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I’m your host, Jamie Davis.
This month marks the one year anniversary of Nursing Notes Live! In this month’s episode, Nursing Notes Live takes a look at the world of orthopaedic nursing. This month’s orthopaedic nursing panel discussion welcomes the President of the National Association of Orthopaedic Nurses, Mary Jo Satusky, Barbara Kahn, nurse clinician at New York City’s Hospital for Special Surgery, and our “Get to Know Nurse” Mary Anne Kenyon, Nursing Director for Orthopaedics at Brigham & Women’s Hospital in Boston, Massachusetts. Join us as we talk about how they each got started as an orthopaedic nurse.
Transcript of the Panel:
Jamie: Mary Jo, why don’t we start with you and I’d like to ask you how you started as a nurse? What drew you to the nursing profession to begin with?
Mary Jo: Well, my mother was a nurse. So I’m kind of second generation from that. I’ve actually been a nurse for 36 years and did a variety of roles of nursing. I worked at Med-Surg. I did some Coronary Care. I worked in a urologist office. I did some Obstetrics and Out-patient surgery. Then back in 1995, I got into orthopedics when I went to work there. My husband’s job had moved us around a bit. I was offered orthopedics or coronary care and I didn’t know anything about orthopedics so I thought it might be a good learning experience, something new. I went to work at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina and they were willing to give me a chance. I really have to say that getting into orthopedics ended up to be kind of a turning point in my career. I realized I had found my niche after being a nurse for twenty years. I ended up getting certified in orthopedic nursing. It was the impetus for me to return to school to get my bachelor’s degree. I really became a professional. I became very involved in the hospital. We had shared governance. Then I joined the National Association of Orthopedic Nurses and now I’m president. Orthopedics really has spoken to my heart.
Jamie: I really think it’s amazing how you have this passion for nursing and I see this in my own experience as a nurse as well as everyone else’s – most other nurses I talked to their passion as a nurse is there, but when they find that thing that really clicks for them it becomes really something even more special.
Mary Jo: Yes, go from having a job to having a profession.
Jamie: Barbara, what about you? Can you tell us a little bit about your background as a nurse?
Barbara: Sure. I had an issue as a child where I have something called “discoid meniscus” which is your cartilage or meniscus is C-shaped and mine was disc-shaped and as a kid I required to have – I had surgery on both my knees at age 7 and at that time they didn’t have arthroscopy. So I was in the hospital for a week to have a cartilage taken out but at seven you kind of remember these experiences. I always said that someday I was going to improve the care that was given to orthopedic patients. So that’s where the desire to be a nurse came in but as well the orthopedics – because I think as a young child I was always going to the orthopedic surgeon, I had issues with my knees that kind of was a big thing when you’re seven and you’re in the hospital and all these things. Therefore, I just developed a desire to learn more and more and more. At first, when I went to college, I got a degree in kinesiology which is the study of human motion. I always knew that I was going to combine this with a nursing degree and stay on orthopedic track. Everything that I’ve done with orthopedics has – I’ve been a floor nurse. I’ve done research. I’ve gone to the national meetings for the past almost ten years. I can’t get enough. It’s like potato chips for me. I feel like there’s so much with orthopedics – edited the core curriculum. I’ve gotten my ONC. The minute I had enough hours I sat for that exam and now I’m writing a chapter on the hip and the pelvis by myself and I’m just – I’m finding that there’s just more and more avenues to discover with orthopedics.
Jamie: You know, Mary Anne, we talked about this in your segment before but there really is a lot more to orthopedic nursing than just attending to patients who had some kind of joint surgery or joint replacement.
Respondent: Oh, absolutely. I think one of the things I found in my career, I’ve been very clinically based – staff nurse, educator, director – and still find my calling back at the bedside. What I tell most of my younger nurses is that the orthopedic patient gives them just a wonderful first start into nursing because they get the surgical aspect of the hip, the knee, the spine, the back. Then they get all the co-morbidities that come with the patient. So they really do get that broad base of how does a surgical patient react afterwards with their diabetes, with their chronic A-fib, with their asthma. How do we make sure that these majority of our elective patients, so how did they – make sure that these elective patients don’t come into the hospital and actually get sick. How do we keep them healthy at their baseline and moving forward through the system?
