagan, 2015), or whether healthy potato chips taste as good as less healthy ones (Wolf, Paoletti, & Hongyan, 2012). While there have been research interventions that claim statistical success, these interventions are expensive and emphasize the learning of research jargon and statistical designs. Furthermore, no evidence was found that these efforts have resulted in the sustainable long-term use of research knowledge translation into regular nursing practice, or how nurses translate research knowledge into practice. In order for behavior change to take place, nurses must acknowledge that (a) the standard of care for patient care changes as new information becomes available, (b) it is the responsibility of nurses to seek sound research knowledge to guide their practice, © there must be nurse buy-in to the concept of lifelong learning. This does not necessitate that nurses master statistical design. There has been little or no research that incorporates practice friendly strategies, such as smart-phone apps, whereby nurses can access sound clinical information, and apply it to their practice. This study has the potential to change the concept of research knowledge implementation into regular practice, in alignment with the vision of the IOM Future of Nursing by assessing capability beliefs of nurses to implement research evidence into regular practice. Emergency nurses will be used for this study. Emergency nurses are well suited to innovative approaches because of the variety and complexity of their clinical experiences. Also, emergency nurses have a multitude of problems that span all disciplines of nursing practice. Furthermore, emergency nurses are often the first point of contact into the health care system for at-risk populations (Hawk, 2013). This study proposes to introduce novel approaches to bridge the research knowledge gap using hand-held and computer technology to develop nurse confidence in the acquisition and implementation of research-based knowledge in practice friendly ways that can be used at the point of care. Handheld technology is an effective clinical tool that can be used to access research knowledge and support evidence- based practice and the complex thinking required to approach clinical problems (Hudson & Buell, 2011.) Research Question. Do Emergency Department (ED) nurses who provide direct patient care and participate in a 3-part Social Cognitive Theory (SCT) evidence-based practice video report higher beliefs in capability levels as measured by the belief capabilities scale, than comparable ED nurses who receive an attention control video about healthy lifestyles? Theoretical Framework Bandura's self-efficacy theory conceptualizes personal efficacy beliefs as "beliefs in one's capabilities to organize, and execute the courses of action required to produce given attainments" (Bandura, 1997). Bandura, (1986) proposed a sociocognitive perspective of human functioning that recognized individuals as pro-active and self- regulating. Bandura (1986) emphasizes that a critical element of human behavior is self-belief. Bandura viewed people as self-organizing, proactive, self-reflecting and self-regulating rather than only reactive individuals, which are shaped only by their environment (Pajeres, 2006). According to SCT, human performance results from a dynamic relationship of personal, behavioral, and environmental influences (Glanz, Rimer, & Viswaneth,2008). For example, how people interpret the consequences or benefits of their behavior informs and may change subsequent behavior. This is the foundation of Bandura's (1986) conception of reciprocal determinism, the view that (a) personal factors (b) behavior, and © environmental influences create interactions that result in a triadic reciprocality. Methods Research Design . A pilot study was conducted in the fall of 2017. A randomized two-group experimental design was implemented using a sample of 45 nurses. Research procedures are described in detail in Appendix A. Setting. The setting was an anonymous, secure, online survey delivered via PsychData®. This method enabled the respondents to complete the questionnaire at their convenience, in their preferred environment. The questionnaire could be completed via any device with Internet access, such as a computer, tablet, or cell phone. Sample. The sample was drawn from a population of nurses, who were at least Registered Nurses that are employed in the emergency care setting and provide direct care to patients. The participants were licensed nurses employed in the U.S.; males and females; had the ability to read and understand English, and were 18 years of age or older. The participants for the study were recruited via placement of the recruitment letter with embedded link onto discussion boards in hospitals. Snowball sampling was utilized by encouraging participants to forward the recruitment letter with an embedded link to other potential participants. A power analysis was conducted using a literature search. Because of the scarcity of experimental studies that closely correlate with my study, in terms of acquisition and implementation of research-based knowledge directed at the place where patient care occurs, characteristics of my study variables, such as self-management and self-efficacy were used. Three experimental studies were found that had enough information to calculate an effect size. The effect sizes of the studies reviewed were .3, .56, and .37. The effect size closest to my study is Borycki et al., so that effect (.3) was used for the study (See Table 1). A minimum number of participants for the pilot study was 30. For a full study, a sample size of 240 was determined via power analysis using a power of .8 and an alpha of .05 based on a literature-based effect size of .35. An anticipated attrition rate of 10% added 24 participants for a total sample of 264. Therefore, 30 (more than 10%) was deemed adequate for the pilot study. Instrument. The Evidence-Based Practice Capability Beliefs Scale (EBPCBS), developed by Wallin (2009) was used for data collection (Appendix B). The instrument has six items that measure the latent variables of capability beliefs; personal factors, environmental factors, and behavior. EBPCBS is a one-dimensional scale that specifically evaluates capability beliefs. The instrument adds to the construct of the study because it measures capability beliefs, which aligns with Bandura Social Cognitive Theory that measures self-efficacy, not intent. The answer choices for the six items on the scale were designed to assess nurses' capability beliefs to access and incorporate EBP behaviors into practice. It is criterion based because it was designed specifically to address capability beliefs. using a four-point response format (1 = to a very low extent, 2 = to a low extent, 3 = to a high extent, 4 = to a very high extent). The Likert-scale questionnaire was validated in a 2012 study conducted by Wallin, Bostrom, & Gustavsson. The reliability coefficient was established by Cronbach's alpha. Data Collection Procedures. Following approval from the Texas Woman's University Institutional Review Board, data collection began. The survey was uploaded into the secure electronic platform, PsychData®. Participants remained anonymous to the researcher and consent to participate in the study was implied by completion of the online survey. The survey was open until adequate sample size was achieved. The participants accessed the survey by clicking on the link in the recruitment letter or by copy-and-pasting the link into their browser. The participants were recruited via the recruitment letter with embedded link, which was posted in 3 hospital breakrooms. Snowball sampling was encouraged in the recruitment letter. Demographic information was obtained following completion of the survey. Information gathered included information about personal practice, including length of time in practice, whether the participant provides direct care to patients, employment status, and number of patient ED visits annually. Personal information was collected that included age, gender, educational level, and race. Demographic questions are listed in Appendix C. Data Analytic Techniques. The completed surveys were exported into the Statistical Package for the Social Sciences (SPSS), Version 25 for analysis. Parametric and nonparametric tests were employed to answer the research question. For the data analysis, a statistician was consulted to determine the best analytical method based on the data collected. The choice of analytical methods would allow for appropriate conclusions to be drawn. Findings Sample Description. 56 participants accessed the link. Of the 56, 48 answered the questionnaire/posttest in full. Of the 54, 28 were randomized to the control group and 28 to the intervention group. 3 participants answered that they did not provide direct patient care, so those surveys were eliminated. There were 45 useable surveys. Of these, 20 were randomized to the intervention group and 25 were randomized to the attention control group. The principal investigator was unable to obtain information on the number of participants who copied the posted link. In addition, snowball sampling was encouraged in the recruitment letter. Therefore, the response rate for the survey was unable to be determined. (See Table 2 for sample description). Instrument Reliability and Validity. Content validity was examined for the CBS with Item-Content Validity indices between 0.8 and 1 (Bostrom et al., 2009). Construct validity was examined by Wallin et al., (2012). The internal structure of the CBS was performed by using two groups for exploratory and confirmatory analysis. Factor analysis of item correlations between the two groups was performed and confirmed the fit of the scale was invariant and could be replicated. Forsman et al., (2012), reported construct validity, with factor loadings between 0.78 and 0.84. Reliability for the CBS has been examined using with Cronbach alphas reported between 0.75 and 0.90., (Forsman et al.,2012; Rudman et al., 2012). Research Question. The completed surveys were exported into the Statistical Package for the Social Sciences (SPSS) Version 25 for analysis. First, Likert type items were checked for normality using skewness and kurtosis statistics. Despite the small sample size, none of the skewness or kurtosis statistics are above an absolute value of 2.0, therefore it can be assumed that each distribution is normal. Next, the statistical assumption of homogeneity of variance was tested. The two groups were compared using independent samples t-tests. There was a non-significant difference between the groups for Likert item 4, p = .16. However, it was violated for Likert items 1, 2, 3, 5, and 6. Therefore, Mann-Whitley U tests were done for questions 1,2,3,5 and 6. The statistical assumption of homogeneity of variance was checked using independent samples t-test. Homogeneity of variance is the assumption that the samples are obtained from populations of equal variance (Pallant, 2013). The independent samples t-test is a parametric technique that requires one categorical independent variable with two