DiversityNursing Blog

A Nurse Is a Nurse

Are you being asked to float in an area outside your specialty? How about stepping in to help out on the Rapid Response team when necessary? How do you feel about it? Do you see it as an opportunity to learn something new and fill in when needed? Or, do you feel it puts the patients at risk because of lack or training? Please read this article and let us know your thoughts.

A recent Medscape article addressed a reader's question about whether a hospital could require critical care registered nurses (RNs) to cover shifts on their hospital's rapid response (RR) team.

RR teams rely on hospital staff with critical care expertise to provide bedside assessment of non–critical care patients who appear to be deteriorating. RR teams can differ in their makeup and typically consist of a "physician and nurse, intensivist and respiratory therapist, physician assistant alone, critical care nurse and respiratory therapist, or clinical specialist alone."^[1]

As many as 84% of patients who have a cardiac arrest demonstrate clinically identifiable signs of deterioration in the 6-8 hours before the event,^[2] and identifying changes in a patient's condition early can often be the difference between life and death. Failure to recognize a patient's deteriorating status and intervene is known as failure to rescue, and although it does not necessarily mean that a patient's caregivers have been negligent, it does represent missed opportunities to prevent potentially catastrophic outcomes.

The original question (above) noted that the nurse's manager said nurses needed only a brief orientation to function on the RR team. The reader asked whether the hospital could force nurses to serve on the RR team.

Carolyn Buppert, MSN, JD, author of the article, responded that critical care nurses are a good choice to be RR providers, and hospitals can require them to participate on RR teams. But, she wrote, "Each nurse needs relevant education and supervised experience to feel adequately prepared to provide the care the hospital assigns."

Nurses with RR experience wrote in with their thoughts, and even more commented on "floating" to unfamiliar clinical areas in general. Many said they had inadequate preparation for these situations and voiced concern about their patients' welfare. Time and again, nurses wrote that they were frustrated with the one-size-fits-all idea that "a nurse is a nurse." Read on for more of their thoughts. (Note: Comments may have been edited for clarity or length.)

The RR Role

Several readers commented that they had been thrown into the role of RR with little preparation. One nurse had many years of intensive care unit experience, but when her hospital instituted an RR team she received no formal training. She wrote:

My first experience as an RR nurse was having a bag, a cell phone, and this role thrust upon me. I had a caseload but another nurse would "watch over my patients." Even as an experienced nurse, I was uncomfortable doing the job and felt that I just had to rely on prudent nursing principles. There was no specific job description or protocol except basic ACLS. There were no specific personnel or roles on the team other than a respiratory therapist. There was no primary physician to manage orders. I had to contact the patient's physician during each event, which meant I was working with a different physician each time (when they responded). This process ate up time. My mind always raced to when could I get back to my patients, were there any new orders or changes in condition, were their medications given? I survived the transition to electronic charting, and I believe this was the straw that finally broke the camel's back for me. I changed jobs and I am happier for it!

Another nurse, who worked as an Army civilian nurse in an administrative position "embedded in an outpatient clinic" wrote:

I was suddenly assigned as RN on the rapid response team, 1 hour a week during the lunch hour. I objected but did not refuse, though I was not trained and in fact had pursued an alternate career path in nursing, starting with inpatient psychiatric nursing immediately upon graduation. I never worked on a medical/surgical unit and had no clinical patient care experience. I was told that my BSN degree and current RN license satisfied the training requirement for clinical nursing.

"It is reasonable to ask some nurses to fill in on RR teams, just as it is reasonable to ask an emergency room physician to assist in an in-house emergency," one nurse explained. "However, it is not reasonable to ask all nurses to do the same task. Would you want a pathologist assisting with the birth of your child? Both are physicians."

One nurse said that experienced critical care nurses "should be able to work as RR nurses when needed" and offered this advice: "You will have to obtain the history on the patient, admission reason, and hospital course, if any. My next step would be to treat the patient as if he or she were my patient in the intensive care unit and make the same basic recommendations within my scope as RR nurse, such as administering oxygen, intravenous access, obtaining an electrocardiogram, and notifying the attending, or start cardiopulmonary resuscitation or code blue if needed," she wrote. "However," she added, "never work outside your scope of nursing practice."

In her article, Buppert wrote that in addition to receiving adequate training, RR nurses must use their skills often enough to stay current. "To be assigned to RR once a month or less is not optimal and may not be safe," she wrote.

"An acceptable alternative would be to be put on the RR rotation once a schedule to maintain your comfort level when responding to these situations," one nurse commented.

Another reader had this to say about RR assignments:

Assignment to an RR role does require specific training. At the least, the nurse needs to know what the protocols are and what can be done independently. Nurses need to remember that if they don't know the role and don't have the training specific for that role, they can refuse that role. Yes, there are consequences to refusing, but there are also consequences to taking on something you're not trained or educated to do.

