Two critical care nurses are here to kick off our panel discussion. Hear what Karen McQuillan, a clinical nurse specialist at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical System in Baltimore and the president-elect of the American Association of Critical Care Nurses (AACN), and Heather Morey, a nurse manager at the Munroe Regional Medical Center ICU in Ocala, Florida and a four-time recipient of the AACN Beacon Award for Critical Care Excellence have to say.
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Jamie Davis: Heather and Karen, I want to welcome you both to Nursing Notes Live and I guess I’ll start off with my first traditional question for our guests and Heather I’ll start with you. Tell us a little bit about why you wanted to become a nurse and how that educational process progressed, what you career through school was like?
Heather Morey: I actually was in school to be a teacher. I wasn’t looking at nursing at all. My mother got very sick and she was in the hospital for probably a month. I was actually just starting school, just starting college at that time so I was going to the hospital before classes, go to the hospital after classes, doing my homework there and saw the interactions that the nurses had with her. And during her hospital stay, I realized that this is what I want to do. I had to change colleges [Laughter] and go to nursing school. I was working fulltime and go to the school part-time. So my ADN degree actually took me about five years to obtain. But once I got that, I never looked back. It was worth the struggle. I was having all of my friends be done with school before I was, to know that it was something that I accomplished on my own.
Jamie: Fantastic. How about you Karen? Why did you want to become a nurse?
Karen McQuillan: Well, I started off by going to school at University of Maryland, College Park. It was near my home and reasonably priced since I live in the state of Maryland. It was a very good college. I started going there and taking classes. Initially, my thought was - is that I wanted to be a Marine biologist and about a year in to school I thought, “I don’t know about being a Marine biologist. I really like to do something where I could help people more rather than just study Marine Biology.” So I actually had lots of the prerequisites started since many are the similar science-type classes that I would need for nursing school. So I finished my prerequisites at the University of Maryland in College Park, and transferred to the nursing school University of Maryland in Baltimore and finished my two years of nursing there to get my BSN. From there, I actually entered nursing and I entered at a community hospital in critical care medical-surgical unit. I just absolutely loved it. I knew immediately I had made a really great career choice and as I spent years working there it’s sort of became apparent that there was still so much more to learn. It’s “the more you know the more you figure out you don’t know.” So I decided to go back to school really to just better understand what was going on with my patients so that I could better take care of them. So I went back and got my Master’s degree in Trauma-Critical Care Nursing at the University of Maryland, Baltimore. I learned an incredible amount. It was an absolutely wonderful program. I actually became a clinical nurse specialist. I have been doing that job for a number of years. So that’s kind have been my trajectory phase as far as education and what my career path has been.
Jamie: Heather, how did you get involved with Critical Care? Was that something you jumped right into after school or was it something that you went into after trying some other fields?
Heather: Actually, I started off - my very first job was at a nursing home. I was living in South Florida and my graduating class was 520 people, I believe, 520 nurses. So we kind of overwhelmed the hospital. So my first job was at a nursing home. I was there almost six months, I believe, and then I moved up to where I’m living now in Central Florida and I got a job as a trauma-tri nurse at one of the hospitals here locally. So I did that – I have to find my passion. I did the telemetry nursing for three years and then I went to the emergency department. It was like I found my home. Emergency nursing was incredible. I did that for 14 years and then this job opening came for the manager of the Critical Care and was working in the ED, I have had a lot of contact with the critical care nurses, between giving them report for patients, I was just calling for advice. We have an intensivist program. So if we have a patient in the emergency department that would be going to the critical care area we can call down some orders to be done. And if there is a drug that they use in the critical care area, but not in the emergency department area, they’ll call down and talk us through [hanging it 0:07:02.5] with the side effects, just keeping us nice and safe and the patients safe. I have a really nice rapport with the charge nurses up there, the supervisors. So when this position became open, I applied for it and I have been there a year and a half one year. Now I’m thinking critical care is now my home. I love it. It’s amazing. So it was a journey for me to find where I want to go, I would say, 17 years - 15 years of nursing, so 16 - and I finally found where I thought I was 10 years ago.