groups (intervention and control), and one continuous dependent variable (confidence levels) (Pallant, 2013). The independent samples t-test compares the mean scores of 2 different groups of people (Pallant, 2013). Homogeneity of variance was violated for Likert items 1, 2, 3, 5, and 6 because, for these items, the significant values are less than .05. Therefore, Mann-Whitley U was used for analyses for those comparisons. An independent-samples t-test was conducted to compare the confidence levels for group 1 (control) and group 2 (intervention). There was a non-significant difference between the groups for Likert item 4, p = .16. Because homogeneity of variance was violated for question 1,2,3,5, and 6, Mann-Whitney U tests were used for analysis of those questions. The Mann-Whitney U test is a non-parametric test that corresponds to the parametric independent samples test (Pallant, 2013). The Mann-Whitney U test compares medians of the two groups, converts the scores on the continuous variable to ranks across the two groups, and then evaluates whether the ranks for the two groups differ significantly (Pallant, 2013). There was significant difference between the groups for Likert item 1, p = .025. There were non-significant differences for Likert item 2, p = .08, item 3, p = .12, item 5, p = .09, and item 6, p = .08. Descriptive statistics and p-values were used to compare the two randomly assigned groups on demographic variables. Chi-square statistics were used to report these findings. There was a non-significant difference between the groups for all characteristics. The results are summarized in table 4. Discussion Relationship of findings to Literature and Theoretical Framework. Bandura Social Cognitive Theory (SCT) is concerned with people's beliefs in their capabilities to produce given achievements (Bandura, 1997). Bandura emphasized that human behavior and motivation are driven by beliefs that people have about their capabilities (Pajeres, 2006). The theoretical basis for the dependent variable in my study, capability beliefs to access and incorporate research-based evidence into practice, aligns with Bandura's ideas about self- efficacy. Self-efficacy is one's beliefs about how his or her actions produce future attainments. Modification of self-efficacy is directed by self-efficacy theory (Bandura, 1997). According to Bandura (1997), how people behave can be better predicted by their capability beliefs, then by what they are actually capable of doing. Table 3 shows how the proposed study connects with the SCT. Evidence-based practice behaviors are described in this study as accessing and implementing research-based knowledge in practice. The study is designed to reflect strategies that can be used to reflect development of EBP behaviors in practice, identify strengths, and highlight areas for potential growth, using examples of clinical situations. In order to ensure a well-rounded perspective, feedback from interdisciplinary colleagues is essential. Use of research knowledge in nursing practice has never been more important because changing paradigms in healthcare demand quality more than ever before (Perez-Campos, Sanchez-Garcia, & Pancorbo-Hidalgo, 2014; Institute of Medicine (IOM), 2001; 2003; 2010). Development of research knowledge is a part of contemporary nursing education, and nurses are expected to contribute (International Council of Nurses, 2013). However, acquisition and implementation of current research in practice is not widely implemented after graduation. In fact, nurses persist in reliance on peer opinions and what was learned in school to guide their practice (Aboshaiqah, Qasim, Abashaireth, & Patalagsa, 2014; Estabrooks, Chong, Brigidear, & Profetto-McGrath, 2005; Pravikoff, Tanner, & Pierce, 2005; Shaflei et al., 2013). The average age of today's nurse is greater than 40 and most nurses graduated before 1998 when research was not routinely included in nursing curricula (Estabrooks, et al., 2005; Fink et al., 2005; Pravikoff et al., 2005). Patient care guided by habit and peer opinion becomes outmoded and has the potential to be dangerous. Evaluation. A major aim of the study is to redirect incorrect self-beliefs and habits of thinking that EBP behaviors cannot be regularly used in nursing practice. From the six questions in the instrument that describe confidence to use EBP behaviors, only question 1 showed a significant difference between groups. However, the remaining p values come close to a significant value. It is, therefore, possible that concluding that the other questions are not statistically significant could represent a type II error, whereby we fail to reject a false null hypothesis. A larger sample may produce significant results. Conclusions The small sample size was a limitation of the pilot study; however, 84% of the participants who began the survey completed it, indicating that the use of the survey would be a reasonable method to collect data regarding the knowledge, attitudes, and self-efficacy of nurses working in emergency care. Recommendations for Revisions for Full Study For the full study, additional methods to access the ED nurse population were warranted and considered. The recruitment methods for the full study were amended to include accessing several Facebook discussion boards of groups of ED nurses, such as "Show Me Your Stethoscope". A reminder letter will be posted on the same member discussion boards two weeks after the study begins. Furthermore, incentives for participation will be considered. References Aboshaiqah, A. E., Qasim, A., Abashaireth, A., & Patalagsa, J. G. (2014). Nurses' perception of barriers to research utilization in a public hospital in Saudi Arabia. Saudi Medicine Journal, 35(9), 1136-1139. https://www.ncbi.nlm.nih.gov/pubmed/25228191 Bandura, A. (1991). Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes, 50(2), 248-287. https://www.sciencedirect.com/science/article/pii/074959789190022L Brown, C. E., Wickline, M. A., Ecoff, L., & Glaser, D. (2009). Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing, 65(2), 371-381. https://www.ncbi.nlm.nih.gov/pubmed/19040688 Bandura, A. (2006). Guide for constructing self-efficacy scales. In F. Pajares & T. Urdan (Eds.). Self-efficacy beliefs of adolescents, (Vol. 5., pp. 307-337). Greenwich, CT: Information Age Publishing. Estabrooks, C. A., Chong, H., Brigidear, K., & Profetto-McGrath, J. (2005). Profiling Canadian nurses' preferred sources for clinical practice. Canadian Journal of Nursing Research, 37(2), 118-141. https://www.ncbi.nlm.nih.gov/pubmed/16092784 Fink, R., Thompson, C. J., & Bonnes, D. (2005). Overcoming Barriers and Promoting the Use of Research in Practice. JONA: The Journal of Nursing Administration, 35(3). https://www.ncbi.nlm.nih.gov/pubmed/15761309 Glanz, K., Rimer, B. K., Viswanath, K., & Orleans, C. T. (2008). Health behavior and health education: Theory, research and practice. San Francisco: Jossey-Bass. Hawk, M. (2013). The Girlfriends Project: Results of a Pilot Study Assessing Feasibility of an HIV Testing and Risk Reduction Intervention Developed, Implemented, and Evaluated in Community Settings. AIDS Education and Prevention, 25(6), 519-534. https://www.ncbi.nlm.nih.gov/pubmed/24245598 Hudson, K., & Buell, V. (2011). Empowering a safer practice: PDAs are integral tools for nursing and health care. Journal of Nursing Management, 19(3), 400-406. https://www.ncbi.nlm.nih.gov/pubmed/21507112 Institute of Medicine. (2001). Retrieved from Crossing the Quality Chasm: A New Health System for the 21st Century : Health and Medicine Division Institute of Medicine. (2003). Fostering rapid advances in health care: Learning from system demonstrations. Retrieved from http://iom.nationalacademies.org/Reports/2002/Fostering-Rapid-Advances-in-Health-Care-Learning-from-System-Demonstrations.aspx Institute of Medicine; Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2010.). The Future of Nursing: Leading Change, Advancing Health. Retrieved from The Future of Nursing: Leading Change, Advancing Health | The National Academies Press International Council of Nurses (2013). Scope of Nursing Practice. 404 Not Found Kaplan, L., Zeller, E., Damitio, D., Culbert, S., & Bayley, K. B. (2014). Improving the Culture of Evidence-Based Practice at a Magnet® Hospital. Journal for Nurses in Professional Development, 30(6), 274-280. https://www.nursingcenter.com/cearticle?an=01709760-201411000-00002&Journal_ID=54029&Issue_ID=2651313 Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses' perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229-236. https://www.researchgate.net/publication/51489842_Adopting_evidence-based_practice_in_clinical_decision_making_Nurses'_perceptions_knowledge_and_barriers Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The State of Evidence-Based Practice in US Nurses. JONA: The Journal of Nursing Administration, 42(9), 410-417. https://www.ncbi.nlm.nih.gov/pubmed/22922750 Pallant, J. (2013). SPSS Survival Manual (5th ed.). Berkshire, England: Open University Press. Perez-Campos, M. A., Sanchez-Garcia, I., & Pancorbo-Hidalgo, P. L. (2014). Knowledge, attitude and use of evidence-based practice among nurses active on the Internet. Investigation and Education Enferma, 32(3), 451-460. https://www.ncbi.nlm.nih.gov/pubmed/25504411 Pravikoff, D. S., Tanner, A. B., & Pierce, S. T. (2005). Readiness of U.S. Nurses for Evidence-Based Practice. American Journal of Nursing, 105(9), 40-51. https://www.ncbi.nlm.nih.gov/pubmed/16138038 Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine:How to practice and teach EBM. Second edition. Edinburgh:Churchill Livingstone, 2000. Shafiel, E., Baratimarnani, A., Goharinezhad, S., Kallhor, R., & Azmal, M. (2014). Nurses' perceptions of evidence- based practice: A qualitative study at a teaching hospital in Iran. Medical Journal F the Islamic Republic of Iran, 28(135), 2-8. https://www.semanticscholar.org/paper/Nurses’-perceptions-of-evidence-based-practice%3A-a-a-Shafiei-Baratimarnani/261084af5f4e65ad93971b10b2fa1c01b72170b2 Titler M.G. (2008). The Evidence for Evidence-Based Practice Implementation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US) ;Apr. Chapter 7. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2659/ Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. Journal of Advanced Nursing, 66(12), 2761-2771. https://www.ncbi.nlm.nih.gov/pubmed/20825512 Wallin, L., Bostrom, A., & Gustavsson, J.P. (2012). Capability beliefs regarding evidence- based practice are associated with application of EBP and research: Validation of a new measure. Worldviews on Evidence- Based Nursing, 9 (3), 139- 148. https://www.ncbi.nlm.nih.gov/pubmed/22458331 Walden, M., Cephus, C. E., Gordon, M. D., & Hagan, J. (2015). The Great American Cookie Experiment: Engaging Staff Nurses in Research. Journal of Pediatric Nursing, 30(3), 508-515.. https://www.sciencedirect.com/science/article/pii/S0882596314003273 Wolf, I. S., Paoletti, C., & Du, H. (2012). Nursing Research Across a Large Health Care System. Nursing Administration Quarterly, 36(4), 332-339. https://journals.lww.com/naqjournal/Pages/toc.aspx?year=2012&issue=10000
  12. Roy Fokker