Floating to Unfamiliar Units

The Medscape article was about whether critical care nurses should be required to staff RR teams, but nurses who have been "floated" to unfamiliar units or settings (and who has not?) related to the article as well.

Nurses widely agreed that floating nurses should be given assignments that reflect their skills and experience, and in some circumstances they should not be given a patient assignment at all but instead perform such tasks as taking vital signs and administering familiar medications.

"I'm in a very similar situation where decisions are made with the assumption that, as long as I am a nurse, I can cover any area," one nurse wrote. "The decisions are being made by managers with non-nursing backgrounds who are looking to get the most out of nurses without providing adequate orientation. Nursing is the only profession that I know of that would allow its nurses to be placed in such a predicament."

"I have been transferred from an acute setting to a long-term care unit where floating for RNs, licensed vocational nurses, and certified nurse assistants happens routinely," commented another reader. "I'm an experienced nurse of 30 years, hold a masters as a clinical nurse specialist, and still find this practice intolerable and dangerous for all. Although nursing care is not the issue, the assignments are. Nurse-to-patient ratios are 30:1."

Floating to other units is a reality that often cannot be avoided, particularly in the hospital setting. Staffing needs rise and fall, and unexpected events occur, including sick calls and census changes.

Refusing Assignments

In the Medscape article, Buppert said that a nurse can refuse to accept an assignment under certain circumstances, including lack of sufficient orientation, inadequate staffing for patient acuity, inappropriate skill mix, and when the assignment poses a serious threat to the health and safety of the patient. Nurses in this situation should file their institution's patient assignment objection form. Buppert acknowledged that doing so may result in disciplinary action or dismissal but said that repercussions, if any, may differ for those working under a collective bargaining agreement. Buppert cautioned against first accepting an assignment and then refusing it, because this could be considered patient abandonment.

One reader related:

On one occasion, the charge nurse gave me an assignment consisting of four patients clustered near each other down at one end of the hall, and my fifth patient was in the very last room on the other end of the hall. Her rationale was, "I want the nurses to keep the same patients they had yesterday." I refused to accept the fifth patient, stating that her decision was not in the patient's best interest, and I felt that she was compromising his care, my license, and the hospital. Was she mad? Absolutely. But after talking to the house supervisor about my refusal and my reason for it, she changed the assignment.

One nurse wrote about her experience of being expected to perform peritoneal dialysis without proper training:

 

One nurse wrote about her experience being expected to perform peritoneal dialysis without proper training. 

The job was thrust upon nurses with absolutely no training. Then they sent someone to train us who had no training skills at all. Peritoneal dialysis is a specialty. I feel that nurses are getting hammered with all sorts of additional duties and being told that it's alright when it isn't. Managers and administrations are causing nurses to treat patients like herds of cattle.

"In this age of specialization," asked another nurse reader, "why is it expected that a nurse can float to any unit at any time? We become specialized in our area of expertise and are more proficient in the performance of our duties because of familiarity. It devalues me as a professional by insinuating that I have no special talents or abilities that I have acquired through years of working on a specific unit in a specific field."

Floating as a Growth Experience

Floating can have positive effects as well, and nurses should try to approach these experiences as opportunities for learning and developing relationships with other hospital staff.

One nurse was advised to be open to floating so that she would become a more well-rounded nurse. "I always spoke up and asked questions, and was received with kindness and patience from the more experienced nurses," she explained. "I was there to help them and they respected me for that. Job descriptions and duties were easily accessible on the units for every shift, so I would know what was expected of me. I find it difficult nowadays to actually find a duties list on any of the facilities that I have been to."

Although many of us have had to float to other units, most of us have also been grateful for extra help when we have needed it. One reader offered, "I worked on a unit where we frequently pulled staff from other units, but I always tried to be careful with the assignment of the substitute staff member, and as charge nurse, I frequently checked on them to make sure they felt supported in every way! Also, I was sure to let them know how grateful we were that they were there with us helping us take care of our patients."

One nurse said, "This article is great because it has provided the resources needed to protect yourself from supervisors who look upon staff as 'anyone who can plug a hole.' It may not prevent poorly made decisions to plug that hole, but as the nurse who is floating, you can be on record as attempting to protect yourself. Document, document, document!"

Floating to Specialty Areas

Nurses working in obstetrics and pediatrics were particularly vocal. If nurses are subjected to the "a nurse is a nurse" concept, obstetric and pediatric nurses may be especially vulnerable. There is a huge difference between caring for an adolescent patient and caring for a newborn, and many nurses accustomed to caring for adults and adolescents are way out of their comfort zone when caring for babies in whom even the smallest mistake can have disastrous consequences.