Jamie: That’s exciting and it really points out how many different ways our careers can change over the course of our lives us to just doing different things and continuing our educational advancement in many different ways, whether it’s through learning new jobs or going back to school. You both are great examples of that.
Heather: The more that you read and learn things. You get such passion to learn something in an entire different area. So there’s always an option. You’re never stagnant.
Karen: You realize as soon as you learn something new, “Oh, my goodness, there’s five more things I didn’t know.” So it’s really energizing. It keeps you going. Yes.
Jamie: Yes, Heather. I was really happy to hear that you had that great relationship between the ED and the critical care nursing areas that you’re able to call for advice and I find that happens in many areas. The critical care nurses really lead the way and help set some of the standards for care in the other areas of the hospital. Is there a reason you think that there is for that, Karen?
Karen: I think in large part, I think the critical care nurses are – there’s really an expectation. You have to have an incredibly strong knowledge base. You have to be able to be good at critical thinking. You have to typically be able to recognize really subtle changes and be able to react pretty quickly, to be able to take the best care of the patient. I think critical care nurses have such a strong knowledge base. They also have to be able to be a real advocate for the patient, be able to speak up and work closely as a team with their physician colleagues and nurse practitioners and such. In doing that, I think they gain a lot of respect for that strong knowledge base, that strong critical thinking and decision-making, that they are able to do. Many of them, both in critical care and outside of critical care, become quite strong leaders. I think it’s easy to see why you would look to that nurse to see, “Gosh, could you help us with implementing perhaps mock codes in our intermediate care unit?” Because they know those nurses have that knowledge base, and would be able to share that. I think perhaps that’s why that’s often the case.
Jamie: Heather, do you have any thoughts?
Heather: I’m going to say I absolutely agree 100%. The other thing that I would add to that is that, with the critical care nurses, with their knowledge, there is a respect that nurses in other areas, the Med-Surg nurses, the Ortho nurses have when they are calling the rapid response, what they’re calling the “code,” there’s that respect that they know these nurses are going down because the doctor might not come down with them. Those nurses coming down will not be angry, will talk me through this, will guide me in the right direction and make sure our patient should get the best care. I think there’s a mutual respect to the nurse coming down and also knows, “Yes, I can run the code. I know how to do these things.” This nurse has seven or eight patients and their patient load might not be able to run this code. So I need to be as pleasant and keep an encouraging atmosphere because if I am negative or nasty they’re going to shut down and not ever learn and want to come up to join me in the critical care in a couple of years.
Jamie: So what are some of the things that are going in critical care right now? I guess I’ll talk to you first about this, Karen, is there’s a lot of things – I’ve had the privilege of being able to attend the AACN-NTI conference for the last three years as a journalist and interview some amazing people and researchers involved with some really groundbreaking things in nursing care, and I wonder if there’s some things that have cropped up on your radar that you see really influencing the way we take care of our patients.
Karen: Oh, for sure. First of all, healthcare is changing at an incredibly rapid pace. So I think that there’s a real challenge there for nurses to be able to constantly adapt and be nimble to a lot of those changes that are coming. Some trends that are clearly seen are, first of all, with improvements in technology and the ability to support just about every organ system in the body, we are able to keep patients alive that, in the past, quite frankly, would have never been able to live. In doing so, we’ve created a patient that lives for a very long time with an incredible number of comorbidities and sometimes extremely serious disease. So there’s really a continuum of critical care. We see critical care really moving out of traditional in-hospital settings so that there’s some people that are being cared for in their home or in long-term care facilities that we would have years ago seen in critical care units. They’re on mechanical ventilation. They may have artificial hearts or number of other organ support mechanisms that they are utilizing just to stay alive. Those individuals also come back and forth into the hospital oftentimes frequently. So there’s a real need to look at transitions of care and to be able to support nurses not only inside, but those that take care of critically ill patients, again, outside of the hospital. So the walls of what constitutes critical care have really changed a lot and a lot of that is due to the changes in technology and what we’ve been able to do as far as keeping individuals alive. All that technology is something too that the nurse has really had to learn a lot more about, there’s just an incredible amount of devices that are used now to keep patients alive. I think the challenge there is that we can never lose sight, of course, of the importance of the caring aspect of the patient, not just managing those devices, which can sometimes be numerous in the patient’s room and really almost take over the room so to speak. But keeping that caring aspect for the patient and family foremost, of course, is extremely important. So those are some of the things that I think are some of the major trends that are going on. We’re also tasked now with making sure that our outcomes are stellar, because that’s how what we get reimbursed. So there are changes in how healthcare actually functions and the emphasis on quality has truly become paramount, which is good, because we want to provide excellent care at the bedside and have good outcomes. But it has changed somewhat in some of the topics that occur when you’re in a meeting or talking about patient care. So those would be a few things that come to my mind.