Mary Jo: I think Mary Anne makes a good point as far as – it’s like orthopedics is in everything as well because everybody’s got bones. Everybody’s got some degree of issues with their bones or issues with their mobility. Even if you’re having a different kind of surgery, you still have to get vertical again and start walking again. I agree with Mary Anne that orthopedics is a great base for so many other disciplines.
Mary Anne: Absolutely. At my hospital, I work at Brigham and Women’s, and we talk a lot about the size of our hospital and yet all roads lead to ortho. At some point, we are going to see our own colleagues. We’re going to see our neighbors or friends or families pass through our doors and we want to make sure that it’s just the best experience for them – get them back to their lives.
Jamie: It’s interesting because there are so many aspects of nursing that we always talk about as nurses. We’re going to focus on the whole patient. You’re right. If it’s an abdominal surgery patient or a patient with some other health issue, we want to get them off their backs and moving around. If we can’t manage the orthopedic aspects of their lives, their mobility, it’s so tied to their functionality, their activities of daily living and also just their sense of self and independence.
Mary Anne: I agree with that. I think one of the things in 2011 that I hear the nurses who work with me talk about is the fact that our patients are – they come from all walks of life, they’re all ages, and really our job as nurses is to control their pain, to make sure that they’re eating, and get them back to moving as quickly as possible and that sometimes is a challenge for us because as we know orthopedic patients were in the hospital for a very long period of time years ago. Now they’re in for such a short period of time. They used to have all the contraptions attached to them and orthopedic nursing was just a little bit scary. The patients had tubes and drains and they had bolts and nuts and screws and things all attached to them. The technology has just moved so quickly into the future and we as nurses have to remember to move our practice forward with them. One of the initiatives we’re doing at our hospital is a care re-design for our total hips and our total knees. It’s new for all of us. We are mobilizing our patients on day of surgery. For my nurses who’ve been practicing for a long time, it’s a little scary. These patients who they didn’t move until physical therapy first saw them are now actually the first people to mobilize these patients and being able to understand the necessity of moving early and the safety of moving early and then being able to articulate that to your patients in a way that they understand. So really patient education has become equally as important as pain management because we want to make sure our patients are informed and understand what we’re doing and they’re in the best mindset and have the most confidence in their own ability to stand and walk immediately after surgery.
Mary Jo: I think that’s a good point because so many patients when they’re coming in before a knee replacement, let’s say, that one of the first things they say is, “When are we going to get up? When are we going to get out of bed?” When we say the next day they turn white. They almost get fearful but then the next day when they stand up and they actually do this it’s such a sense of accomplishment for them. So it’s very important that they make these milestones so that they can move on to the next challenge.
Barbara: Yes. I remember years ago, we used to say “Discharge planning began on admission.” Well, now no way. Discharge planning begins – especially for elective surgery like total joints – it begins when they decide they’re going to have the surgery and they’re scheduling it. I work with an orthopedic surgeon in his office. Our discharge planning work with them starts from the very get-go trying to make sure that they have realistic expectations of what’s going to happen from their pre-op teaching and then what happens in the hospital to when they go home and when they’re picking up the phone and calling because we’re not keeping them in the hospital for days and days anymore. They’re home and they’re sometimes on their own.
Mary Anne: That’s so true. I think we’ve found the same thing at our hospital is that it sounds funny but you do start planning before they ever get here but I think that gives the patient a sense of calm or – most of our patients are – they’re planners, they’re smart. They know what they’re doing. This is elective. They’ve researched it. They figured it out. What we see at my hospital to balance that is then we have the trauma patients. The trauma patients who come in and they didn’t have the luxury of having an opportunity to plan for discharge before they got here. It’s interesting to watch the dynamics between the care coordination nurse and between the family and between the patients. When you see them not struggling but really challenged by – am I going to rehab, am I going to go home, where am I going, I don’t know what that facility looks like – you realize that it’s very much a disservice. I don’t know how you fix it but it’s a disservice because they’re a little more uneasy than the elective patients. They’re just confident. Know where they’re going and what they’re doing. It makes for a completely different hospital stay and for a different outlook on having procedures.
