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The latest nursing news and information brought to you by the Johnson & Johnson Campaign for Nursing’s Future – This is Nursing Notes Live.

Nursing Notes Live is an audio extension of the national award-winning monthly e-newsletter, Nursing Notes – which offers the latest industry news, trends and updates in nursing. You can subscribe to the e-newsletter at www.discovernursing.com. Each month’s Nursing Notes issue will be accompanied by a couple of episodes of Nursing Notes Live, which will expand on the content and provide you greater insights into the topics presented in the e-newsletter. You can listen to previous podcasts on the Nursing Notes by Johnson & Johnson Facebook page or NursingNotesLive.com; or visit iTunes to subscribe to the podcast! The Campaign encourages you to check out its Portrait of Thanks Mosaic Project which invites nurses from around the world to submit a photo online to be part of a historical image of nursing. For every photo of a nurse uploaded between now and February 1, 2012, the Campaign will donate one dollar to the Foundation of the National Student Nurses Association to help fund nursing student scholarships. Submit your photo today at www.campaignfornursing.com/portraitofthanks. And check out the five finalists of the Amazing Nurses Contest at the Nursing Notes by Johnson & Johnson Facebook page! The Grand Prize Winner will be announced on December 11.

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.

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The latest nursing news and information brought to you by the Johnson & Johnson Campaign for Nursing’s Future – This is Nursing Notes Live.

Nursing Notes Live is an audio extension of the national award-winning monthly e-newsletter, Nursing Notes – which offers the latest industry news, trends and updates in nursing. You can subscribe to the e-newsletter at www.discovernursing.com. Each month’s Nursing Notes issue will be accompanied by a couple of episodes of Nursing Notes Live, which will expand on the content and provide you greater insights into the topics presented in the e-newsletter. Check out NursingNotesLive.com or visit iTunes to subscribe to all episodes of this podcast!

Emergency or Trauma Nursing?

This month’s Nursing Notes newsletter takes a look at the fast-paced field of emergency nursing including sub-specialties in trauma care. I got a chance to sit down with two experienced emergency care nurses to talk about the differences between emergency department nursing care and the specialized emergency field of a trauma nurse. Paul Bond is an emergency nurse with over 20 years experience in the field. He’s also the host of a bi-weekly online radio show found at EmergencyNursingToday.com. We were joined by Susan Cox, a trauma nurse at Rady Children’s Hospital in San Diego where she is Director of Trauma and Volunteer Services. Susan is also the President of the Society of Trauma Nurses.

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Interview with Paul Bond and Susan Cox on Emergency and Trauma Nursing

Jamie:                  Susan and Paul, I’m happy to have you on the show here at Nursing Notes Live. I’m excited mostly because I think it’s important to draw distinction between the specialty of emergency department nurse and the subspecialty or its own specialty in its own right of trauma nursing. So Susan I thought I would start off with asking you, what do you see is the key differences between being a trauma nurse and perhaps being an ER nurse?

Susan:                  Yes. I’d be glad to help with that. Actually trauma is a subspecialty of nursing. It is specific to the phase of care that you’re talking about. The emergency department or the emergency center phase of care is one phase of care in trauma nursing. So there are people who work in the emergency department. Sometimes all of the people who work in the emergency department function as trauma nurses. But there also trauma nurses in all of the other phases of care in the hospital or outpatient setting. We have trauma nurses who function on our floors. We have trauma nurses who function in a radiology department and our critical care units. They are all caring for trauma patients and have a subset of clinical expertise and knowledge that is specific to trauma patients and anticipatory knowledge and expertise in anticipating what might occur ongoingly with the trauma patient related to mechanisms of injury and what has happened to the patient. So the difference between an emergency department nurse and a trauma nurse is basically that a trauma nurse can be an emergency department nurse but there are also trauma nurses in many other phases of care in a hospital.

Jamie:                  It’s interesting that you say that, Susan, because I didn’t know that the trauma nurses extended beyond, say, a specific trauma center or beyond the emergency department setting but that’s very interesting that they extend into other realms.