Jamie: Heather, I know you’ve been recognized by the AACN. I think some of their awards in the past were some of the things you have been doing. What do you see is the emphasis to continue to build research and build recognition of nurses that are leading the charge in providing great care?
Heather: I think a lot of the desire of the nurses to be recognized and have those years recognized goes back to they want to provide the best quality care and they want the patient’s experience to be a pleasant one and not one that the patient is fearful of the hospital or the ICU or nurses. So I know that with my unit, we have a research team. Every year, the research team gets together and say, “Okay, what’s going to make the biggest impact on our patients this year?” Their first article is actually going to be published this year on temperature, temperature difference, which is the most accurate way to do a temperature. Their research changed the whole process for the hospital. The hospital got the tympanic temperatures. They did a study. Tympanic temperatures were really as accurate as oral temperatures. They worked. Their research led to the hospital change in their policy where we no longer use tympanic thermometers. We only use the oral thermometers. That will be published in the journal. Right now on blood pressure, when the focus was infection, so there’s a higher infection rate. They did a good study on the wash basins. They cultured the basins and the amount of bacteria in the wash basin that we bathe the patient with was extremely high. They developed a protocol for the ICU on cleaning the bath basins out every shift, put them upside down, not putting personal belongings in them. Then they cut the infection rates tremendously in the unit with this research team. So the nurses want to be the best. They want to provide the best. They really care about their patients. That is what drives them to learn and research to do more.
Jamie: I love hearing about that. That’s fantastic. And it just speaks to me of the whole nursing process which is, to me, making simple small incremental changes that have a big impact on patient outcomes.
Heather: Yes. It is washing their hands. Just simple act of washing their hands makes such a difference and I think sometimes we forget that. So we’re involved with the – you want to just hurry and get it done because you need your time management. You have to hurry, get things done. But it’s the simple acts of washing your hands or sitting down and talking with the patient if you have five extra minutes, holding somebody’s hand when they’re visiting their loved ones who are sick. It’s the little things that truly make the big difference.
Karen: That’s really exciting. I totally agree with you Heather. Nurses feel so good when they can make a difference and that’s what your nurses are doing. That’s wonderful. It’s really great.
Jamie: Karen, you worked at Maryland Shock Trauma Center, so you see patients in a different setting where they’re coming in with major multisystem trauma injuries and things like that, is that a different specialty within critical care or is it all just really just critical care?
Karen: Well, critical care has really become specialized. We have nine different ICUs at University of Maryland just as an example. You have pediatrics, neonatal, neurosurgical, neurotrauma, multitrauma, cardiac surgery, coronary care, Medical ICU, Surgical ICU. It really has, in some of the larger centers, you can see where their specialization even within critical care arenas. So it’s pretty interesting. Those nurses actually have an incredible amount of expertise in their particular specialty. So again, that really makes them really able to pick up the subtle changes just in working on my neurotrauma unit, for example, when those nurses, day in and day out, take care of traumatic brain and spinal cord-injured patients and they can pick up on some of the most subtle changes, really get on top of that, and I think really make a huge difference in the patient’s outcomes. Yes, in many different areas, particularly, where there are large academic medical centers, they’ve got specialty ICUs. So there is, in fact, specialization that occurs in those settings.
