Meet Bonnie Jennings, professor of nursing at Emory University Nell Hdgson Woodruff School of Nursing in Atlanta, Georgia. She served as a nurse in the U.S. Army for many years, eventually retiring at the rank of Colonel. We are also joined by Larry Lemos, president of the Nurses Organization of Veterans Affairs and a nursing officer/supervisor at the Veterans Affairs Long Beach Healthcare System in Long Beach, California. Here’s what they have to say.
Subscribe to the MP3 Audio Podcast
Jamie Davis: Bonnie and Larry, thank you for coming on Nursing Notes Live and joining us for our show today. So I’d like to start off with the first question I always ask our nurses here on the show - everybody who listens will probably know what I’m getting ready to say - but we’ll start with your, Bonnie. Tell us a little about why you wanted to become a nurse and give a brief rundown of how you were educated and what your career looked like to date.
Bonnie Jennings: That’s interesting, always looking backwards. So why I wanted to become a nurse, the answer is a little bit trite. I think it goes to the heart of helping others and caring. Something about healthcare really intrigued me. Engineering, Architecture, something that would be related to landscaping, business those things didn’t flip my switch. But what really intrigued me was the health aspect. I think that was borne from two key people in my life. My maternal grandmother had very severe diabetes. She wound up with a leg amputated and I watched all that. We helped with her care and I thought, “Truly, even as a child, isn’t there a way to do this better?” My dad died when I was 16. He had cancer. He was sick for quite a long time. We did most of his care at home and I was very much a part of that. Then even when he was hospitalized, watching the way nurses – and I think it really was nurses more than physicians - interacted with, assist the family and with my dad. All of that, as well as books I read about famous nurses and people in healthcare, the whole notion of healthcare just very much intrigued me. And, of course, I’m of an age that there were fewer career opportunities for women, so that affected my choices. But also while doors to medicine were opening up, I quickly realized that the disease focus of medicine was not what I wanted to do. The caring-people component, where my heart and soul resided in, that’s the passion I pursued. You also asked about my education. So very quickly with that, again, based on my age, it was at a time where things were shifting from diploma programs to BSN programs and a friend, who was diploma-educated, advised me, she said, “No, don’t get a diploma. The way the world is going, you need to be a BSN-prepared nurse.” And I feel so fortunate because, at that point in time, I think I got the best of both worlds - the very scholarly academic background, but still lots of interface with procedures both in acute care settings, as well as, the community and following patients in their homes. So I loved my BSN program. I think it really was very good. And somehow through that, and I have tried to track and identify why but I can’t, I believe a professor and instructor must have made mention at some point about the importance of ongoing education. I reached out after practicing for a few years and I went on to get my Master’s degrees and then I have always been interested in research. So it was very natural for me to, some years later, had been practicing as a clinical nurse specialist and yet I wanted more. I realized it was a pivotal “Aha” moment where I could give really good care to a few patients as a CNS. But if I took on responsibility in leaving the hospital, I could set the standards for care related to all the patients. And through that research, it just remained important to me. The way I wanted to advance my leadership level and knowledge and skill was to get a PhD that would allow that research focus as well. And so that’s what I did and, for me, education is lifelong learning. So although those are my official educational experiences, I learned every day from everyone - from patient to staff to student to other faculty and learning is just a joyful experience for me.
Jamie: That’s awesome. Now your primary career in the beginning was as an Army nurse. What drew you to nursing in the military?