Paul:                    I really didn’t either, Jamie. I understood that trauma nurses were not just in the emergency department. But my understanding was more the critical care post-ER like in a trauma ICU or those types of things – the OR. I didn’t realized that they went into radiology and the regular force too which I think was great because trauma is its own continuum of care. Since the ‘60s with the advent of the Golden Hour and everything that R. Adams Cowley did through shock trauma, we’ve noted that there’s a major difference in how you care for trauma patients versus medical patients or simple trauma patients, if you will, somebody’s just had a broken leg as compared to somebody who was stabbed or shot or fell of a building or whatever it may be. There is an entire continuum of that patient’s care related to the trauma as compared to just the ER which is how it originally was. It was trauma with trauma. Once you got out of the ER it was just general nursing care or just general medical care. I’m glad to see that the specialty has blossomed, if you will, into the other realms of nursing – critical care as well as radiology and out on the floors after they come from the ICU into the Step-Down units. I think that’s great to have that care all the way through to discharge because, truly, trauma is – just as Susan said, it is a sub-specialty of its own but it’s a very specific specialty that has a lot of information that you need to know. Kind of like an ER nurse, it’s almost the same but it’s different in that an ER nurse has a lot of things that they have to know very specifically for right-now but doesn’t necessarily have to know anything for two, three, four days or a couple of weeks’ out. Whereas trauma nurses have to know the right-now with trauma but also a month down the line what to expect with what’s going to happen after the patient. Somebody that has massive barotrauma, let’s say, they may end up going into ARDS and that could be two to three weeks’ out from the trauma. To know those types of things and to have that specialty, I think is a wonderful way of handling it.

Susan:                  Right. It works really well. I think one of the really confusing things for our public, for the citizens, is that with the advent of so many emergency department-based shows on television and so much drama around the trauma that happens on those shows, people really have trouble distinguishing between an emergency department and a trauma center. They think they are the same thing. The whole continuum of care is what’s really interesting to people when you sit them down and talk about it. That the emergency department is one phase of care and that in our – I work in a pediatric hospital where we don’t get a lot of acute-status patients, you know, knives and guns club types of patients – so we don’t have a lot of really seriously injured kids who come into our emergency department but those who are seriously injured spend the least amount of time in the emergency department. They are expedited either to the operating room or to the ICU or to imaging, the CAT scanner. So the phase of care is really different depending on the acuity of the patient and the perception that all of the operations and all of the diagnostics go on in an emergency department for most hospitals is really confusing to our citizens.

Paul:                    Right. I have to agree. Susan, I work in a community hospital so we’re not a trauma center. The traumas that we get, that come in, most of everything you’re talking about actually happens through the ER prior to us transferring them out. We work with two trauma centers, they are relatively close. One is about thirty miles away which is a level two trauma center and one is about 70 miles away which is a level one trauma center. Speaking with those nurses and in dealing with them over the years, what you’re saying is exactly true. A trauma patient or a trauma stat patient when they come in will spend no more than 30 minutes in the ER and then they’re gone. But the trauma care continues on and the trauma nurses continue that on. The ER nurses only do that first 30 minutes of initial assessment, maybe starting IVs, hanging some blood, whatever the case may be to move them on to the OR or wherever else they need to go.

Susan:                  Correct. I think something else that’s really confusing too – even professionals who don’t really spend time thinking about the difference between a trauma center and an emergency department, really don’t understand that there is a huge number of patients who come in as injured patients into emergency departments, even emergency departments of trauma centers who are not trauma patients. In our hospital 90% of the injured kids who come in are not trauma patients. They are managed by the emergency department or they’re managed by our clinics, especially orthopedic clinic and never rise to the level from a mechanism of injury or acuity point of view to a trauma status. So the whole continuum of injury is confusing to people also even our own profession don’t get that. There are injured patients but then a subset of those injured patients is trauma patients.

Paul:                    Right, I agree. Right now, we’re going through some of that same type of learning with not only the nurses that I work with in my emergency department but also the more of the two local trauma centers. Florida, originally when they setup the trauma system, had set it up based on the ACS criteria which included mechanism of injury. But within the past, I’m going to say, ten years – I don’t know what exactly the time frame is – the state had decided to take that out of the trauma stat criteria because of the push from the trauma centers, because they were getting so many patients that were coming in a trauma stat. So instead of going back and saying, “Okay, they may not be trauma stat but they can still be considered trauma patients that you go to your ER” being a trauma center, the state – because there was a crisis at that point, all the trauma centers were threatening to drop their certification which meant Florida will have no trauma centers at all. They moved that out of the trauma stat criteria. So now it puts the burden back on the paramedics to make a decision based on things other than MOI which, as you know, plays a big role in trauma patients. Trauma patients for the most part are young and healthy so they manage very well and they can maintain for a longer time until all of a sudden they’re not maintaining at all. That MOI, I think, needs to truly be in there because if somebody falls from twenty feet, they may be fine for an hour, but an hour and ten minutes later, they’re crashing.