    Mothers Day

    I bought a motorcycle last year. I've always loved riding and I've been wanting to get one for years. I finally cashed in some vacay time and bought a Honda Shadow 750. I love the bike and ride as often as I can - even commuting to work. It is very therapeutic - cathartic even - for me. I get extra depressed in the winter because I'm not on my bike. What does all this have to do with nursing and Mothers Day? Well, earlier this year, when I took my bike out of storage, my Mother made a quiet request: "Be a darling. I would love it if you could call me when you reach work and before you leave for the ride home at the end of the day." I essentially pooh-pooh'd her concern and essentially never really honored her request. Mom never brought it up again. Fast forward to yesterday. Charge nurse recd. an alert from EMS that they were bringing in a young MVA/ATV victim - intubated. Unresponsive but un-cooperative on the scene. Looked bad. Mind you, the ED at this time is its usual bedlam: Shift change due shortly, monitors and alarms going off, people talking in the crowded department, overhead pages announcing bake sales in the cafeteria, phones ringing constantly... KWIM? A few minutes after this call and before the patient arrived in the ED, the secretary answered what seemed like a routine phone call. But with each passing minute, the look on her face got more and more strained. I mouthed a silent "Need help?" to her and her eyes practically screamed, "HELP ME!" She put the call on hold and walked over to me (even though she was sitting opposite me at the desk.) "I don't know what to do! It's a patient's Mother and she's calling about her son. I've tried looking him up with what detail I can get from her - by the way, it must be an awful cell phone connection because she keeps cutting out. But I can't find him on our campus. He can't be an admit (ER and Inpatient use different charting systems) because she says he must have been brought here just recently because she was notified just now. Some kind of mudder/ATV incident or something? That last part sent a spark through my brain. As I was walking back after I'd discharged one of my patients, I passed the charge nurse desk and overheard her ask one of our techs to clear one of our trauma rooms and set it up for an intubated patient. I wondered 'Hmm, maybe this Mom's son and the tubed patient we're supposed to be getting are the same?' "So anyway, I tried checking with XYZ Campus and they didn't have anyone by that name there either" the secretary continued. That's unusual because the secretaries do this on a daily basis. They know how to look up patients and records better than the nurses and docs. Records are their bread-and-butter. "By the way, I'm not even sure that's the actual name either. The phone connection is awful and she's so upset that she's not answering questions appropriately!" "I'll speak to her. See what I can do", I said with a smile. I put all the cheeriness I could muster into my voice "Hello my name is Roy. I'm a nurse in the Emergency Department. How can I help you today?" The voice that responded drained what cheeriness and sunshine I had left in me. I didn't need to be a psychiatrist to hear the desperation, anxiety, anguish, heartache, dread, and pain in that voice. "PLEASE! HELP ME PLEASE! My name is Jane Doe and my son was brought to your hospital! They told me he's in bad shape. Can you..." "Ma'am, what's your son's name?" "John Doe. He has..." *cuts out* "...old. He said he was" *cuts out* "friends. Are they..." *cuts out* "...EASE HELP ME!" "Ma'am I'm so sorry but I kept losing you during your last conversation. Could you please repeat that slowly..." "He has red hair! He's a good kid! *sobs* PLEASE HELP ME! His ID says 100, Main Street, Anytown but that's not true *sobs* He lives with me! 10, Home Street! *sobs* PLEASE HELP ME!" "Ma'am, what's the last name, first name and date of birth on his ID? It might make it easier to locate your son." *sobs* "My son is John Doe. He was born 01/01/1991. PLEASE HELP ME! IS HE ALIVE?! IS HE BREATHING?! THEY CALLED MY YOUNGER SON WHO TOLD ME THAT HE WAS IN BAD SHAPE! IS HE DEAD?! OH GOD PLEASE...." The sobbing had turned to crying. My usual calm demeanor had turned to anguish! Anguish because my heartfelt every *sob* and plea entrained by the Mother. I was starting to get frantic because I couldn't locate her son ANYWHERE on our 5 campuses! I was just about to put Mom off hold and ask her if EMS or whoever called her had specified where they were taking her son, when out the corner of my eye, down the hall, EMS rolled in with a fairly young looking intubated patient. On a hunch, I said, "Ma'am, I've very sorry to put you on hold again but it will be for just a second." I put her on hold, made laser eyes at the secretary and said: "run down to ambulance receiving and get me data on whom/what the patient is!" She needed no encouragement - ran down to the Charge Nurse desk, got info and ran back. "It's a 20 some year old, intubated patient. Name is John Doe. Found unconscious by friends. Unknown downtime." "Ma'am, I think your son just arrived at my Emergency Department. This is go..." "IS HE OK?! IS HE BREATHING?! *sobs* SIR, YOU HAVE TO HELP ME! *sobs* IS HE ALIVE?! YOU HAVE TO TELL ME!" That last part was expressed as she dissolved into tears and crying. There are very few times I hate my job. This is one of them. I 'hate it' because I hate giving people bad news. "Ma'am - I'm so sorry I can't give you more information. But your son just got here and I can promise you that the best medical team in the world will be looking after him." "IS HE ALIVE? IS HE BREATHING? (Anguish still in her voice) "Ma'am, your son just got here." I looked over and saw the team swarming him in the Resuscitation Room - docs, nurses, techs, respiratory therapists. I saw a multitude of complex machinery being used to try and keep the patient alive. My heart sank. That's usually not a good sign. "Ma'am, he's alive as of now. He's very sick BUT ALIVE, as of now." "NOOOOO! NOOOOO! MY BABY!" she wailed. I felt horrible. I didn't want to crush her spirits but I didn't want to give false hope either. Besides, I barely knew anything of what was going on with the patient. What I did know what that Mother and Son (even unconscious) needed each other. As gently as I could, I spoke into the receiver again "Ma'am, please listen to me. Your son needs you right now. Where do you live?" *sobs* "Farawaytown" Ouch! But at least she isn't screaming hysterical anymore... "OK. I need you to call your youn..." I paused as the secretary slipped a note in front of me - 'EMS dispatched a patrol car to the address of the Mother to escort her in.' "Ma'am, the EMTs just told me that a police car has been sent to your address to escort you here. Call your younger son and have him come too. Either as a driver or as someone to help you. Please DO NOT drive yourself." *sobs* "My son is already on his way!" *sobs* "Good! Do you know where this hospital is located?" "Yes." "Good! Ok. I'm so sorry Mrs. Doe." "Thank you so much Sir! Thank you for your help!" *sob* I looked at the receiver incredulously and hung up. I probably delivered the worst news she's probably ever heard in her life and she ends the call by thanking me?! I shook my head and took a deep breath. One of the other nurses from night shift stepped up to me and said "Hey Roy! Wanna give me report and get outta here?" "Brother, you have noooo idea!" As we were punching out after shift, my colleagues and I commiserated over the case. We all agreed that it was a horrid story and we all felt bad for the patient and his family. On my drive home, all I could think of was that anguish and pain in that poor mother's voice. That phone call played back over and over again in my head. Heck, it's playing back in my head right now (and I have the goosebumps to prove it.) As I parked my car and walked home, I noticed that the light was still on (it was well past midnight.) Mama is still up... I shook my head. My parents are retired and split their time living with my older Brother and Me. For years I've told Mother she doesn't have to stay up for me. That I'm a grown man now and I can take care of myself. But she insists. She says she can't sleep until she knows I'm home and safe. I unlocked the front door and walked in. Mother looked at me and smiled. She looked worn and tired but she still smiled and said "Ah! You're home! How was your day?" I didn't bother taking my jacket or shoes or my backpack off. I walked straight over, gave her a bear hug and a kiss and said "I think I'll call you when I get to work from now on." Mama just smiled and said "Good!" I still haven't told Mama about the case - because I know she'll worry. She worries enough as it is. I'm just gonna try and be a better son... - Roy PS: That phone call hit me like a wrecking ball. I just couldn't bear to even 'imagine' my dear Mama on the other end of that phone call. Talking to who knows who as she's frantic about the status of her son? And what was I pooh-pooh'ing anyway? A mothers love and concern for her son? What kind of a special, ungrateful, dimwit was I?! I was raised in a culture that didn't have special holidays for "Mothers Day" and "Fathers Day." Where I come from, everyday is 'Mothers Day' and 'Fathers Day.' 'Honor your parents, for not only did they give life to you; they sacrificed a lot to try and make sure you had a better life than they did.'
  13. nurseraya1