Bonnie: Money, being very frank. I was on the Pay-For-It-Yourself program and am very fortunate to have some scholarships and also some jobs to help cover expenses. But by my senior year, it was getting more tricky and the Army, Navy and Air Force came to recruit. They had a panel. I will be very honest. I was attracted to the Air Force because of their uniforms. So I’m not much of a fashionista, but it’s like, “Oh, those are cool uniforms.” I learned they wouldn’t offer a scholarship benefit. So it’s like, “Okay, that’s not going to work.” I explored a bit about the Navy and each of the services are very different in terms of their practice and just the nature of nursing practice in the Navy wasn’t what suited me. Quite frankly, it was by default, what was left? The Army. I became an Army nurse. I have some experiences initially. This is important for me to convey to people where I thought, “Oh, the leadership was making foolish decisions. This is silly.” After a couple of years, I got out and I worked at a very progressive civilian hospital. The lesson in that for me was that the grass wasn’t greener elsewhere. Despite the reputation of the hospital, there were still foolish leadership decisions at times and, at the end of the day, largely governed because of my father’s illness and the financial devastation to our family, I decided I’m going back into the Army and I will forever have healthcare benefits, which is a little laughable now because that’s all changed. But that’s the honest truth about what guided me to the Army Nurse Corps in the beginning and then what drew me back to it. No job is perfect so on the days when I would go, “Oh, gracious, what am I doing here?” I would truly think back to that “Grass is greener” story and remember, “Hey, be happy with what you have, make the best of it and take responsibility. If you don’t like what it is, take responsibility for making it better.”
Jamie: Awesome. Larry, tell us a little bit about your desire to become a nurse. What led you to nursing and a little bit about your education and career?
Larry Lemos: Sure. One of the things that Bonnie said that stuck with me was, as a clinical nurse specialist, I thought, “Aha, that’s something that we were able to have in common.” I actually went to a Jesuit High School, which, of course, focuses on community service and taking care of others, and I thought after talking to a college counselor, “You know, I’ll go to college.” I know I wanted a degree and i kind of was thinking that nursing would work. I thought, “You know, might as well. If it doesn’t work, I’ll try something else.” It really was in - and I can remember my second year because in my program - the first year was all classroom - we didn’t hit the hospital till second year. It was being young. I probably was 18, 19, somewhere in there, because I went directly from high school into the college program. Being in the labor and delivery room and helping somebody who was my age give birth to a baby and I thought, “Oh, my god, this is really amazing. None of my college friends are helping someone. You have a baby today.” That was sort of the beginning of understanding of all the opportunities within nursing. While the nurses said, “Yes, we see patients who are being born and then on the other spectrum, nurses are around when patients actually pass away.” So that’s what really got me in nursing. So I completed my BSN and similar to what Bonnie said, I actually was fortunate at the time. The military did come and recruit at my college but I already signed up with the VA. At that point, they were giving scholarships and paying for people to finish college and then come to work for the VA system. And I really knew nothing about the VA at that point. It was, more or less, an opportunity to get my education funded. But it was after actually where i met a Gerontological clinical nurse specialist who opened my eyes to working with the elderly. In the late ‘80s in California there were no requirements for a Gerontological nursing course. So it kind of mixed in with everything else and here I am working with a lot of elderly and don’t really feel like I knew enough about what I was doing. So I went back and got my Master’s degree as a Gerontological clinical nurse specialist a few years later. Then I had left the VA and then went back to the VA actually for a position. I have worked at four different VAs in California. That’s one of the nice things about the system sort of being able to move around. But as a clinical nurse specialist, again, looking at system issues and looking at nursing practice, I began to realize, “Okay, great, I can speak nursing but there’s a whole other side of the medical center that I really don’t know a lot about.” This is around the time that the VA was giving money out to nurses to go back school and I thought, “Well, I have a Master’s in Nursing, are they really going to pay for a second Master’s degree?” Somehow they did and I went to school and got a Master’s in Healthcare Administration, which I think has been pretty helpful in terms of understanding sort of the clinical side, but also the business of healthcare that we’re in. As a clinical nurse specialist, again, always looking at that system and looking at making improvements and how do you affect change and not seeing myself as a researcher. So the PhD idea was something that was never in my mind, but then, lo and behold, now there’s a clinical doctorate, the Doctor of Nursing Practice, and I thought, “You know, there really is no excuse. I can’t think of an excuse other than perhaps time.” I guess I’m laughing. I said, “Oh, great, there’s no other person who spends a lot of time in school.” So that’s what I’m actually heading tomorrow out of town for my program. I’m in a Doctor of Nursing Practice program up in San Francisco and will graduate hopefully this December. I told my friends and family, “You only have to call me ‘doctor’ for one week. After that you can go back to calling me ‘Larry.’” One of the things as a Master’s prepare Clinical Nurse Specialists that really opened up the opportunity. I always tell students when I’m talking to them, as a clinical nurse specialist, I can work as an educator. I can work as a nurse manager or program developer. I can work in a wide variety of areas. But an individual with a degree that is in Nursing Education or Nursing Administration or even as a Nurse Practitioner, again, cannot work as a Clinical Nurse Specialist in California now because we have the Title Protection. So that really opened a lot of opportunities within the VA. I spent 15 years working in long-term care with the VA system as a Clinical Nurse Specialist. Throughout my career there were many times where either a manager with an extended leave for surgery or they’re between hiring positions and I found myself in a Nurse Manager role for a couple of months to a couple of years. Then I would go back to my clinical role. So I kind of danced on that fence. And then I would think, “Oh, I would never be a manager.” Then the next day, “Oh, I would never go back to my clinical position.” So there have been many opportunities in the VA like I said to move around as needed to be in your family as life has happened. Just recently I became a Night Nursing Supervisor because it was easier with my school schedule to have more flexibility. So that’s where I am today, soon to be Dr. Lemos which my mother would be very proud.