Susan:                  Absolutely. That’s really where the whole concept of trauma centers came to be. I live in San Diego where we’ve had a trauma center for about 26 years but I was a nurse in our pediatric ICU before we had a trauma center. It was very frustrating for all the clinicians in our center to see kids come from small community hospitals that really didn’t have the resources to adequately manage critically-injured patients who tried for a couple of days and then realized they went over their heads and then transfer the kids. So we got kids with not only what’s called “primary injury” but also secondary injury – swelling and bleeding and things that could have been prevented had they been in a trauma center which is the concept of the “Golden Hour” and trauma center system. It’s getting the patient to the right place. Our county of about 4,000 square miles, we do use mechanism of injury as a determinant because kids can compensate very well for a period of time and sometimes to the uneducated eye or the more naïve clinical eye of a paramedic or young paramedic, the child can look perfectly fine and be compensating for a critical or really life-threatening injury that’s internal and not readily apparent to somebody who doesn’t do pediatric care all the time. Depending on environment, and San Diego is kind of a combination of urban and rural, mechanism of injury does enter into our definition of the trauma patient and I think we just have to as regions decide what makes sense for our own areas. But certainly we have understood and have greatly appreciated the ability of a small child to compensate for a very serious injury for a period of time and look pretty good.

Paul:                    Right. I think if you talked to most ER nurses who have been in the emergency department for a few years, and paramedics the same way, if they’ve been on a bus and then the streets for five years or so, they’re all going to tell you the same thing, that they have seen these patients that looked fine and all of a sudden they weren’t fine. So they understand and I think that’s a good thing too in that although it may have happened haphazardly, a lot of people who are in the community facilities that aren’t a trauma center now realize that this person, although they look great, they really need to go to the trauma center to be checked out a little bit more definitively because we can’t handle it. Right along the same lines, I’m glad to see the CDC pushing the full ACS criteria as the trauma stat criteria now that’s been backed by seventeen different agencies. I’m hoping that that’s going to come around nationwide as one set criteria.

Susan:                  Exactly. One of the things that I thought that might be helpful to talk about, you’re probably confronted with this also, is the new generation of nurses, the young nurses are all really anxious to get where they’re going in a hurry. I get a lot of phone calls and a lot of people coming to me and saying, “I want to be a trauma nurse.” They have a month of nursing experience or they’re right out of school. I think it would be helpful to talk about – so what does it take to really be a trauma nurse or experienced emergency department nurse that deals with trauma in a really effective clinical way, what do you think about that?

Paul:                    I think that’s a good idea too. As a brand new nurse coming in to the emergency department especially if you are a grad nurse, it can be very overwhelming because you think that you got a handle on things coming out of nursing school and all of a sudden, you’re thrown into a completely different environment that that’s – I don’t want to say “uncontrolled” but it’s controlled chaos. As you know, an ER is not anything like the floor. It’s a totally different animal. Nurses, especially new nurses, can be very overwhelmed with what’s going on in the ER and having to manage multiple priorities. I always tell brand new nurses that I think it’s a good idea that they start thinking about becoming at least a certified emergency nurse so they can start understanding what it is to be an ER nurse first and then if you say, “I want to specialize past that,” you’ve got that foundation of managing multiple priorities and dealing with critical patients and then move on from that.

Susan:                  Yes, I totally agree with that. I do think it is underappreciated by new nurses coming in to the profession, how much knowledge you acquire just by doing basic nursing care either in an emergency department or on a basic floor where you’re just honing your skills and moving from novice to expert and being able to look at a child or an adult. Really, with your gut, because of all the knowledge and experience you’ve acquired, be able to say to yourself, “This is a patient who is fine” or “This is a patient I’m really worried about.” That ability really requires a certain amount of in-the-trenches, basic nursing work where you’re just acquiring skills and learning from the people around you.

Paul:                    Right. I agree. It’s a shame that as nurses come out of school, they’re given the impression – and I don’t want to say that they’re told is – but it’s almost like they’re given the impression that they are nurses and they can take care of patients. To a point, they can, but I don’t think they realize that nursing school gives you the very minimum basics of what you need to become a nurse and then you have to start applying that and learning the nuances of the care, if you will. Like you said, once you see a lot of things you start getting that gut impression that “This person isn’t as well-off as they look.” That only comes with actually seeing it and doing it.