Although many nurses who work in obstetrics are expected to be proficient in all areas of obstetrics—labor and delivery, newborn nursery, postpartum, and even high-risk antepartum—some nurses have specialty areas within the obstetrics unit in which they are most proficient. Many of these nurses strongly objected to being floated to other areas of the hospital, such as adult medical/surgical and orthopedics, and some were uncomfortable floating to the neonatal intensive care unit (NICU), labor and delivery, and pediatrics.

Would you want an adult nurse to care for your preemie baby in the NICU? 

One nurse wrote, "I work postpartum, and we don't take laboring patients—only stable women in preterm labor. Or we act as a second pair of hands, helping with patients or assisting with deliveries and cesarean deliveries. In pediatrics, we take the easier patients, usually those who are almost ready to go home."

Another nurse added, "I work on a mother-baby floor where we also take care of high-risk antepartum patients. Not every mother-baby nurse works in the baby admission area on labor and deliver—only those who want to. Why," this reader asked, "is it okay to float to a NICU where all the babies are on cardiac monitors? I feel like a fraud going to NICU. I've been a nurse since 1983, and I don't feel safe going to NICU or pediatrics. Why do hospitals think it's okay to do this? Would you want a pediatrician to see your adult mother? Would you want an adult nurse to care for your preemie baby in the NICU?"

Gratitude and Solutions

Nurses on all sides of the situation may be able to make things easier by being proactive. Critical care nurses, particularly newly hired ones, can ask about RR responsibilities and training. It might also be helpful for RR nurses to request a 1-day or half-day orientation on units to which they might be expected to respond.

All nurses can ask their employers for additional training, and although it should be provided, when it isn't, nurses can obtain it for themselves. Having additional critical care training, including the care of pediatric and neonatal patients, is a feather in a nurse's cap if and when he or she is looking for employment elsewhere.

One nurse wrote:

Good action points at the end of the article! Let's push our organizations for the training. Say how inappropriate it is and what the barriers are when you assume a position that you don't have any training for. Be specific. Propose a training plan; say what protocols/equipment nurses need to be familiar with. Talk with people who are long-time RR nurses. Identify issues (eg, no one skilled in drawing arterial blood gases when you evaluate a patient on the medical-surgical floor) and make solutions (develop a go-bag with an arterial blood gas puncture kit and analyzer, and all the other gear you would need).

Another nurse added, "We solved this issue by asking for volunteers who would be in a critical care float pool, and float nurses were oriented to a unit similar to their own. We had an RR team. We set up a competency review for the float pool and the RR team that had to be completed yearly. We had a good turnout of nurses who were willing to be oriented and float."

It is helpful to develop collaborations between units with similar types of patients, and nurses who feel comfortable floating to certain units should speak up. For example, a nurse on an obstetrics unit may also have pediatric experience and volunteer to float when nurses are needed there. Postpartum nurses with experience in adult medical-surgical or orthopedics units might volunteer to float there when needed.

Nurses whose units receive help from a floating nurse can also help to make things run smoothly.

A nurse who works in maternal-child health wrote:

Once in a while, we will be bursting at the seams, and so will our other maternal-child health units. When that happens, we are usually able to get a certified nursing assistant or licensed vocational nurse to float to us. Sometimes we will get a registered nurse, and they seem really nervous at first. When we tell them that we would never give them a patient assignment and just ask them to help out with vital signs, basic patient care tasks, and whatever they might feel comfortable with, they relax a bit. At the end of the shifts, they always tell us that they would be happy to come back and help us anytime!

One nurse suggested, "When a nurse from another unit floats to our department, we only give them very stable, easy patients, with our charge nurse being a resource person and the rest of us helping out. We only take 'growers and feeders' when we float to the NICU."

Another nurse stressed, "Nurses want what is best for the patient—no one is shirking their duty. Safety of the patient is the first order of business. But how safe for a patient is it when the unit does not have adequate staffing, and the floating staff member is not familiar with the unit's protocols for patient care?"

Another reader summed it up with, "I love safety, I love competence, but I love stretching my abilities and being the best nurse, too—one that could handle anything. We got this, nurses! Good luck!"

Have questions about floating and rapid response duty or maybe just a general question? Ask one of our Nurse Leaders! 

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We’ve all experienced or heard about long wait time to receive medical attention in the Emergency Room. It’s tough on everyone involved – the patients, their families and medical staff. Many people put off going to the emergency room for this very reason. If they can avoid it, they do. Here’s an interesting article about a Canadian study where Nurses are helping to alleviate this situation. Seems to make sense. What are your thoughts about it?

Emergency room crowding is a common and complex problem for hospitals all over the world, and anything that can be done to improve patient flow without compromising care is a great help. Now, a new study shows how carefully written nurse-initiated protocols can dramatically reduce time in the emergency room for certain targeted patients.