Bonnie: I think that’s a great story.
Jamie: Yes, it really is. It seems like there’s a theme about returning for education and I think that’s something that a lot of nurses should keep in mind that it doesn’t matter at what point you are in your career or how old you are or anything else, the blood can strike you to come in and, “Hey, I want to move forward. I want to get some more education. I want to do something a little different and get educated to do something a little different.” That’s exciting to hear both of you talk about how you continued to look at getting more education as a nurse.
Larry: I teach part-time for a nursing school here in Los Angeles. They asked me to give them a graduation speech here. They have their ceremony on Friday. I thought, “Oh, my God, what advice can I give them?” The advice I gave not really to them but to their families was, “I don’t know if you realized but this is just the beginning because all of these people here, I can tell, are going to go back to school. And if they’re not thinking about it now they will at some particular point because they went through this is an accelerated program and you put the time and energy to become a nurse and there’s people that spend a lot of time and money and years of school and working to get to the point where they finally have that license. They can put the “RN” behind their name.” The next thing I say to them is, “This isn’t the end. You need to continue going because why wouldn’t you? The reasons you wanted to become a nurse, you need to know this is more for others. Of course, you get the benefits of it, but all of your education and knowledge, your patients benefit from it. So why wouldn’t you? From that perspective, why wouldn’t you want to go back and get a Master’s degree when you find what niche in nursing that you like or what other degree that can assist - whether it’s business. It could be in Divinity or anything that relates to working with patients. There are many opportunities and it doesn’t always have to be a nursing degree” - and many nursing professors will probably not like that - but it all adds to the profession. It’s something that we’re able to give to our patients. So that’s the sort of a pep talk of “Keep going. It is lifelong learning. It’s meant to be.”
Bonnie: A couple of thoughts that were sparked, Larry, as you were speaking, one is that I think both the military and the VA, for whatever reason, really have a strong affect and belief in supporting education. Just like now, they switched you to a night supervisor position to facilitate you finishing your studies to become a DNP. The military is equally willing to work with people. Still the military has some very wonderful - it’s called “long-term education” in the Army, maybe the Air Force has the same thing, they call it different of course to keep it as confusing as possible – but a really strong belief in advancing people’s education. I think if you look at the military services as well as the VA, you’ll see a higher proportion of men in them than civilian practice. I think there’s something that draws male nurses into military and VA settings. You will also find higher proportion of DSN, MSN, and whichever kind of doctorate – DNP, PhD - prepared. So there’s something about the learning. All of that comes together to manifest in a practice environment that’s really exhilarating. This morning, I was at the Atlanta VA judging posters for research and evidence-based practice. It’s a really nice partnership. We do have led the VA Nursing Education Collaboration Partnerships with the Atlanta VA and Emory University and to watch the students thrive in the VA environment, to watch the VA nurses grow because of affiliation with Emory faculty. But all of that is so - I am so accustomed to that because of my military background. Some of the challenges they had in civilian hospitals, and I don’t mean this in any way to diminish them, I smile to myself because nurses seemed at times to be more satisfied with where they are. They are happy being staff nurses. They are good at being staff nurses. They are thrilled they have the education. They had to get them where they are to be RNs. Yet somehow you can hear the desire, the enthusiasm in Larry’s voice about his education. I hope it also comes through in my voice and sometimes I don’t find that everywhere. So I think that educational ethic is really - seeds are planted in the military and the VA. What Larry also commented about that I think is a bit different than civilian practice, he talked about dancing on the fence as being both a manager and a clinician and the opportunities to move back and forth. The military is very similar. Leadership is at the heart of what people do because people were ranked on their colors and there are selection committees to decide when you advance to the next frame, can get