Jamie:                  You need a baseline. You need to have a normal to be able to recognize the abnormal. I run into this one. I educate students. I do a lot of EMS, paramedic and EMT education and they ask me, “Well, I need to know the different lung sounds are supposed to sound like.” And I said, “Well, you need to be assessing lung sounds on every single patient whether they’ve got a respiratory issue or not because how else are you going to recognize normal?”

Paul:                    Exactly. When I was a paramedic actually, when I have had new EMTs as a partner or any EMTs that had never been my partner before, I always make sure that they understood what normal sinus rhythm was on a monitor, what asystole was, and what Vfib was because past that, they don’t need to necessarily know. It’s good that they know but those are the three that they need to know. If they see it, they need to tell me right away. Everything else can kind of wait a second or two and you need to let me know if it’s not normal sinus. But those three were emergent things that I needed to know about right away. So it was still just the basics. One thing that has stuck with me for 28 years when I was in EMT school, was my EMT instructor told us that if you are going to go on to be a paramedic, you need to be a good EMT first before you can even think about being a paramedic because it doesn’t matter if you intubated the patient and did everything else correctly but you miss the fact that they were bleeding out from their leg. You need to do the basics first. I think the same thing is true for nursing. If you understand what the basics are, of the ABCs and what a normal person looks like, then you start getting the feel of what an abnormal person is. Even if you don’t know what’s wrong, you know something’s not right and that’s the important part.

Susan:                  Exactly. I think the other thing that is underappreciated by new people coming in to the profession – I don’t know about you but I can’t tell you how many times people have asked me why I didn’t just become a physician. Like if you’re really intelligent, you’re not going to be a nurse, you’re going to be a physician. I have made a point of having a conversation with those people to talk about the fact that I made a conscious decision to be a nurse. Nurses and physicians have different roles. The caring part of nursing is what really drew me to this profession. The caring part of nursing is something that you really have to learn. You can be a really caring person but the psycho-social aspects of being a nurse, especially a trauma or an emergency department nurse or a critical care or cancer nurse, it’s really a burden initially because it really requires acquiring skills that most people don’t have. The ability to talk about death and dying, the ability to talk about loss of function, the ability to talk to people about things that most people aren’t comfortable talking about is something that it takes time to acquire and you can’t fast-track it.

Paul:                    No. It takes a special type of personality too.

Susan:                  It absolutely does. That’s what I see is the real beauty and real satisfaction of being a nurse: is being at the bedside, caring for families and patients and really making a difference in their life not just technically, that’s a part of it, but if you ask families, they kind of weigh equally the caring and the technical. They want both and both of those are skills that take time to acquire.

Paul:                    Right. I agree. I’ve had the same conversations with people before too because, just like you, I’ve being this for a lifetime it seems and people will say, “Well, you’re so smart, why don’t you just go get your MD?” and I’m like, “Oh, I don’t think so. First off, I don’t want to be in that end of healthcare. I enjoy the fact that I can do a lot of medical things but also time with the patients.” Just like you, you can educate the patients about what’s going on or talk to them about what to expect and help alleviate their fears and you actually can interact with the patients a little bit more than what physicians can do. Especially nowadays, physicians are pulled in so many different directions more so than nurses, I think. Nurses are burdened with a lot of things too but we still have that expectation that we want to be at the bedside and we push to be at the bedside more so than physicians do.

Susan:                  Right. I think it’s a really exciting time. I know you’re probably seeing this in your organization also but we’re seeing a huge drive toward collaboration between the different organizations. ENA and STN have worked together for a long time, have been complementary to each other in educating and supporting our profession. What I’m finding in the last few years, and I’m really heartened by, is that the physician groups are starting to collaborate with the nursing groups in not only education which we’ve done I think pretty effectively for many years but also in pathway development, guideline development, injury prevention strategies, regulatory stuff, all the forums where we’ve kind of dabbled and touched on as nurses. Now we’re being seen as important partners in the discussions at the table and we’re being pulled in to the basic preliminary meetings to develop collaborative for many of these agendas that have heretofore been primarily physician-driven. We are now partnering with many of them and it’s an exciting time for young people to come into nursing because we build our systems on these shoulders of giants. We’ve had many nurses who are now retired, who have established some of these inroads to make this happen. This is not something that happened overnight. The new nurses coming in to what our profession now is going to benefit so greatly from all the hard work of the pioneers in nursing, we have slowly changed the culture.