    Real Life and Death

    Nurses are often viewed as kindhearted lifesavers...angels in scrubs. Still others view us as hard, harsh, impatient and to the point. Well, please allow me to give you just a small glimpse into our world; for its all too real and grossly misunderstood. Imagine the chaotic, yet organized scene as and ambulance gurney rolls through the bay doors. You find yourself sweating, heart racing as you instinctively jump into action. You straddle and ride aside the gurney, compressing a small chest, trying with everything you have to save a child's life, knowing that despite your valiant attempts, it will be futile in the end... But you continue for the sake of the mother and father praying in the background that their child makes it; bartering with whomever for that one shot in the dark. So you continue compressing the fragile chest, assisting with ventilations, pushing medications, placing tubes and lines wherever you can...knowing in your head that life is already gone...his soul still lingers in the room...you get a chill, perhaps it's the child begging you to stop. Time flies, yet ticks by so slowly until the code is called; attempts to save the young life, not long ago, so full of hope...now terminated, time of death frustratingly and begrudgingly announced. Now the time has come to transform into the nurse with the comforting arms that hold tight the father, mother, sister and brother as they fall apart, crumbling into a million pieces. Hot tears soaking your hair and streaming down your neck, body wracking sobs surely forever to haunt you. But you won't let go; you can't, for you are their sole lifeline between life and death, joy and sorrow, hope, heartache and reality. It's all one in the same really. You hope and pray for the best, most times knowing the "best" in reality is actually the worst. But you do it anyway. They don't know, but we do. Oh the heartache, the gut-wrenching wails, fists pounding on walls, begging to take their place; they can't though, they have to let go, unwilling and unprepared. We weep with them whilst trying to be strong.... Sorry we couldn't save him. We're not God, though they think we have that power... We don't and we're so sorry for it. While you're attempting to comfort the family, another team member is trying to make the now motionless body presentable for loved ones, hoping to somewhat ease the pain. Alas, no amount of preparation can soften that final punch to the gut, squeezing of the heart or calm the complete mind **** to ensue. We're sorry it isn't enough, so, so sorry. When you leave, taking one less family member with you, a toe tag is placed to identify the young life that once was...a tag, on a toe...how unjustified; you're now identified by a slip of paper. I'll fill out a stack of paperwork and make countless phone calls before I'm able to release your cold, blue and battered body to the mortuary or coroner. The dreaded ring of the radio is heard in the background, time to move on to the next life... hopefully we can save you. We've finally reached the end of another shift; it's now time to go home. You hug your loved ones a bit tighter and try to sleep off the tragic events of the shift. You pray for peace for the families affected and pray the ones you couldn't save don't torment your dreams. Nightmares are sure to ensue... What could we have done differently? Probably nothing, but the questions will continue to bombard your brain. Sleep; please take me, for the burden is far too great....
  14. This is Part 2 of a two-part series of articles on caring for the elderly in the ED setting. Sanders (1996) developed 11 principles of geriatric emergency care that should be used when assessing older adults. These precepts are as follows: Complex Presentation Older adults, those at least 65 years of age, often present as complex patients for a number of reasons that extend beyond physical disease. It may be difficult to distinguish which symptoms are the patient's chief complaint, as well as which symptoms are the most important, as the elder may have multiple complaints. In fact, the clinician may feel overwhelmed by the deluge of complaints. The nurse needs to take the time to listen carefully, record each complaint, and ask insightful questions. For instance, late one evening, an infirm older adult came to the ED with complaints of back pain, indigestion, and headache. Upon further questioning, the patient mentioned that he was also experiencing chest discomfort, tightness, and pressure. It was interesting that "chest pain" was not even mentioned in his initial litany of complaints. Teasing out this vital information took quite a bit of time and effort. Atypical Symptomology The elderly patient often presents atypically. Because illness in older adults is complicated by the normal changes of aging and multiple chronic conditions, many older adults do not display the usual signs and symptoms of illness. Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss. For instance, the typical symptoms of pneumonia include chills, fever, cough, chest pain, labored breathing, fatigue, and bloody sputum. In the older adult patient, many of these signs and symptoms may be absent. The elder with pneumonia may simply present with level of consciousness changes and anorexia. Depression may be masked by nonspecific somatic complaints, such as multiple "aches and pains." Falls may signify serious illness in the frail patient. Confusion, lethargy, new-onset incontinence, and/or anorexia may signal a urinary tract infection or urosepsis. Atypical presentation often delays the diagnosis of acute illness with a resultant higher rate of mortality. It is essential for nurses to conduct careful and thorough assessments of older adults to consistently recognize vague presentations of illness and ensure appropriate and early treatment. Multiple Pathology (Comorbidities) The majority of the elderly contend with two or more chronic medical conditions, or comorbidity. Chronic diseases are more common than acute illnesses in the older age group. The chronic disorders most prevalent in the older population are ones that can have a significant impact on independence and the quality of daily life. Examples of comorbid conditions are cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), diabetes, arthritis, hypertension, and Alzheimer's disease. Elderly patients with multiple chronic conditions often have worse outcomes and increased mortality. Indeed, chronic conditions account for 70 percent of all deaths in the U.S. Older adults usually visit the ED for an acute exacerbation of chronic disease such as heart failure or COPD. Polypharmacy The elderly are more likely to take multiple medicines. People aged 65 and over comprise 13 percent of the population but account for 34 percent of all prescriptions. On any given day, the average senior takes four or five prescription drugs and two over-the-counter (OTC) medications. Because they take more medications than younger people, the elderly have a higher risk of adverse reactions. As a matter of fact, 5 percent of all elder hospital admissions are related to an adverse drug event. It is vital to have an effective method of medication reconciliation in the ED. This includes accounting for all prescription medications, OTC products, herbals, and supplements. Cognitive Impairment An estimated 40 percent of all elderly ED patients have some form of cognitive impairment (i.e., dementia or delirium). Older patients with cognitive impairment are vulnerable, since they may be unable to make decisions for themselves or function independently when they visit the ED. This can pose many challenges for ED clinicians during admission, assessment, and treatment. Delirium is the most common cognitive impairment, and it is often under recognized and overlooked. Also known as an acute state of confusion, delirium is a medical emergency, with a fatality rate as high as acute MI or sepsis. It can present as lethargy, agitation, or a fluctuation between these two transient states. Correctly identifying cognitive impairment is critical for medical testing, effective treatment, and to facilitate safe and realistic discharge planning. Physiological Efficiency Aging results in a diminished ability to maintain homeostasis and regulate body systems. Organ function becomes less efficient with age, correlating with laboratory values. For instance, the glomerular filtration rate (GFR) of a ninety-year old is normally half that of a