promoted. When you are promoted in rank with that comes additional responsibilities. So from staff nurse, you may go to nurse manager. You may then go to director of a two-tier section, but they are of the primary care areas. You may be doing things that are a little bit outside like Larry commented traditional nursing. There’s a lot with sort of research and development units where nurses have key roles not just as data collectors. So there is this whole advancement, leadership, promotion opportunity that if you are a nurse who wants to remain at the bedside, and I’ve come to learn that’s what some people want, then the military in my opinion would not be a good place for those individuals. I know people who have worked in the same hospital for 35 years. They don’t want to leave that hospital, that town. They may have switched from a surgical unit to a medical unit but they want to be where they are. Larry commented about moving around in the state of California. In the military, you would move around through not only the country but the world. With the VA, I think, there are also opportunities to move around the country. So the point in common is moving. Whether that’s moving from one position to another, clinical to management and back or whether it’s moving into different facilities within a state or across states, that I think is a unique opportunity that both the VA and the military offer.
Jamie: It’s interesting to hear you talk about that, Bonnie, and I know you retired from the military as a Colonel, what would you say to someone thinking about moving into a career as a military nurse? Are there some skills or some mindset that they might need to have or keep in mind as they consider that career choice?
Bonnie: Yes. What you should not be saying when you’re chatting with people, so I apologize for not being a toast mistress at this point, it relates a little bit to some things that I’ve said. If moving is not for you, then I don’t think the military is a good place because you’re going to have to move. The military has developed great sensitivity to families and family issues and if those issues arise trying to get people to be co-located with family who are perhaps sick and ill and you need to be closer by. That can’t always happen though. Some people, again, are hometown folks and they loved where they are and if that’s you, then the military would not be a good fit. But if you like moving, I cannot tell you how many places I was sent to that I thought, “Oh, goodness. I really wouldn’t choose to be in this particular location.” And yet, of all those places, I’ve loved them. So by being open, by being flexible, which I think many people stereotyped the military history as being very rigid, following orders, do as they’re told. When somebody says, “Jump,” you say, “How high?” That is such a false stereotype. Yes, there has to be order and discipline but authority is challenged, just like it’s challenged anywhere. When it comes to being relocated, you have certain opportunity to have that discussion. Overall, the moving teaches you a great deal about flexibility and adaptability and all the incredible things there are to discover in places you may never have thought you wanted to go. The deployment issue in the military, I think, is one that folks have to consider very seriously. When I retired in 2002, it was right after 9/11 and the nature of the military changed after 9/11. I would like to hope people within the United States know that. People from all branches of the service and all branches within the Army, including nurses, are deploying to combat situations, and some people find that unacceptable. So there, too, there’s the whole commitment to understanding that you are preserving the health and welfare of the people who are doing the combat mission and there is opportunity in that despite the challenges that exist, but if, morally, you are put together in a fashion that you have issues and problems with the notion that preserving the peace sometimes requires conflict then again the military would be a bad fit for you.
Larry: And then you come over to the VA which is a wonderful opportunity for individuals who want to give to their country or want to serve or want to thank better for the service they did and the VA provides that opportunity. Again, the Department of Defense is active duty military and once they are no longer active duty, veterans who are eligible can be seen in the VA system. Where I am particularly, I spent the last 20 years in that sort of my way of getting back to them because I know that as an individual I couldn’t go and do what the military would have asked of me, but yet there’s a way for me to serve and still very patriotic about giving back to the country by taking care of the veterans, so that’s how that’s been an option. [I just have to put 0:26:01.3] that plug in there.