Jamie: It wasn’t that long ago that patients were staying in for a week or more on some of these surgeries. It’s like they were moving in.
Mary Jo: When I used to be a staff nurse back in the ‘90s, you brought the patient in the night before. They got their sleeping pill. They got adjusted to their room. It’s different now. You bring in the patient into the hospital it’s already a stressful day. A lot of things going on and they don’t even have the night before to get acclimated. Then if they had traffic on the way to the hospital, there’s a snowstorm. There are all these other things that now play into the anxiety of the patients, you really have to work to put as many fears away and to really be as organized as possible for the patients so that they don’t have additional stresses going in to the surgery.
Jamie: Mary Jo, you had lent some comments to the upcoming newsletter that’s coming out on orthopedic nursing from Nursing Notes. The term was coined “boomeritis” by the American Academy of Orthopedic Surgeons. Talking about these active aging adults who have had led active lives, have previous sports injuries and problems but have been very active and want to remain very active. Certainly, orthopedic nurses are going to be seeing as our population continues to age more and more of these elective knee replacements and hip replacements, in non-elective situations too. Certainly, as the population ages, orthopedics is going to be coming even more in the forefront.
Barbara: Well, I think it already has. You have people that are not waiting as long to go ahead and get a joint replacement. People in their 50’s and early 60’s are now saying, “I don’t want to wait till I’m 70, 75. I want to continue to play double tennis or get back on the golf course.” They don’t want to wait as long as patients in the past. We’re already seeing a significant increase and all through the younger patients which is a challenge in and of itself.
Mary Jo: Well, and to this, the folks that are coming in, they have learned so much before they walk in the door. They have diagnosed themselves. They know exactly what’s wrong with them. They think they know what kind of device they want. They kind of shop around to see who’s doing what and what did they read about. I think nurses can play such a key role in that patient education. Helping them to sort out because anybody can post anything on the web and that’s where they’re getting their information and really helping these patients to kind of hone in on what’s really important. It may not be really important to which device is going to be put in and that they understand that’s not necessarily the way to maybe approach their surgery but they want to see, for example, which hospital has MAGNET status and therefore has attracted the best and brightest nurses, which hospitals are having good outcomes for their patients. That’s the kind of thing that we have to help patients sort through as nurses to help really prioritize what’s important in their surgery.
Mary Anne: At the Brigham, we really tried to get the message out that we should be the ones, just as you’ve said, to provide the information for our patients and to try to cut down on all the miscellaneous googling. We’ve been doing a lot of work around – patient education, patient videos, making sure that we have written and audio and visual materials for our patients to access at home and to access when they’re here so that we’re giving them a clear message. We’re giving them a message that we believe is accurate information. I think they appreciate it because they will come in to the hospital, especially our knee patients, and say, “Am I getting one of those machines that bends my knee? My cousin had it. I saw it on the web.” Our facility has stopped using CPM machines. For us, we have to say then not make them feel like they’re missing out on anything but an opportunity to educate them that we’re using a different approach and we’re getting the same, if not better results, so that they don’t feel gypped.
Mary Jo: As far as the National Association of Orthopedic Nurses has total hip and total knee education manuals that can be personalized to those patients. So if you do have a hospital that is not using a particular thing, like the CPM machine, that can be taken out. So patients aren’t confused by – “Am I supposed to have it? Am I not going to be doing quite as well because I don’t have it?” They need to understand that these things are based on evidence and evidence in the literature and through research to what do work.
Jamie: It’s nice to hear that younger patients are recognizing some problems earlier and not letting things sit and get worse because certainly I would think the outcomes are better when you bring in a 50- or 60-year old for knee replacement than when you have a 75-year-old coming in for some kind of knee replacement or hip replacement surgery.