Implementing procedures where nurses start the diagnosis or treatment before patients are treated by a physician or nurse practitioner have been suggested as a possible way to improve the flow of patients in the emergency room (ER).

The new Canadian study, published in the Annals of Emergency Medicine, describes how nurse-driven protocols cut ER lengths of stay for patients with fever, chest pain, hip fractures, and vaginal bleeding during pregnancy.

Lead author Matthew Douma, clinical nurse educator at Royal Alexandra Hospital in Edmonton, Alberta, says: 

"Nurse-driven protocols are not an ideal solution, but a stop-gap measure to deal with the enormous problem of long wait times in emergency departments especially for patients with complex problems."

Protocols cut ER time in busy, inner-city hospital

For their study, Douma and colleagues carried out a  controlled evaluation of six nurse-initiated protocols in a busy, crowded, inner-city emergency room.

They measured a number of outcomes, including length of stay in the ER, time to diagnostic test, time to treatment, and time to consultation.

The results showed that nurse-driven protocols:

• Reduced the median time taken to administer acetaminophen to emergency patients with pain or fever by over 3 hours (186 minutes)
• Decreased average time to troponin testing for emergency patients with chest pain suspected to be heart attack by 79 minutes
• Cut average length of stay for patients with suspected hip fractures and patients with vaginal bleeding during pregnancy by nearly 4 hours (224 and 232 minutes, respectively).

"Given the long waits many emergency patients endure prior to treatment of pain," says Douma, "the acetaminophen protocol was a quick win."

Need for 'broad and creative strategies' to cut ER time

The researchers conclude that implementing carefully written nurse-driven protocols targeted at specific patient groups can result in improved time to test or medication, and in some cases, cut length of stay in the ER.

They also note that, "A cooperative and collaborative interdisciplinary group is essential to success."

According to the Centers for Disease Control and Prevention (CDC), around one in five American adults visited the ER one or more times in 2014, the most recent year for which full data is available.

In 2011, there were nearly 136.3 million visits to the ER in the United States, and 27 percent of patients were seen in under 15 minutes.

A number of approaches are being tried and used to improve patient flow through the ER. These include: extending the chain, decreasing and smoothing variation, matching capacity to demand, scheduling the discharge, and pull systems.

An example of a pull system is the "Be a Bed Ahead" scheme of pulling patients from the ER to the inpatient unit.

"Emergency department crowding will continue to require broad and creative strategies to ensure timely care to our patients."

Matthew Douma

Related Article: Emergency department nurses aren't like the rest of us

Nurses are always learning. Whether it’s on-the-job with practical experience or continuing your formal education, you are always on a quest to learn more. Perhaps you’re trying to figure out how to do something better, earn your next degree, improve your relationship and listening skills, or how the latest electronic medical records program works. You are determined to move forward and be your best. If you’re looking to advance your formal education, we offer this article as a source of information on Nursing schools and acceptance rates.

If you are a Nursing student wondering what Specialty is right for you, please read on. Perhaps you’re an Experienced Nurse thinking about changing your area of focus. If so, this article is for you too. We hope you find it helpful!

The nursing profession has evolved considerably over the last century, including the introduction of specializations for nurses, with specific knowledge and experience to practice in certain fields. There are now many possible areas that a nurse may choose to specialize in, and these continue to grow.

Some of these are covered in more detail below, although there are more beyond this list.

Advanced Practice Registered Nursing

Advanced practice registered nurses have acquired more advanced skills and knowledge through a master’s degree program, in addition to the undergraduate degree to become a registered nurse.

This extended training distinguishes them from other nurses and they often go on to work as a clinical nurse specialist (CNS), nurse practitioner (NP), nurse anesthetist (CNA), or certified nurse-midwife.

Ambulatory Care Nursing

Ambulatory care nurses provide health services to patients directly in an environment outside of a hospital, wherever it is required. They are responsible for following treatment plans for acute conditions, monitoring signs, communicating with the patient and their family, and promoting overall patient health.

Cardiac Nursing

Cardiac nurses care for patients with cardiovascular disease or health problems related to the heart and have specialized knowledge in this area. They are responsible for monitoring signs, treating symptoms, addressing clinical needs, and providing relevant support and education to the patient and their family.

Case Management Nurse

Case management nurse care for patients who require ongoing support and work to develop and implement a treatment plan that aims to stabilize health and minimize hospitalization.

Critical Care Nursing

Critical care nurses work with patients who are critically ill or injured and require close monitoring and care. They are responsible for looking after patients with potentially fatal conditions and following the treatment care plan for the best outcomes.

Dialysis Nursing

Dialysis nurses care for patients who require dialysis as part of their treatment plan, such as those with kidney disease. They are responsible for monitoring signs and progress, administering medications, and providing support and advice to patients throughout the process. They may work in a hospital, clinic, or provide in-home care.