Jamie: Absolutely. I was coming to you next, Larry, because I wanted to see what alternatives there were. What were your thoughts about? Is there anything that folks need to think about when moving to a career in a system like the Veteran’s System?
Larry: Again, it’s a government agency. So you’ll be dealing with bureaucracy outside of just the hospital and things that are directed at a - particularly for things that cannot be decided, particularly, on a local level. That’s one thing, but also knowing that the VA is a teaching hospital. It’s the mission –research, education and patient care. So for individuals who like the idea of working in a teaching hospital, where there’s always students around. The doctors are rotating through and they’re learning. The nursing students and every other allied health professional comes in as opposed to a community hospital that be might all staffed by private physicians. So that’s one of the pluses, I think, particularly is that we draw individuals that want to be in that sort of academic education environment and that’s why I think the VA is very supportive of education because they see that as part of their mission. Again understanding that, if we invest in you as a VA nurse, then that’s going to come back to the patient care you provide. That’s one of the reasons that the VA for individuals that are certified or individuals that have advanced degrees, the VA recognize that and you actually get paid more. So there is the opportunity of receiving a higher pay and other opportunities because of the education and the flexibility of - if you choose to move around on your own, once you get in the VA system, you’re able to move around. Because we are a federal agency, you only need a license from one of the 50 states and I can move to New York and get a job working at the VA without having to apply for a New York license because it’s federal property. So that has pluses and minuses. One of things we’re struggling with in the VA right now is the idea of our advanced practice nurses in the VA system being full practice providers. This maybe off-topic, but it just came to mind the idea that, as a staff nurse, with my RN license working at a hospital, I had more practice autonomy than I do currently as a clinical nurse specialist because I have to have a collaborative agreement with a physician even though I’m certified, I have a state certificate and a Master’s degree. So it doesn’t really make sense. That’s one of the things that the VA system is trying to change in saying, “Okay, we need to remove these barriers. We need to let individuals practice to the highest of their ability, their skills and knowledge and their certification, in order to provide care without this sort of idea that there has to be someone overseeing their practice, that they should be full practice providers. I think that nurses are the only ones that have that and there, again, I maybe not aware – and I know physician assistants operate differently, but I’m talking about the other allied health where there has to be this collaborative agreement once you’ve reached a certain point with their licensure. So the VA, being a government agency, has the opportunity to shape nursing for the whole country because a lot of nursing, they look to the VA and what we’ve accomplished because there’s I think over 50,000 registered nurses employed by the VA system currently. We’ve been the largest employer of registered nurses in the country. So there’s lots of opportunity.
Bonnie: I’d like to expand upon that just a little bit because I think Larry hits an important point. This whole notion as we look at scope of practice for APRNs and who is practicing at the top of their license and is it independent or restricted. That was a conversation that I didn’t understand when I first left the military because APRNs were practicing at the top of their license, the full scope of practice. So it’s a very different model that I’ve had to what I’m accustomed to with more state regulation. I don’t want to convey that APRNs or RNs are doing anything beyond what their license allows them to. Yet it really, again, the stereotype of the military or the VA perhaps being more restrictive when, in fact, I think there really is a push to use people to the full extent of their ability and within the scope of their licenses. The military also has a number of teaching hospitals, not all of them, so that creates that very, what I would call, “collaborative environment.” So when people talk about physician-nurse acrimony, I go, “Hmm.” Overall, that has not been my experience. That’s not how I grew up. A final point I want to put in, I guess too, because Larry talked about how he had so much autonomy as the staff nurse. Then I think that is also very true within the military. People have to learn how to practice autonomously because you never know where you’re going to go and whether you’ll have a lot of resources available or you’ll be kind of the person leading the charge. So you need to develop that confidence and competence and know how to practice autonomously but also know when to holler for help. The point I wanted to toss in to make sure folks who may be listening are clear, I think there really are three government-level departments to keep clear. As Larry indicated, military is within the Department of Defense, the VA is within the Department of VA, a lot of people get this very confused and think they are somehow co-mingled and we are relatives but those are separate governmental federal departments. Then the third point that can be a little bit confusing as well is that the public health service people, they have a uniform corps, it’s very small, and they work within the Department of Health and Human Services. So a lot of the CDC people are with the commissioned Corps in the Department of Health and Human Services and they are quite different, I think, than the VA or DOD, yet there are nursing opportunities as well within DHHS. But those people, while uniformed, are not a part of the military services. So that’s just a point of clarity.