twenty-year-old. Other alterations include alkaline phosphatase, cholesterol, PSA levels, and sed rate values, which increase somewhat in seniors. To provide safe and effective care in the geriatric population, clinically significant changes in lab values need to be recognized and accurately interpreted. Decreased Functional Reserve As a result of the effects of aging on the physiological processes, the elderly have less functional reserve. While performing normal activities, the elderly may function well. When stressed by illness or injury, however, their functional reserve may be depleted quickly. As people age, functional reserve diminishes so that a stressful event can have much more severe consequences. Older people who develop acute illness or suffer a trauma usually require longer periods of recovery and have more complications from these conditions. Importance of Family or Community Support Does the older adult require assistance with performing daily activities? Are caregivers available to help him or her? Correctly assessing an elder's support system is critical to discharge planning. Baseline Premorbid Health Status It is important to know the older person's baseline health status to discern cognitive and functional decline and assist diagnosis and treatment. A simple strategy is to compare the presenting signs and symptoms with the elder's normal baseline that preceded this occurrence. Medical history provided by the family can provide important clues as to what is normal and abnormal for the patient and what may be the underlying cause of the presenting signs and symptoms. Psychosocial Impact of Illness and Trauma Social and personal concerns of the elderly are frequently not addressed in ED encounters. Emotional problems, such as depression, often influence somatic complaints and can disguise underlying health problems. The Need for Comprehensive Assessment Some specific areas that ED nurses can focus on include a more comprehensive approach to assessment and discharge planning, improved communication with the patient and their informal caregivers, substance abuse, and elder abuse and neglect. Failure to consider the possibility of abuse and neglect will mean that the appropriate diagnosis is not made and the older adult is returned to an unsafe environment. Danger signals are sudden weight loss, dehydration, medication over dosing or under dosing, injury marks, personal neglect, car accidents, forgetfulness, extreme suspiciousness, fires in the house, bizarre behavior, or disorientation. Emergency department nurses are challenged to meet the needs of older patients, who have complex presentations and require comprehensive assessment and referral. Problems such as atypical presentation, chronic health conditions, altered cognitive state, and polypharmacy can complicate diagnosis and management. These 11 principles can assist clinicians in meeting these challenges and help ensure that older adult patients receive appropriate care in the ED setting. References Aging Effect on Laboratory Values The Unlikely Geriatricians
  15. Founded in 1970, ENA has proven to be an indispensable resource to the global emergency nursing community. With more than 42,000 members worldwide, ENA advocates for patient safety, develops industry-leading practice standards and guidelines, and guides emergency healthcare public policy. Dates: Sep 13-16, 2017 Registration: Online Form Attendance:3,500 Highlights: CNE contact hours. CERPS, Up to 150 Sessions, Hands-On Learning, 200+ Sponsors and Exhibitors, Advocacy, Networking, Music & Dancing, Welcome Party at Ballpark Village. Emergency Nursing Conference 2017 Be part of the most exciting hands-on emergency nursing education: Emergency Nursing 2017. Held in St. Louis, Missouri, this four-day conference is an opportunity to expand your knowledge, learn new skills through hands-on opportunities, and return to your ED reinvigorated to share new ideas and best practices. The largest conference dedicated to emergency nursing includes: More than 150 sessions ranging from pediatrics and geriatrics, to leadership, trauma, and more Interactive demonstrations, hands-on learning labs, and Mass Casualty Incident (MCI) Training ADVANC-ED - a 6-bed area with interactive manikin simulation exercises, and a SIM Wars friendly competition against your peers The NEW TECH-ED area, a close-up look at the newest and most advanced high-tech emergency care products Electronic Posters (ePosters), featuring the latest emergency nursing research and evidence-based practice Cadaver and Ultrasound hands-on labs Networking, networking, and more networking Some of the sessions include: Strategies for Implementing the Geriatric ED Guidelines: Education, Best Practices, Quality Improvement Ultrasound Assessment and Guided Procedures in the Emergency Department Bridging the Academic-Practice Abyss: Nurse Residency and ED Professional Development The Colorado Cannabis Experience - Lessons Learned for Other States Trauma Nurse Fellowship: Developing the Novice Trauma Nurse Human Trafficking in the Emergency Department: Navigating Medical Forensic Protocols Emergency Management of Chronic Pain Body Modification: The What, How, and Pitfalls ED, ICU, Critical Care in the Emergency Department Opioid Addiction and Death Spiraling Out of Control Download Emergency Nursing 2017 Registration Brochure WELCOME PARTY AT BALLPARK VILLAGE Thursday, Sept. 14 - 7:00-11:00 pm Enjoy an evening of fun at Ballpark Village, the newest dining and entertainment district in the St. Louis area. This first sports anchored entertainment district located next to Busch Stadium, home of the St. Louis Cardinals, offers a wide variety of restaurants, bars, lounges, and entertainment venues. Come join us for great food, and a whole lot of fun! Exhibit Hall The Exhibit Hall offers hands-on training, product specific training, and access to more than 200 leading suppliers of products and services for every type of emergency care environment. Take new product ideas back to your institution. DisastER From natural disasters, to major accidents, DisastER requires emergency preparedness for catastrophes in the field. Located in the Exhibit Hall, this hands-on DisastER area offers techniques in S.T.A.R.T. Triage, self-aid, buddy-aid, tourniquet application and lessons from the field. Featuring hands-on work with MCI, military SMRT tents, and medical helicopter, these exercises prepare nurses for emergencies outside of the ED. Short ED Talks will also be held here. All hands-on training and ED Talks in the DisastER area start at the top of the hour during Exhibit Hall hours. ENA Way Follow the arrows on the Exhibit Hall floor and head towards the music. ENA Way is where you will find: ENA Marketplace, filled with ENA educational products and merchandise ENA Foundation, where you can donate to help nurses further their education, or learn about how to apply for a scholarship. ENA LEARN kiosks, where you can learn about and purchase ENA digital educational products ENA Career Fair and Wellness, hosting a professional headshot photo lounge and job center ENA Education Booth #426 Journal of Emergency Nursing Booth #429 Academy of Emergency Nursing Booth #427
  16. traumaRUs

    Critical Incident Stress Debriefing

    What is a critical incident? They are typically sudden, powerful events outside the range of ordinary human experiences. There is likely to be a powerful response within those individuals who work in an arena where critical incidents readily occur. Who should attend? The debriefing should be available to all ER staff: from the housekeeper, tech, nurses and physicians as well as ancillary personnel. The debriefing should occur as soon after the traumatic incident as possible. We as human beings are just as vulnerable to stress-related problems as the civilian population. However, we (as super calm, efficient and nothing-can-get-to-me ER nurses) don't like to acknowledge it! If you've experienced an especially stressful event, contact your local CISD team, start one at your facility if one doesn't exist. Here are some resources: How to start a CISD team: http://www.pcchap.org/PCMANUEL/Chp%204/chapter4.htm From: traumatology, volume 9: http://www.fsu.edu/~trauma/V9/v9i1_911Aftermath.pdf Lenore Behar article about CISD: Dr. Lenore Behar - Publications and Articles American Academy of Experts in Stress: Providing Critical Incident Stress Debriefing (CISD) to Individuals and Communities in Situational Crisis
  17. awongaemtcc