Genetics Nursing

Genetic nurses care for patients with a genetic disease and have in-depth knowledge about the role of genetic in the pathology of these conditions. They are responsible for conducting family risk assessments, analyzing genetic data, researching genetic diseases, and providing support to affected individuals and families.

Geriatric Nursing

Geriatric nurses care for elderly patients and have a thorough understanding of the health and treatment of conditions that commonly affect the elderly. Geriatric nurses often specialize further, to care for elderly patients with a specific health condition.

Mental Health Nursing

Mental health nurses, also known as psychiatric nurses, care for patients with mental health, psychiatric, or behavioral disorders. They help to provide support to these patients and their families while they recover.

Neonatal Nursing

Neonatal nurses care for young infants in the first few weeks of their life and have specialized knowledge about how to take care of infants and the conditions that may affect them.

Oncology Nursing

Oncology nurses care for patients who have cancer. They help in the treatment and monitoring of the disease, in addition to providing support and education to patients and their families.

Pediatric Nursing

Pediatric nurses care for young children and their families. They have specialized knowledge about the function of young bodies and the health conditions that may affect them and assist in the diagnosis, treatment, and monitoring of these patients.

Other Specializations

There are many possible fields that a nurse may choose to specialize in, including:

• Gastroenterology nursing
• Holistic nursing
• Medical-surgical nursing
• Midwifery nursing
• Neuroscience nursing
• Obstetrical nursing
• Occupational health nursing
• Orthopedic nursing
• Ostomy nursing

You must take the time to read this article! If ever there was a tribute to Nurses, this is it! This story is written by an oncology patient who pays wonderful tribute to many Nurses, but also a particular Nurse who took care of her and helped her get through her surgeries and treatments. I think most patients feel this way about the Nurses that take care of them. They don’t always show their appreciation, but this patient took the time to write about her experience. I hope this will make your day.

RELATIONSHIPS WITH NURSES can stick with patients for the rest of their lives. From nurses, I learned the power of accompaniment. One held my hand as I uncontrollably teared up before port surgery. Another nurse on the oncology floor, when she found out that my husband and I had been married two weeks before I had checked into the hospital, made me a pillow adorned with our wedding pictures. Another shaved my head for me when my hair started falling out at an unsightly pace. A patient-care technician—what used to be called a nursing assistant—held me while I threw up in the bathroom after a two-hour MRI.

Though I don’t like to remember these things, I feel deep gratitude for the nurses who were there with me during painful and sorrowful days. In Siddhartha Mukherjee’s The Emperor of All Maladies: A Biography of Cancer, he quotes journalist and breast-cancer patient advocate Rose Kushner. “Few doctors in this country seem to be involved with the non-life-threatening side effects of cancer therapy,” Kushner notes. “In the United States, baldness, nausea and vomiting, diarrhea, clogged veins, financial problems, broken marriages, disturbed children, loss of libido, loss of self-esteem, and body image are nurses’ turf.”

Although I respected my oncologists for the important role they played in my cancer treatment, I found the wide and varied “turf” that exceptional nurses cover astounding.

A year ago last May, I was checked into Boston’s Beth Israel Deaconess Medical Center (BIDMC) as a 29-year-old non-Hodgkin lymphoma cancer patient just out of spinal surgery and unsure if I’d be able to walk again. A few days post-surgery, two nurses held me next to my hospital bed to see if I could stand. Although I was frightened, I particularly remember Neely Beaulac, R.N., joking with me in her thick Boston accent while I slowly tried to march in place with feet that moved like cinderblocks. Somehow, I broke into a small smile and laughed as Neely cheered me on.

Nearly a year later, I walk the 1.1 miles to the BIDMC from my apartment, stroll into the ’80s-style lobby, and wait in a herd of visitors to ride the elevators to the upper floors. I had planned to meet Neely after her shift. I wanted to interview her about working as an oncology nurse. But when one of her patients had an allergic reaction to a transfusion, she asked if we could meet at the outpatient clinic instead in order to be nearby in case her patient needed her.

While in the elevator, I remember my own allergic reaction to a transfusion, which made my eyes puff up to the size of bouncy balls. Given the complexity of cancer treatment and the series of patient issues that arise moment to moment, the end of an oncology nurse’s shift can be fluid.

“Sorry to make you come here!” Neely says with an incandescent smile. I greet the other staff I know, and the two of us head to a break room to sit and talk. She puts a small bottle of water in front of me, as she has so many times before.