Jamie: I think that’s important to point out and, yes, the Department of Defense and the Department of Veterans Affairs are two distinct agencies in the US government, but they both clearly offer a lot of opportunities for nurses to practice and get a lot of education. So that’s fantastic. Just a brief comment from each of you, I’ll go to you, Larry, first. What’s been that quick lesson that you’ve learned in your nursing career when caring for patients that you’d like to pass along to one of the nurses listening?
Larry: Never wake up a veteran by touching them on the shoulder.
Bonnie: I second that.
Larry: Again, knowing that I’m working with a population of people that may have trouble sleeping, that maybe having dreams about things that happened to them whether it happened after the military or in the military. Nurses, you wake somebody up by touching them, they’re going to come up swinging. That’s a natural response, that fight or flight. Again, use your voice and if you have to touch them, wiggle their toes, I always tell the students. Let them wake up. That’s important because not every veteran comes to the VA. We only see a small portion of the veterans in our country. So for nurses that are in community hospitals and you happen to know someone is a veteran, you never know what they experienced unless you ask them. Many veterans are open about telling you about their service and they are proud of their service. You can learn a lot about them particularly if you love history. I met some wonderful people and learned a lot about history. I met a Tuskegee airman. I met the personal secretary to Eisenhower. You get the history in there. But again, knowing that when you’re working with an individual that either startles easily or have trouble sleeping, again, we’re so helpful and as nurses we want to go in there and, “Oh, good morning!” You put your hand and wake them up. No. Don’t do that. Step back and use your voice. I think that’s the one thing I always tell my students on their first day at the VA.
Jamie: Bonnie, you get the last word. Why don’t you share that lesson that you’d like to share with the nurses and students out there?
Bonnie: I have a couple, if I may, taking off on Larry’s point because not everybody will be working at the VA or within the military. There is a campaign that was launched by the American Academy of Nursing this past fall last October. What they are trying to accomplish, and I think it’s so important, is for any nurse anywhere taking whatever kind of intake or initial history on a patient is to ask the question, “Have you served?” What that allows for is you probably can’t continue the depths of the conversation at that point, but you will know that you have a World War II veteran or a Vietnam veteran or someone who served in Iraq or Afghanistan. By knowing that you then can anticipate, as Larry said, don’t touch them on the arm. Wake them up perhaps by wiggling the toe. Maybe World War II vets have accommodated and grown beyond some of the hypervigilance, maybe not. So by asking the question, “Have you served?” You establish whether someone was in the military. As you have time to converse further, you can find out more about their experiences. Some veterans are very willing to talk. Some do not want to relive their experiences and they’re very close. Right there, that tells you something about the individual and the dynamics. So that gets to my key points whether you’re military, whether you’re VA, whether you’re civilian, I think the most important thing for nurses to do and because we are so rushed and have so many demands, we often forget to do them. And that is to pause and truly listen, truly attend to what people are telling us not just the actual words but the tone, how it’s coming out – softly, harshly - and look people in the eyes because there is so much nonverbal communication. I remember a nurse one time looking at a patient and saying you’re in pain and the patient said, “I am. How do you know that?” And the nurse said, “I can see it in your eyes.” So using all your senses, not just focusing at the screen of that computer-on-wheels as you rushed from room to room, taking just a moment - it doesn’t have to be a half-hour, it doesn’t even have to be five minutes - to stop, to look, to listen and then act upon what the patient has told you during that interaction. And for anybody listening who’s a student, I would like to conclude by saying I just wish you the very best because I think you have selected the most wonderful career you could possibly choose. The opportunities are absolutely endless and you will just have years and years of joy that comes back to you because of what you invest in your career and your patience.
Make sure you check out the entire May, 2014 issue of Nursing Notes, where we look at nursing by and for military service members and veterans. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I sit down with our Get to Know Nurse Captain Estacy Porter, the public health nurse officer in charge at the 14th Combat Support Hospital in Fort Benning, Georgia. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.