    In My Prayers

    We do the best for our patients and then we don't try not to take the job home or let it bother us. But I give credit for those floor nurses who are busy taking care of our grandma's, grandpa's, mom's, dad's, siblings and friends because in a way, they become their own family. Their work family. For the most part, they see them every day, day by day. All the things nursing school focuses on care plans and stuff actually matter up there. In the ER not so much. But today, I felt like I connected with a patient. It wasn't a bad night in the ER. We had my first cardiac arrest at Crouse tonight which was definitely different the way it is run at the Brook. But that's a whole other story. I was working at the Acute end of the ER tonight but I thought I'd go help one of the nurses who was drowning with patients. I went to go check on her patient who was hypotensive. I walked into the room and the small frail lady in her 80's sat there in her bed with her son and her daughter at her bedside. I took her BP and asked her how she felt. She said I feel like "crap". Laughing I looked at her BP and it was 70/40. Low. Her son made a comment about saying mom you could've said you felt like ****. And the woman laughed and yelled at her son for cursing in my presence. So we bolused her and I went on my merry way. About 20 minutes later they rush her to the Acute end. Apparently, she went into rapid A-Fib and her pressure kept dropping. She had a positive troponin. Pretty much whatever was bothering her was becoming systemic. The doctor wanted to cardiovert her. All the sudden this frail old lady who laughed and joked looked like a scared child. She kept saying how scared she was. She told me one of her grandson's names were Andrew and that he didn't like being called Andy. I told her she could call me whatever she wanted. We tried to calm her down, had the family step out and gave her some propofol. Once she went out we cardioverted her 3 times. We couldn't get her back into a sinus rhythm. She slowly came around and looked at me and said to me. "Andrew I'm scared. You see, I didn't call you Andy." I felt horrible for the poor old lady who was being shocked over and over. I kneeled on her side and held her hand. I told her exactly what the doctor was doing through each step of the central line. She squeezed my hand and said "I trust you, Andrew. I'm scared... but I trust you." I kept reassuring her that it was going to be ok, we did the central line and I explained each step telling her how great of a job she was doing. I tried to talk to her about her family to get her mind off things. She was a mother of 8 children oldest in his 50's and youngest in his 40's. She had 15 grandchildren and 3 great-grandchildren. She just kept smiling when we talked about them. We started her on pressors to bring her BP up. When the doctor was done, I left the room to attend to another patient. A few minutes later I figured I needed to get something from the room and check on her and she's in the room and the doctor is doing chest compressions and intubating her. I don't know what it was. I've been doing this for so long and I've seen people crash before but I felt like I was connected to her. As if that was a family member on that stretcher. We got her back and she started waking up from the sedation. She had an ET tube in and she just looked at me and tried to mouth words. I just tried to comfort her and tell her it would be ok. She looked at me and I could tell she recognized me. So tonight I pray for her. I hope she gets better. I try not to get too attached but I am only human. So even though I don't know her and probably will never see her again, I hope that I've made all the difference in my hour with her.
  18. The nurses took report on both patients and prepared the trauma bays for a couple in their 80's who had been T-boned when the husband pulled into an intersection. No current life threatening emergencies were reported. Each patient was assessed and stabilized. A recurring theme was each spouse asking about the other spouse. After the hustle and bustled settled down we reassured each patient that their spouse was fine. We opened the curtain separating their rooms and informed them that they were right beside each other and they could talk to one another. They could not see one another because they were secured to backboards and unable to turn their heads to the side but they could hear one another. The wife wanted me to know her husband had a blood pressure problem......oh dear she couldn't remember the name of the medicine he was on. The husband told me how they had been married for 60 years and I could see the sparkle of love in his eyes. As time went on and test results returned it was decided that the wife had an injury that required her to be shipped to a Level 1 trauma center. The doctor informed the couple of the care decisions he felt were necessary. I began to see fear and worry in the husband's eyes. That is when I jumped into gear of getting the portable heart monitor. I connected the husband to the monitor and moved his IV pole and bed right beside his wife's bed. I put his left bed rail down and her right bed rail down. I told them that if they just reached out they would be able to feel each other's hands. They reached out and found each other's hands and held on tight. They talked and reassured each other it would all be okay. They told each other they loved them. The husband told her as soon as he could find someone to drive him to the other hospital he would be there. The doctor told the wife it would be best if her husband stayed all night for just one night to be observed and make sure he was okay. The husband didn't want to but the wife encouraged him that he could see her tomorrow. The helicopter crew came and the beds had to be separated after a final hand squeeze and I love you. The Mrs. was loaded and transported to the other hospital while the husband was admitted for overnight observation. The next day I came to work I found out the wife had died that night from her injuries. I was heartbroken for this lovely couple. As I reflected, I was so thankful that I had taken the time to connect the portable equipment and rearrange the beds and allow them to hold hands. Many times we are too rushed in the ER to make time for the important things in life. And what was more important at this point in time? To hold hands for the very last time...
  19. While at the 2017 ENA Convention in St. Louis, allnurses got the opportunity to interview Alex Wubbels, the Utah nurse who in July 2017, was violently secured in handcuffs and placed in a squad car for not complying with a police officer's request to draw blood on an unconscious patient without a warrant or consent. The video of the incident went viral. Alex has received support not only from her place of employment but also from an outraged nursing community. "The University of Utah Health supports Nurse Wubbels and her decision to focus first and foremost on the care and well-being of her patient," said Suzanne Winchester, the hospital's media relations manager. "She followed procedures and protocols in this matter and was acting in her patient's best interest. We have worked with our law enforcement partners on this issue to ensure an appropriate process for moving forward." We talked with Alex at the 2017 ENA Conference about how she is coping with this traumatic event. Alex Wubbels also shared with us that there has been an update in the investigation. The Salt Lake City Mayor announced that "The findings of the IA investigation and the Civilian Review Board will be sent to Chief Mike Brown who will use them to help guide his decision as it relates to the employment status of the two officers involved." The officers were found to have violated department policy. The following video gives additional details.
  20. Respiratory issues represent a significant proportion of pediatric illness and hospitalizations.1 Viruses such as the common cold, croup, and RSV, while often benign, can wreak havoc when, for example, they occur in infants who have tiny airways or in children with pre-existing conditions such as asthma or allergies. Several anatomic and physiologic differences place infants and children at an increased risk of respiratory distress and failure. To put it simply, their airways are smaller. They get obstructed easier, they swell faster. Added to that is the inherent age-associated hazard of foreign body ingestion- young children who decide they want to eat the coin they find on the floor or the battery they find in a toy. However the differences in pediatric airways and adult airways go beyond simply size, and any nurse who assesses children should have a core knowledge of what makes the pediatric respiratory system unique. The following are some of the primary differences, with nursing considerations for each: Anatomy & Physiology Infants and young children have higher metabolic rates, increased oxygen demands, fewer alveoli, weaker chest walls and lower residual capacities.1 The diaphragm is the younger child's major muscle of breathing, hence the phrase that children are "abdominal breathers". Nursing Considerations: Hypoxia occurs more quickly when a child is in respiratory distress. Retractions secondary to distress may be seen anywhere from the substernal area to the supraclavicular area. Observation and auscultation is crucial; infants and children cannot be adequately evaluated through layers of clothing or blankets.2 Other factors which increase the metabolic rate, such as fever, can also elevate the respiratory rate. Antipyretics should bring the respiratory rate down in children who have tachypnea due to fever only. A Child-Centered Approach Crying and agitation, anything that increases respiratory effort, can also increase respiratory distress. Nursing Considerations: The child should be kept as calm as possible during assessment and treatment. Sitting down while assessing the child, to meet them at eye level, can go a long way to reduce their anxiety. Telling them what you are doing before you do it, ("I am going to place my stethoscope on your chest and listen to your breathing") can foster trust. Parents should be allowed at the bedside (or even in the bed, with the child in their lap if appropriate). Auscultation and the Respiratory Rate For a thorough pediatric respiratory assessment, listen to breath sounds both anteriorly and posteriorly, and under the axilla. If the child will cooperate, ask them to take deep breaths with their mouth open, and listen to both the inspiratory and expiratory phase of each breath prior to moving your stethoscope. The normal respiratory rate varies with age; it is higher in infants and eventually reaches that of an adult in adolescence. Count the respirations for one full minute and don't tell the child that you are counting their respirations; this will often cause them to breathe abnormally.3 Children with a sustained respiratory rate over 60 breaths per minute are considered at risk for respiratory arrest.1 Nursing Considerations: Being aware of the age-based norms for respiratory rates and other vital signs is very important in helping determine the degree of respiratory distress and risk for failure. The following is an example of pediatric respiratory rates as stated in one Emergency Medicine Textbook.4 Age (yr) Resp. Rate (breaths/min) 1-2 24-40 2-5 22-34 6-12 18-30 >12 12-16 A sustained respiratory rate over 60 reflects a higher risk presentation in any pediatric patient 1,2 and should serve as a red flag. Note that infants who are born prematurely, or children with chronic illnesses, may have different normal baselines. Pulse Oximetry Any infant or child who presents with respiratory symptoms or respiratory distress should have a pulse oximetry reading.2 Factors such as cool extremities, anxiety/movement and impaired perfusion can make it challenging to obtain a pulse oximetry reading. Nursing Considerations: Infants and young children may tolerate a pulse oximeter probe wrapped around their large toe, or the top or bottom of their foot1 and covered by a sock or blanket, more than one wrapped around a finger. Being able to identify respiratory distress in an infant or child starts with knowing the basics about pediatric anatomy, physiology and vital signs. A developmentally appropriate approach assists the nurse in gathering the pertinent information efficiently without causing additional distress. References 1. Emergency Nurses Association (2012), Emergency Nursing Pediatric Course. The Association (ENA). 2. Gilboy, N., Tanabe, P., Travers, D., Rosenau, A., Eitel, D. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 12-0014, December 2011. Agency for Healthare Research and Quality, Rockville, M. Emergency Severity Index (ESI): A Triage Tool for Emergency Department | Agency for Healthcare Research & Quality (AHRQ) 3. ATI Nursing Education. "Physical Assessment: Child". Accessed online 1/23/2015. 4. Marx, J., et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia: Saunders, 2013.
  21. OIFSapper