Barbara: I think it all depends on the individual patients. You have some 50-year-old that have co-morbidities or medication issues or histories that make them a more challenging patient and you have some older patients that have maybe cardiac or other types of medical issues that you have to handle. At least for me and my practice – I work with two orthopedic surgeons in their office, private practice – I find that you get challenges at every level as well. The younger patients have less patience for their recovery. So that in itself can be a challenge because they’re the people that have to play football with their kids on the weekend or have to get back to a job. There are different stresses for different ages.
Mary Jo: I think there’s also the concept of getting these patients aware that there can be treatment. We used to think, for example, with arthritis that “That’s old age. That’s just the way it is. You’re going to get old and get cracked and not be able to walk.” We’re finding that there are some things that can be done such as weight loss and some exercises that can be done. So if we can get these patients into treatment earlier, then their outcomes will be better from those interventions.
Jamie: I said something to Mary Anne the other day. I had a nurse once told me when we were walking through – when I was at nursing school, we were walking through the orthopedics in the hospital I was doing clinicals. It was interesting. She made the comment and goes, “Yes. We’re now in the construction zone.” [Laughter] But it’s not all about the erector sets, adding new parts to patients. It is about the ability to give these patients some other alternatives. They may not necessarily need surgery to manage their problem, like you said, weight loss and some of the other things. So really orthopedics is looking at some of the major public health issues we’re dealing with right now.
Mary Jo: Oh, absolutely. Obesity in America is – we are literally growing and it’s having a very negative impact on those joints – the bone health with things like osteoporosis and our teenage girls, not wanting to gain weight, so they’re not drinking milk. Then we’ve got the problem with osteoporosis. It’s a silent disease that until you have that ground level fall and have a fracture from that, you may not know that you have it.
Jamie: I have a question. I guess I’ll throw this out first to Barbara: if you look at orthopedic nursing right now and look where it’s been and where it has come to at this point in time, what are some of the things that you’re looking forward to in the future of orthopedic nursing?
Barbara: I’m very excited about the fact that orthopedic nurses are getting more and more involved in research. I think you really need a good research, continuing research background, in order to take care of your patients. You can’t stick with what you know being tried and true. You need to see the whole spectrum of what is going on. So I’m very excited about that aspect of nursing. As well as, I think that nurses are given a lot more responsibilities now. It’s not just putting CPM machines on, giving pain medications. It’s really taking the next level and coordinating your patient’s care, involving their families, making sure everything is done and then modified. I have the luxury of being with my patients before surgery, during and after and it’s just a complete fulcrum of the patient. You follow them from the minute they come in for their first consultation till whenever the end comes. It’s a constant evolution. I think it just gives you so much ability to share your knowledge, problem solve, put a whole picture together for your patient as well as facilitate things for the surgeon that you’re working with and the whole team that you’re working with. I really feel that nurses are the glue that binds because we really take care of everything for the patient – obviously, including the patient – but the whole team with the patient to make sure that there’s a successful outcome and a positive outcome.
Jamie: Barbara, do you feel orthopedic nurses have enough time to spend with their patients? It’s one of the key issues that come up and I don’t want to get too political about some of the things that are going on with the staffing and things like that. Certainly, there’s a concern among many nurses in different professions of nursing that they are not having enough bedside time with their patients that they cannot dedicate enough time. Yet, everything I hear about orthopedics and my knowledge itself, of what I’ve seen, it certainly leads me to believe that you need to have a certain amount of time with that patient one on one to help them get mobilized, to help them understand what they need to do in the process.
Barbara: Again, that’s a little bit of a team approach. In this day and age, I feel that you have to kind of – one thing that nurses do well is they organize. They organize their time. And if you have a patient that’s going to need extra time, then you know when that patient calls that that’s just going to be a ten or fifteen minutes that you’re going to give to that patient and, yes, maybe it means you’ll have to stay an extra ten minutes or cut back on something else that you’re meant to do that day that you couldn’t quite get to. Overall, I feel that we manage our time well. I haven’t been a floor nurse since 1994 so I don’t know about that aspect but from what I can see when I’m rounding in the hospital I don’t see nurses that are stressed, that are running in and out of rooms. I see nurses that are happy to spend time talking with patients. I really feel that maybe that’s just the hospital that I work in. I can’t speak for everybody but at least where I am I feel that everybody has the allotted time that they need to spend with the patient even the more challenging patient.