Neely is in her mid-thirties with clear blue eyes and dark hair. She’s attractive in that cool-girl way that makes you want to know her jokes. When she’s doing her job, she can be efficient and quick but also chatty. She makes her nursing tasks look easy yet precise. She’s the kind of nurse who makes a note of when your IV bag is going to run out so you’re not repeatedly awoken by a beeping apparatus. She’s at home barging into a room to restore order. The blue shirt of her scrubs matches her eyes and is adorned with a flowered nametag and a pin a patient gave her, a take on the Superman insignia.

Neely was born for nursing. She tells me her mother would describe her as bossy, organized, particular, “and just that little bit defiant.” Even as a child, she always liked “to be a little helper.” If she thinks she can help by providing information, she wastes no time telling a patient the truth of the matter. She doesn’t sugarcoat.

Once when a consult team visited my room to inform me of a drug called Lupron, used to protect ovaries during chemo, they called it a quick shot in the arm. Neely’s eyebrows furrowed. As soon as the doctors left, she told me, “It’s not a quick shot in the arm, it’s actually a pretty large shot in the tush.”

But for all her native bossiness and helpful bluntness, she says nursing has changed her: “I’m definitely still organized, but I’m not as uptight, not as intense.” She has become better at listening rather than convincing. When frustrated and overwhelmed patients say they want to stop cancer treatment, not an infrequent occurrence, Neely now tries to hear them out, helping patients feel they have more control and aren’t being bossed around.

“I’ve come to realize that a lot of times people don’t want to just go home and be left alone and die,” she says. “They want treatment. But they just want to hear they can leave if they want to.”

ACCORDING TO THE Bureau of Labor Statistics’ Occupational Outlook Handbook, important qualities for nurses are attention to detail, critical thinking, communication, compassion, emotional stability, organizational skills, and physical stamina. Nurses spend their days multi-tasking and managing all kinds of people throughout the day, from patients to parents to spouses and doctors. Although they take on many roles throughout a shift, an eye for detail is essential. Oncology nurses administer chemotherapy and other cancer drugs, making sure that “the correct dose and drug are administered by the correct route to the right patient,” as the nursing reference book Cancer Medicine puts it. Too much of the poison can be fatal.

Oncology nurses also take on other more complicated and personal roles. When I was a patient last year, feeling miserable and immobile in a hospital bed, saltine crumbs were scattered all over the bedtable. I had not asked my husband to clean it, because I was tired of asking him to do things, and I figured crumbs were the least of my worries. Neely then came into my room, and before leaving, wiped down my table. It wasn’t part of her job; she just did it. I felt comforted by someone willing to blur the lines between professional nursing responsibilities and basic human-to-human caregiving, as if going out of her way is not out of her way at all.

“I never want anyone to feel like they’re imposing on me or to say sorry I’m keeping you,” she says. “You’re keeping me?” she pretends to ask a patient while talking to me. “I’m going home…I know you’d rather be anywhere but here.”

Not only do nurses do small things to give you dignity, like picking up crumbs or wiping your mouth, they also clean up filthy messes to restore livable conditions for their patients. One night early in my treatment, my husband and I had friends visiting. As I began falling asleep and my husband was saying goodbye to the friends in the hallway, I had a late onset of nausea from the chemo drugs. Before anyone knew what was happening, I was throwing up my dinner without being able to get off my hard neck brace. In what seemed like seconds, nurses rushed in to clean me off, change my sheets, and generally get the room back in order as if the disgrace had never happened.

Those nurses’ NASCAR crew-like handling of my soiled room helped me move past such a gross and miserable situation more quickly. While receiving cancer treatment and undergoing several surgeries, I encountered numerous take-charge, warm, nursing souls who literally ran toward problems rather than away from them.

And oncology nurses don’t just keep things orderly; the great ones boss people around in both clandestine and overt terms to get the best outcomes for their patients. When I was Neely’s patient, she would gently boss around my husband. “Don’t forget to pack her underwear!” she would remind him, when I had to stay in the hospital longer than expected and he’d rush home to bring me more T-shirts and yoga pants. “Husbands always forget underwear. I don’t know why that is,” she tells me during our recent interview.

Good nurses chase down doctors, assert their opinions based on their sometimes superior knowledge of a situation, and appease family members and other caregivers. Once my discharge was postponed for 48 hours by the attending doctor who barely seemed to have read my file and was rarely available. I felt I could not spend one more day in the hospital with its scratchy sheets, bad food, being woken up every few hours for vital signs, no chance of getting outside into the light of day, institutional showers, and daily injections. It was a nurse who listened to my husband’s rising anger throughout the day as he saw how my mental state was deteriorating. The nurse didn’t have the power to discharge me, but sought out answers from the doctor time after time, despite having a list of patients in equal or worse predicaments.

Oncology nurses are masters at balancing the tensions between patients and doctors, family and treatment team, all the while remaining upbeat and encouraging. Of her tireless questioning of doctors, Neely shrugs and laughs. “What’s the worst they’re going to say? No? And I’ll ask again, ask someone different. And sometimes you never get the answer you want, but at least you feel like you tried.”