Jamie: It’s July, and I always call this the “NCLEX” season. This is when all the nursing students are – I see on Facebook and on my page from my shows and stuff that there are nurses posting, “I just passed!” It’s that time of the year where there are a lot of new nurses coming in to the hospitals. Heather, I’ll ask you first, what advice would you give to that new nurse who is thinking critical care is going to be “where I want to go.” What skills does she need to develop? What special things does she need to have in mind if she wants to go in to critical care?
Heather: The most important thing is assessment skills that you don’t truly get from school. You need some time on the floor to get that assessment skill. You need some time in a noncritical care setting where you listen to the bowel sound, listen to the patient’s lung sounds and learn the difference between the different types of sounds and what they mean, because on the floor, you just have that time where if you miss a specific lung sound, it might not mean the difference between life and death. But in a critical care area, it could mean difference between life and death. So you really need those excellent assessment skills so that you can pick up on the subtle changes. And you learn to get that trust in your gut feeling. Where you can walk into a room, look at the patient and say, “Oh, something’s wrong and I need to get some help.” When you’re first out of school you don’t really have that gut yet, that instinct that you just look and know. You know, this treatment isn’t working and you need to turn it off. Do you agree with that, Karen?
Karen: Yes, I do think that you kind of get that sixth sense that people talk about. Over time that really develops and becomes, I think, really fine-tuned. I think the other thing too is that those nurses really learn how to critically think and quickly prioritize and decision-make because they have a strong knowledge bases. Like Heather said, they can assess and see what’s going on. And then they can react appropriately. Definitely, all those skills are incredibly important. It’s an incredible challenge but it is incredibly rewarding.
Jamie: So, Karen, as we wrap up here, let’s looks at the future of critical care nursing. What do you see are some of the challenges and some of the exciting things on the horizon for critical care nursing?
Karen: Well, I think one of the biggest challenges is I hate to say, but I don’t think the pace of change is kind of slowdown. From the looks of things, that will probably continue. So I think that’s challenging for nurses to have a quick change occurring in the health care environment. So I think that’s a challenge. I think that we’re going to be faced increasingly as we, I think already you are starting to see, that when you have these folks that oftentimes live with numerous comorbidities, there’s a lot of moral distress that often can occur with the nurses where they sometimes feel like they’re doing things to the patient, but perhaps not in the best interest of the patient. So I think there’s going to be a lot of challenges ahead as far as looking at how we can best integrate palliative care into our critical care environments, how we can address end-of-life issues best with patients and families and really how nurses can take good care of themselves because that moral distress can be one of a number of factors that can really cause the nurses to develop compassion fatigue and really decide that nursing is just not for them anymore and we don’t want that to happen. We want to keep those nurses that have great skills and knowledge base working with our patients. So I think those are some of the challenges that kind of as we deal with more complex patients. There’s, of course, the challenge with the knowledge base, but there’s also the challenge with, I think really looking at those issues related to palliative care, end-of-life pain management and such. I think those are some of the things. I think as far as trends, I think we’re going to continue to see sicker and sicker patients moving outside of the walls of our traditional critical care environments and acute care hospitals. We’ve seen that over the last few years and I suspect that will continue and we’ll be tasked with trying to figure out how we can take the best care of those patients most efficiently. I think we definitely have a number of challenges ahead of us. The good thing is I watch critical care nurses all the time and they seem to be able to come up with great solutions to take great care of patients. So I have no doubt that we will be able to weather all those storms and really do a great job taking care of our patients.
Heather: That was wonderful. I agree with that 100%. It’s rolling and learning and rising ourselves up to meet the challenges of the comorbidities and education and palliative care and telehealth is coming and just getting access to care for these patients at outpatient clinics, home health critical care. It’s an ever-changing field. It’s very dynamic. It’s fluid. I think the nurses are ready to rise to the challenges that ahead, absolutely to take care of the patients.
Make sure you check out the entire July, 2014 issue of Nursing Notes, where we look at the field of critical care nursing. 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 Steven Neher. Steven is a flight nurse and advanced practice RN. He’s also president of the Air and Surface Transport Nurses Association. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.