Mary Anne: I would agree with that. I think that I am at the bedside not with the patient assignment but with my staff and I think that an orthopedic nurse, an orthopedic-trained nurse, is absolutely essential at the bedside with this patient population because as we said their length of stay is so short their primary focus post-op is pain management and increase their functionality and their mobility. To do that, you need a nurse there to assess their readiness. We need to make sure that – patients aren’t mobilizing or standing on a leg that may have an unresolved nerve block. We need to make sure that patients aren’t on such a fast pass to get out of the hospital that we’re not paying attention to their regular post-op complications: nausea, a little bit of dizziness, some hypotension. We want to make sure that these patients are safe to mobilize. That really takes the skilled eye of a nurse. The nurse is the only one who can assess them and make sure that they’re good to go.
Mary Jo: I’d like to throw in here too that you mentioned the orthopedic-trained nurse. We also need to have orthopedic-trained nurses so that the nurses don’t become the patients. There’s a lot of body mechanics involved in moving patients and lifting patients and there’s tools now to help nurses lift patients safely – the Safe Patient Handling Movement. It’s important that that word gets spread around too that, “Yes, we have patients to take care but as nurses we need to make sure that we are also taking care of the nurses and that we’re not doing damage to our own bodies when we’re moving some of these other folks around.”
Mary Anne: Exactly. Yes.
Jamie: Yes. I’m sure we all have friends and colleagues that have those back injuries from handling patients, from catching a patient at an awkward angle when they started to fall. It’s a challenge. Mary Jo, do you find that orthopedic nurses are valuable in that as a resource for those kind of body mechanic issues?
Mary Jo: Oh, absolutely. In fact, the National Association of Orthopedic Nursing worked to put together some algorithms for how to move patients and to help you be able to have an objective decision – how much can this person do on their own and if they’re not going to be able to stand their own, if you’re doing transfers that you’re going to need two sets of hands or maybe you’re going to need a machine or some kind of device to help you move the patient. Absolutely, the orthopedic nurses are the ones that can help people be aware of body mechanics whether it’s in the operating room, moving a patient, or in the intensive care unit. These maybe places where sometimes you wouldn’t necessarily see an orthopedic nurse, you might see some in the operating room, in the ortho OR, but in the other ORs as well. They’re moving these patients in the PACU, all kinds of areas. The orthopedic nurses are the ones that are aware of your bodies. The most common worker’s comp injury is an orthopedic injury like you talked about the back. So, yes, the orthopedic nurses are a great resource for those safety measures for ourselves.
Jamie: As we wind down the call here, I’d like to ask each of you to kind of go through and offer what advice you might have for an individual that is either an existing nurse or maybe a prospective nurse, a nursing student, considering a career in orthopedic nursing or maybe a career change to orthopedic nursing. What kind of things they should keep in mind or maybe try out or maybe additional education they should seek?
Mary Jo: I would suggest that they seek out some educational opportunities to see if that is something that they are interested in. My office here, the orthopedic surgeon that I work with, actually we sponsored and hosted a total joint office fellowship through the NAON foundation. So we have somebody come in. Spend 3 ½ days with us to see if orthopedics is something she would be interested in. Seeking out some of those educational opportunities, attending some conference, reading some things, and then finding a mentor, somebody in the field that they can kind of talk to them on one-on-one – what is it that you like about orthopedic nursing, what are its challenges. The thing can be that orthopedic nursing spoke to was that it won’t necessarily kill you all at once like a heart attack but it robs you bit by bit of your pleasures in life, the things that you’d like to do and it kind of whittles away at your life. So I think talking to other orthopedic nurses and finding out what is it about orthopedics that speaks to them that’s really going to help.
Jamie: Barbara, what about you? Do you have any advice you’d like to offer to a prospective orthopedic nurse?