    ED Shocker

    So I am an ED RN at a large hospital in St Louis,MO. I started my career later in life in my early 30s. I am a 15 year Disabled Army Veteran with 2 tours in Iraq. I am currently 37 years old. I am a loving husband and have two beautiful daughters that I love dearly. I have great faith in God and try my best to impact the lives of those around me. I was part of a Unit that did Roadside Bomb removal and due to a shortage of medics were cross trained to be a combat life saver placing IV lines, needle-chest decompression, tourniquet and dealing with amputations and sacking chest wounds. I ended up being fairly good at all of those and it inspired me after a long road of recovery to use my GI bill and go to school to become a RN. I faced a lot of adversity dealing with residuals of traumatic brain injury and a processing delay and through a lot of therapy and treatment passed an accelerated program with a respectable GPA. I started my career in a Trauma/Neuro ICU fellowship and had to step back after a while as it was a little too close to home with my combat experience and also having some cognitive delay from a TBI I felt concerned that in 12 hours of non-stop chaos I couldn't keep up mentally and didn't want to hurt anyone. After a long search through multiple different areas in nursing I have found my love. The emergency department at night has just enough chaos to feed the adrenaline junkie in me but has such a variety that it isn't just 12 hours of titration to keep people from death. To be honest in all my time in the unit I never had my own patient crash and only assisted with codes of others. Two weeks ago in the ED I had my first code since the military and it was a patient I never expected to go that route. I'll spare the details to keep privacy but long story short after reviving and getting up to the ICU they coded again and ultimately died. Once I got back downstairs I took a moment and went outside of the ambulance Bay in the wee hours of the morning to take 5 and decompress. I felt weird. I was uncomfortable in that post CPR moment. I remember the absolute shock of the patients wife's blank expression as she just didn't even process that I was breaking ribs and crushing her frail husbands chest trying to save him as the DR tried to intubate. After I wanted to go give her a hug and console her as she was waiting in The ICU waiting room for an update but I just couldn't do it. I had to go back downstairs and try to process what had just happened. I wouldn't know what you say anyway. I have never had an adrenaline dump like that and soon found myself puking in the bushes and choking back tears. I was shocked! This isn't like me. Is it always like this? I felt like it was hard to let go of it. I am OK now but the impact was much more than I expected. Any tips to help process these moments? I have always counted myself good in chaos and am seldom at a loss for words. I would be encouraged to hear your stories and suggestions so I can grow and learn to deal better in these situations. Much love ... Matt, RN
  22. When I finished nursing school my belief was I was going to be easily hired within my organization into the new grad program, unfortunately, that was not the case. When I questioned my seniority with the other candidates that were not already employed I got told that I would have to wait another year to reapply for the new grad program because they didn't have the time to go through all the applicants to see who was already hired within. I decided to apply with another organization in town in which I got offered a position with their new-grad med-surg program. I signed a contract for 1 year in which they promised to guide me through my 1st year as a nurse and provided me with all the support I would need. Unfortunately, the work environment was terrible, short staffed, harassing physicians, high patient acuity, and lack of support from the program when told of issues with the unit and that fact that it was affecting me emotionally and physically. At the end of one of my shifts in April, I resigned and I had never quit a job without giving at least two weeks' notice. I then got employed with a long-term facility for which I thought was going to be a floor nurse and to my surprise, they hired me to be charge nurse. The facility has been open for 8 months and they have had 7 charge nurses hired and resigned because they don't provide proper training and also the few RN's they do have are not too happy I'm not of the same ethnic group as them and spend all day speaking in their native language. Most days I come in and feel like I have no clue what I'm doing, luckily most of the LPN's I'm "supervising" have years of experience. I started for the third time looking for employment again and decided to try a staffing agency while I still worked the long-term facility. The staffing agency offered to give me assignments at the hospital I had worked for as phlebotomist and in other facilities that had med-surg floors. Unfortunately once I finished the hiring process and all their test and paperwork, I got offered assignment in another long-term care facility because they stated that orientation for the hospital wouldn't be done till September and the other hospitals require more experience from nurses. Now I'm stuck with two employments I don't like and have no clue how I will get back into acute care. When I worked as a lab tech I loved my job when I worked trauma E.R. and my heart was set in me becoming an E.R. nursing. How do I get back on track to acute care and potentially prepare for emergency nursing with my current background? Dear Having a Bad Experience, You are right, you have not had a good experience thus far. In 8 months of being an RN, you have worked in acute care which you quit without notice after signing a 1-year contract, and then in long-term care, which wasn't what you expected. Reading your letter, you had expectations of being hired at hospital A because you were employed there as a phlebotomist. Is there a reason you believed you would automatically be hired as an RN, meaning did you talk to any nursing managers, or did anyone lead you on? Being hired by Hospital B was good fortune because you were given an opportunity as a new grad to work in acute care. What was your career plan when you resigned without notice due to frustration? Unfortunately, nursing can be a small community and let's hope this event does not trail you from facility to facility. My question about working registry is how will it be tolerable for you working in acute care as a registry nurse if it was not tolerable working as a staff nurse? Plus you really need 1 year's experience minimum to work as a registry nurse. Your strategy now is damage control. That will take some reflection and insight into yourself to avoid future rocky employment situations. Were your expectations unrealistic? Do you consider yourself to be impulsive to your detriment? What part of this unhappy 8 months of employment is your responsibility? You may get lucky and land the job you want, in ED, and that would be great, especially if they give you a good orientation. Be careful what you wish for, because ED is stressful and demanding. Talk to some ED nurses so you know what you can expect. You may have to compromise and work in another setting for a time, such as long-term care. Look for a job that is not a Charge Nurse position so you can get the experience you need. Best of luck to you, Nurse Beth
  23. spotangel