BEFORE SHE KNEW so much about the packing tendencies of husbands or the best ways to get patients discharged, Neely wanted to be a teacher. In fact, she went to college for teaching. She had considered nursing, but felt teaching sounded “less stressful and more fun.” During her junior year of college, her cousin had a car accident, and she went to San Diego for the summer to help him around the house and take him to medical appointments. She was inspired by the nurses that cared for him and could see the tangible and emotional difference they made. “That intrigued me,” she says.

Six months before graduating with a degree in teaching, while gaining experience in schools, Neely decided working in a school system wasn’t for her. “I love spending time with children,” she says now, but the built-in tension between teachers and parents and the regiment of teaching to tests didn’t appeal to her. “It wasn’t as fun as I thought,” she admits, even though her parents told her to stick with it.

Just six months after graduation, she had her way and got into nursing school at a two-year program at Labouré College in Dorchester, Massachusetts. After a semester of science courses, she could then start working in hospitals as a floating patient-care technician (PCT). First she gained experience as a PCT in Beth Israel Deaconess Hospital’s Needham outpatient center, and then at BIDMC’s main campus in Boston in an oncology inpatient unit, where I met her and where she has been for more than ten years.

Neely says she’s had no doubts about her profession since graduating from nursing school and has found oncology nursing especially intimate. Instead of patients coming in to be “fixed” and then put on their way, in oncology units, patients often stay for days or weeks, or come back repeatedly for treatment or follow-up in an outpatient clinic. Nurses know everyone’s name and usually the names of many family members or friends. “You want to put a lot into it,” she says, “because you know [your work] really affects people.” Getting to know someone as a person instead of “just a body,” in her words, does make a difference. I can testify.

Each day she’s on the inpatient unit, Neely tries to give patients a goal to improve or maintain their mental state. “Every patient needs a goal for the day, whether that’s to get out of bed, or to go home, or to visit with family,” she says. When she starts her inpatient shifts, she tries to check in with each patient to set a goal and ask, “OK, we have 12 hours, we need to get this done, how do you want to do it?” And on the inpatient floor, she’s up front about how few choices there are for patients. “It’s not rainbows and sunshine. Let’s be real,” she says.

On some days, I remember my goal was to have a bowel movement or to get from the bed to the chair. “Hopefully by the end, you’re getting out of your chair and doing a few laps [in the hallway] before you go home,” Neely tells me in our interview.

Another of her daily exercises is to put herself in the shoes of others: “I feel like if this were me, what would I do? If this were my husband, my father, what would I do? That’s what it comes down to.”

SEVERAL STUDIES HAVE SHOWN that workplace stress for an oncology nurse can lead to compassion fatigue and burnout that’s caused by just this kind of effort to help others. One 2010 study on oncology nurses, done by Washington University Medical Center in St. Louis, measured compassion fatigue through surveys that captured data on secondary traumatic stress, burnout, and compassion satisfaction. For the study’s 153 oncology inpatient staff participants, 132 of which were registered nurses, nearly 40 percent were at a high risk for compassion fatigue, while 44 percent of inpatient staff were at high risk for burnout.

But another 2008 study conducted by Beth Perry, a professor at Athabasca University in Canada, found that “exemplary oncology nurses were able to avoid compassion fatigue by creating moments of connection and making those moments matter.” Sometimes small moments are all that’s left.

Neely says that one of the hardest parts of her job “is when you’re giving someone treatment and it’s not benefitting them. When you know you’re prolonging these horrible side effects.” She tells her patients in that situation, “I’ll give you chemo until your last day if that’s what you want, but I just want you to know you’re not gonna get better. So if there’s anything else you wanted to do, get it done. Don’t have me poison you to the very end.”

I ask Neely about how she manages working through life and death situations daily. She admits that other nurses she works with are better at erecting emotional barriers. When one of her patients has a bad outcome, “It still rocks me every time.…I can’t separate myself,” she says. “I’m home praying for these people, I say my prayers every night.”

But even in hopeless times, she still feels she can help. “If you know someone is not going to do well—and ultimately die—because that’s what everyone is afraid of with cancer, the Big C, just give them dignity. If there’s something they want to do, get it done. You want your dog to come in? You want to leave and go wherever? Just help them get that done.” She admits that if she were in that situation, she would most likely want to go home with her husband and dog to die.

Neely’s husband, Jamie, survived testicular cancer before they met, which gives her additional personal insights, but also makes her feel she shouldn’t discuss emotionally difficult parts of her day with him—it would hit too close to home. On the other hand, their joint experiences with the effects of cancer help crystallize their priorities. “There’s a lot that just doesn’t rock us,” she says. “To me, unless someone’s dying, dead, or suffering from extreme illness, I’m like, how stressed out can you be?”