Barbara: Sure. I think one thing that you can really say for orthopedics is, for the most part, it’s a happy area of medicine. You have patients that come in. Their quality of life is altered and they have an operation and they recover and then you can just see the expression on their faces. It’s different because they don’t have pain. They’re back to what they’re doing. For the most part, everybody – there are unfortunate circumstances but it’s a happy area of medicine. In that, I think nurses that go into orthopedics can really expect not to come home and say, “Oh, my goodness. Patient in this room passed away today and this one had a heart attack.” All these things you can really feel good about when you come back tomorrow that you’re going to see an improvement every day and when the patient leaves they’re going to be thankful and they will have a good experience. That’s something – when you’re doing something for ten years, twenty years, thirty years, it’s really helpful to avoid burning out and really getting to the point of “I can’t do this anymore.” Additionally, I also agree that there are so many aspects. Yes, maybe you like orthopedics but you really love the rush of the OR so then you do that or you really like the PACU, the critical care aspect but you can do it along with orthopedics. There are so many avenues that you really can combine something with orthopedics if you’re not 100% sure that this is what you want to do at the beginning and then of course you fall in love with it. But, after that, well, I agree that there is so much to be learned by going to a conference and it’s not even just the orthopedic knowledge but the mentoring, the networking, that you are surrounded by how many people that has the same passion for orthopedics that you do. If you go to the NAON, maybe it’s a little bit smaller, but if you go to the American Academy of Orthopedic Surgeons you breathe orthopedics. It’s an experience that every orthopedic nurse should do once because there’s just – everybody there is on the same page as you are and it’s hard to find that in other specialties.
Jamie: Yes. You’re right about that. Somebody else has probably solved the problem you have. Networking in these conferences certainly give you the ability to get someone else’s solution to a problem. Maybe more elegant than the solution you came up with and really helped the patient a lot better than what you are able to come up with. That’s great. Mary Anne, we’ll wrap up with you. What are your thoughts about what someone could do if they wanted to, say, “I wanted to become an orthopedic nurse and I want to become certified in that specialty.” What would be your piece of advice to that individual?
Mary Anne: Well, I think here in Boston, we are very fortunate that there is never a shortage of nursing students. So we have easy access to find our future orthopedic nurses. On my unit alone, we have students usually in their very first clinical and then they come back several times later and the amount of nurses who end up on my unit in a capstone project is very high. We have our pool and we get to nurture them and mentor them for several years while they’re going through their nursing career. I think the thing that really draws them back to orthopedics is when they first come they’re just focused on the patient – passing the meds and having the patient mobilized and making the sure the patient is independent with their activities of daily living. By the time they swing back for their third or fourth rotation, they’re really able to look at the things that are exciting in ortho such as the collaborative practice and all the work that ortho is doing right now around patient affordability and looking at research, things like custom joints and podcasts and webcasts to get patients ready for surgery. Then, of course, we look at orthopedics. It’s a specialty and underneath that specialty, there are even more layers – there’s joints; you could focus on spine; you could focus on sports; trauma. What we’re starting to see a fair number of is orthopedic oncology patients. Some of them have an orthopedic problem, maybe a bone cancer something, but others are patients who are on other areas of the hospital when we’re talking before about orthopedic nurses being a resource on some of our oncology floors, young breast cancer patients and other sorts of cancers who may have a pathological fracture because of their primary oncology diagnosis. Orthopedic nursing is just spreading through the whole hospital. I think it’s exciting to see initially, nursing students want to be in the OR, they want to be in the ED, they want to go to the NICU. A lot of times they [students] pass over us because it’s basic med-surg. We’ve done a lot of campaigning to say that we are not basic in any way, shape or form and that there’s so much to learn. Orthopedics is just a great career. It just keeps growing in so many different directions. It has just about everything you could ever want.
End of Panel Transcript –
Don’t forget to check out the entire October 2011 issue of Nursing Notes, digging into the world of the orthopaedic nurse. This month’s Nursing Notes newsletter reveals the origins of orthopaedic nursing, injuries that lead to “Boomeritis” and takes a look at the upcoming National League for Nursing’s technology conference. You can read the entire issue online at www.discovernursing.com and don’t forget to catch the other Nursing Notes Live episode this month featuring our “Get to Know” nurse Mary Anne Kenyon’s nursing story. You’ll find this and other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.