    Mary's Gift

    It was Christmas Eve and I was in the ER working a 11am-11.30pm shift. I eyeballed her across the ER. She walked in with her son, an old frail lady. I looked at her pallor and shaky steps and knew in my gut that she was deathly ill. "She's not going to make it out of here alive," an unbidden thought sprang to my mind as I walked towards her. Cindy was the charge nurse and as she looked to see who was on next to take a patient, I reached her. "I'll take her Cindy," I said smiling easily at mother and son and taking the paper chart from Cindy. "Hi, I'm Annie. I will be your nurse today," I said as I deftly got her on a stretcher and closed the curtains of cubicle #4. I helped her change into a hospital gown, hooked up to the cardiac monitor and got my first set of vitals. Her name was Mary. She had been feeling more tired, fatigued and had lost her appetite for over a week. She was a little short of breath. Her vitals were normal. Her BP was border-line. I listened to her lungs and abdomen while my mind raced. I suspected that she was septic and so drew 2 sets of blood culture along with other labs and got a urine sample that was a tad cloudy. Probably a UTI that turned into sepsis, I thought. By the time the doctor came in to see her 15 minutes later, and EKG and CXR was done and I had normal saline running. The doctor agreed that she could be septic and I monitored her vitals carefully. The lab called back half an hour later with her blood count. Her WBC was 37. Bingo! I thought. Right on the money! I had antibiotics running and we kept pushing fluids. Her pressure began to drop and she started becoming tachycardic. I knew that she would crash pretty soon and wanted to make sure I was prepared. So I gently broached the subject with her son James who had no clue how sick his mother was or what her wishes were in case of an emergency. I talked to Mary in her son's presence and asked her. She looked at me, with wise knowing eyes and told me, "If you can save me, go ahead and do what you need to do, but at any point if you see it not going to help me, then let me go. I do not want to be hooked up to machine and it is futile." I told her, we would follow her wishes. I took James aside and talked to him. I asked him if he had any other family. He said he was the sole caretaker of this 87-year-old mother. His dad had died many years ago. He had a sister, who he had not talked to or seen for 20 years. She lived in the same city but they had a fight and stopped talking. I told him gently that it would be a good idea to call her as his mom was very sick. It would only be a matter of time before her systems collapsed due to the overwhelming infection in her blood. He was bewildered and said, "But she walked in! She can't be that sick". I told him that UTI and sepsis signs in the elderly were very subtle and that she might take a rapid turn for the worse very suddenly. I encouraged him to call his sister Ella. "After all, wouldn't you want to know if your mom was very sick and you were not with her?" I asked. He readily agreed to that and dialed her number (I got it from the patient) as I held my breath. They talked and Ella asked to speak to me. She told me that she was an RN and so I was able to give her an update on her mom's clinical status. She had just picked up her husband from another hospital after discharge and promised to be there in half an hour. "Try and keep her alive for me, Annie" she begged. I stayed by Mary's bedside but she was rapidly going downhill. I looked at her and marveled at how her dying was bringing her two children together one last time. I now had her on multi drips. She crashed. We intubated her. Five minutes later her daughter rushed through the ED doors. I took her and her brother to our tiny family room where they talked for the first time in 20 years and hugged each other. Tears and laughter rang as they reconnected. Later Ella came to me and told me that her sick husband was sitting in the car and she had to take him home. She gave me her number and left. James came to me and told me that he could not watch his mother die. By now she was made a DNR after they talked to the doctor. He gave me his number and left. Another nurse relieved me for break but I stayed at the nurse's station drinking my coffee and writing my notes playing catch up. A few minutes later I heard a voice in my ear, "It is time". Probably my guardian angel Providence, I thought to myself. I quietly got up and went to her cubicle. I sat down near her and held her hand. I spoke to her softly, "Mary, you did it. You got them back together one last time. Now it is up to them. Go in peace." As I recited the Lord's Prayer, she flat lined and was gone peacefully. I sat at the nurse's station and made the calls to her children. Mary had gone leaving her final gift behind; the gift of peace to her two children. I walked out of the ER at 12 midnight on Christmas day marveling at a mother's final act of love where she used her dying to bring her children together. Merry Christmas and God bless us all!
  24. I have been a nurse for 8 years now and had worked in a nursing home. I recently decided to transition to a hospital as everything in my life is undergoing change. I do believe in God and with every decision that i make, I always ask his guidance. Thus, when i uploaded my resume, this hospital called me with a job interview for Med-Surg. During the interview, the hospital recruiter asks me if I would be open to be interviewed for telemetry, rehab and ER. I said yes and fortunately, 2 offers came my way. Tele and ER. Of course, I chose ER just because I can see myself working in that kind of setting. I am currently 3 months in the ER and I can say that I am learning a lot. For a long time nurse like me who is new to the ER setting, I am obviously struggling. A colleague of mine told me that it would take me a year to get at least a bit comfortable with the transition. It is a fact that nursing home nurses are being looked down upon by hospital ones. But i don't let that get to me. I am lucky to have a "good bedside skills" preceptor but she has a tendency to become a sucker for her colleagues. Sucker in a sense when her colleagues has 4 patients, she has 8. The charge knows she will not complain to him/her. Nonetheless, I am not expecting anybody to hold my hand. I am currently reading/reinforcing further on things that I've learned for the day. Now my question is, how do I become a better ER Nurse? What are the things I should read/take/undergo? Certifications? (I did not acquire my BSN Degree nor my schooling in this country and I am originally not from here) I am also looking to get a masters degree.. What career path do you think I should take? is it better to get it online or in a classroom? How does one get a higher pay grade? Also, have you ever experienced workplace politics? The reason why I asked is because i realized, the hospital is no different. I hate racism and although I shrug it off, i can't help but feel it. The hospital is trying to promote cultural diversity but apparently majority of the nurses there are not open to this idea. They can be very ****** and gang up on you as what happened to the other orientee in our batch. As a nurse, do I have to be a member of certain organizations? If yes, which one? ANA? What else? Anyways, thank you Nurse Beth. I'm Looking forward to reading your advice for me. Dear New to the ED, Good for you for in having the courage to make such a huge change! Time and experience will make you a better ED nurse like your colleague said. Give yourself time. Emergency (ED) nurses typically are required to have Pediatric Advanced Life Support (PALS) and Advanced Cardiac Life Support (ACLS). I would start with those and then later ask your manager or colleagues if they recommend Trauma Nurse Core Course (TNCC) for your particular ED. Becoming board certified (CEN) requires two years of ED experience. Put off your MSN decision until you are more comfortable in your new job. Before embarking on your MSN, spend time considering what role you ultimately want in what setting. MSN programs offer educational tracks, administrative tracks and more. You may even decide that you want your FNP. Check with your manager and/or HR for information on pay grades, as they vary from facility to facility. Some hospitals reward advanced degrees, some do not. Start working on your Clinical Ladder advancement if your facility offers one. Workplace politics exist everywhere, and ED settings are no exception by any means. In some specialized ED circles, you have to "earn your stripes", which is often a function of time and learning how to fit in. Racism in the workplace should never be tolerated but unfortunately, stereotyping and hostility do exist. Blatant discrimination may not be apparent, but subtle social messaging is. The challenge is knowing when behaviors cross the line and become reportable - which isn't really what you asked but bears mentioning whenever this topic is brought up. We still have a long way to go, and nurses all need to be part of the solution, not the problem. Consider joining the Emergency Nurses Association (ENA) and getting involved in your local chapter as well as joining the American Nurses Association (ANA). Nurses can only bring about change when we work together and the benefits of professional membership are enormous. Best wishes, Nurse Beth
  25. allnurses

    Addressing Bullying in the ED

    allnurses.com staff recently had the opportunity to interview Lisa Wolf, PhD, RN, CEN, FAEN, Director of ENA's Institute for Emergency Nursing Research. She has published research about bullying and how it affects nurses patient care. How does bullying in the ED manifest itself? Bullying can manifest as the dynamics of aggression, which includes overt hostility, denigrating comments, giving inappropriate assignments for the nurses' experience and expertise, and selective reporting. More difficult to identify and call out, however, are the dynamics of exclusion, which is marked by a withdrawal of help, support, and information. These types of behaviors often result in a nurse being "set up to fail", which has consequences for patient care. How does this differ from bullying in other departments? I don't know that it is very different in other departments, but the constant flow of patients, the short turnaround times, and the initial lack of knowledge about patient conditions make the emergency department a particularly high-risk area for this dynamic to manifest. What kind of collateral damage results from bullying in the ED? Workplace bullying is a significant factor in the dynamics of patient care, nursing work culture, and nursing retention. The impact on patient care cannot be overestimated, both in terms of errors, substandard care, and the negative effects of high turnover of experienced RNs who leave, compounded by the inexperience of newly hired RNs What methods did you find to be the most effective in addressing/decreasing bullying? Our respondents report that a "calling it out" strategy by both staff and management is the most effective way to reduce bullying and its consequences. An assessment of hospital work environments should include nurse perceptions of workplace bullying, and interventions should focus on effective managerial processes for handling workplace bullying As a result of your research, what type of training do you recommend? Given that management is the key role in mitigating bullying behaviors, education in the identification of bullying behaviors (especially those marked by the dynamic of exclusion) and in addressing them with staff is probably the most effective way to reduce workplace bullying. Bullying is becoming more pervasive in our culture as a whole. However, as nurses on the forefront of life and death decisions, it is imperative that nurses have a toolkit to deal with bullying at work. The American Nurses Association published a position paper on this in 2015 with a goal; "to create and sustain a culture of respect, free of incivility, bullying and workplace violence." ENA has also published guidelines to deal with and curb lateral violence which is defined as; "violence, or bullying, between colleagues (e.g. nurse/nurse, doctor/nurse, etc.)." "According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are "part of the job"." ENA offers a toolkit with six distinct steps to address workplace violence. The first step is acknowledging that it exists and that nurses have the capability to decrease the incidence. There are many shareholders in this initiative including the front line staff but managers and administrators also have a key role in this. JCAHO, OSHA and other governmental agencies require documentation of a safe workplace and offer recommendations as well. Violence should never be tolerated. Do you feel safe from lateral violence in your emergency department? What has your ED done to combat lateral violence?

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