She knows that life can change in a minute. Neely texted me the day after I met with her to say our discussion had made her reflect more deeply on her nursing career. One thing that kept coming to her mind was something that happened to her in college. While on a jog, a car hit her.

“I don’t remember much from that day,” she wrote in the text, “But I do remember I had this nurse who was with me every moment and kept telling me everything is going to be OK.…He was so comforting, and when I decided to go into nursing, he always stuck with me. I always want to give people the comfort that he offered me that day.”

As for me, I’m grateful that I can sit up, reach my computer to type this, and be able to thank Neely for the part she played, alongside many others, in getting me to where I am today. When I do thank her during our interview, she looks me in the eye and insists, “You did it!” Of course she would. 

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We here at DiversityNursing.com are looking for a variety of topics that we hope you’ll find interesting. Is this article about new bundled payments models something that is helpful and informative for you? Please let us know your thoughts.

On July 25, the Centers for Medicare and Medicaid Services (CMS) proposed a new bundled payment model for heart attacks and bypass surgeries; it will be launched in 98 markets that have yet to be determined. The proposed model is scheduled to go into effect over a five year period, beginning in July of 2017.

“The extension of mandatory bundled payments to cardiac care provides further confirmation that CMS means to reshape healthcare delivery away from fee-for-service and towards value-based care,” says Michel Abrams, co-founder and managing partner of Numerof & Associates. “Practically speaking, it means that the profitability of two high utilization treatments in cardiology has likely peaked, and for many hospitals, these important revenue centers have leaner days ahead.”

The CMS proposal also extends the current Comprehensive Care for Joint Replacement (CJR) model to include other surgical treatments for hip and femur fractures beyond hip replacement. It also includes:

• A new model to increase cardiac rehabilitation utilization; and
• A proposed pathway for physicians with significant participation in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program.

How the proposal will affect continuity of care

Abrams says the fee-for-service model has, over time, encouraged healthcare delivery organizations to allocate fewer resources to activities that weren’t explicitly paid for, such as care coordination. “This has been one of the drivers of the high costs and mediocre results that characterize our current system of care,” Abrams says. “Making acute care providers accountable for the costs and outcomes of the total care experience is a logical path to reversing the current situation.”

“Bundles encourage care redesign by incentivizing gainsharing and risk taking among previously disparate provider groups,” says Christopher Donovan, partner at Foley & Lardner LLP. “This will produce better outcomes over the long term through IT investments and clinical practices that focus on care management and continuity/prevention.”

Do bundled payments keep costs down?

To make its case for mandatory bundled payments, CMS points to a number of pilot programs it claims have shown they can help providers work more closely together to provide better care at lower costs. These programs include:

• The Medicare Acute Care Episode (ACE) demonstration project tested bundled payments for cardiovascular and orthopedic care;
• The Medicare Participating Heart Bypass Center Demonstration project tested bundled payments for bypass surgery; and
• The Bundled Payments for Care Improvement Initiative included cardiac and orthopedic bundles.

“Data from these pilots and other state and private research initiatives all suggest that bundled payments encourage better care coordination and lower delivery costs,” says Abrams.

But according to Denise Burke, a partner in the Memphis office of Waller Lansden Dortch & Davis, LLP, official CMS studies show that bundled payments have had only limited success so far. For example, Burke says the CMS ACE pilot project, which included 28 cardiac and nine orthopedic procedures, reported a savings of only $319 per patient. “Preliminary results from the voluntary programs, however, show promise,” she says. 

Why make bundled payments mandatory?

CMS has set a goal of having 50% of traditional Medicare payments flowing through alternative payment models by 2018. According to Abrams, results of a recent company survey, which assessed U.S. hospital progress toward adopting value-based care models, “confirmed that hospitals, given the option of staying with the historical fee-for service model, won’t meaningfully change their approach to care delivery on their own.”

“CMS is in a unique position to reshape the industry, and it must do so if it is to connect payments with improved outcomes and avoid the sea of red ink that waits at the end of the current trend in healthcare cost inflation,” Abrams says.

What could be bundled next?

Jerrod Ullah, RN, BSN VP Product Management at ViiMed, says based on conversations with practitioners and experts, he believes the industry can expect to see similar models on the horizon for oncology and maternity care. “Each of these areas involves a significant amount of care coordination throughout the treatment process, and patients could see big benefits through a bundled payment approach,” he says.

According to Abrams, the industry can expect to see the subsequent expansion of bundled payments for chronic conditions within already established service lines. “For example, congestive heart failure is a likely candidate for expansion once the cardiology project is underway,” he says.

The proposed rule was published in the Federal Register on August 2. Comments will be accepted for 60 days after publication.

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