Paul:                    I agree. I think too that one thing that both you and I can agree on is that with the years of experience that you have and the abilities that you have technically to be able to care for the patients and do the skills and do the assessment, that has allowed nursing to look better in the eyes of physicians because they recognize that nurses can do these things and they can rely on nurses for what’s going on and they can trust them. That has allowed nursing to actually get a seat at the table because physicians look at nurses more so now than they did even ten years ago as partners or as peers as opposed to a subordinate.

Susan:                  Exactly.

Jamie:                  Really quickly, Susan, what’s the advanced practice version of trauma nurses there – as a clinical specialist or is there an advanced practice, I don’t know, nurse practitioner in trauma care?

Susan:                  I think you see all three actually: physician assistants, you also see nurse practitioners and clinical nurse specialists. I think, for pediatrics, we have nurse practitioners who work in the critical care unit, who are partners with us on care of trauma patients. We have nurse practitioners in the emergency department who are partners with us and caring for trauma patients. We do not have a sustained inpatient census of trauma patients enough to support a nurse practitioner dedicated to trauma in our particular organization because our average daily census is somewhere between three and ten patients. But in an adult acute trauma center where their inpatient census is twenty or thirty, the nurse practitioner model of case management, of being a physician-extender or physician-partner is alive and well. One of the wonderful collaborations between physicians and nurses is caring as a team for a patient population. It works very well in the adult trauma centers. It actually started – one of the trauma centers here in San Diego started that concept many years ago and it works really well. It’s a great opportunity for advanced practice nurses to work in trauma but pediatrics is a little different. We just don’t have enough of the census to support it in our center at least.

Paul:                    Susan, I have a question for you, just along that same line, I know that some universities are now beginning to start nurse practitioner programs that are geared toward emergency medicine, so instead of getting an adult nurse practitioner or pediatric practitioner, you come out with a specialty in emergency medicine, are they doing the same thing for trauma nursing also? Have any university started that at all?

Susan:                  I think there are trauma nurse practitioner programs. I know there are. I think they are generalists, not specific to pediatrics or adults. I actually think that’s a very wise way to go because in our emergency departments, most emergency departments in our state, at least, are at least basic emergency facilities that care for both adults and children. Even if we’re a pediatric center, we do have adults present to us and we do take care of them. So somebody who has an expertise in both adults and peds, I think it’s really a wise approach especially with disasters kind of being very carefully planned for and have been a reality in our world, to have the ability to be able to be a generalist in trauma is a really good thing to do.

Paul:                    I agree. I didn’t know if there is a trauma specialty for nurse practitioner programs. I’m glad to see that there are.

Susan:                  There are. They are just becoming more available. I’m not sure how many there are in the country but I know there are at least a few.

Paul:                    That’s great. That’s awesome.

Jamie:                  Well, I think we’ve kind of gotten to the end of our time. I know all three of us could probably sit and talk about this for quite a while. It’s a fascinating topic. Susan, I know the Society of Trauma Nurses, at traumanurses.org, is that’s correct?

Susan:                  It is. Yes.

Jamie:                  Okay. There’s information if someone’s interested in what it takes to become a trauma nurse, there’s a lot of great information available on your website. I was taking a look at it.

Susan:                  There is certainly and it has a lot of contacts. They can get a hold of any of us and we’re happy to talk to people.

Jamie:                  Well, fantastic. Thanks a lot.

Susan:                  Thank you.

Jamie:                  And Paul, you have your show, emergencynursingtoday.com? You put out bi-weekly and just a great resource in emergency care and what’s going on in emergency nursing.

Paul:                    Thank you, Jamie.

Jamie:                  Yes. It’s great. So that’s one resource. Of course, ena.org for the Emergency Nurses Association also, a resource for people interested in emergency nursing.

Paul:                    Right. Thanks, Jamie, I appreciate being on the show.

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Don’t forget to check out the entire February, 2011 issue of Nursing Notes, featuring a peek inside the specialized fields of emergency and trauma nursing. You’ll find links to resources like the Nursing Campaign’s “A Day in the Life” video which follows emergency department nurse Laurie through her day while she balances family, hobbies, and a second career as an ER nurse, and the Emergency Nurses Association’s latest set of Emergency Nursing Resources.  You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where we brought together a group of emergency and trauma nurses to discuss the unique challenges associated with their jobs. You’ll find this and our other podcast episodes at www.NursingNotesLive.com and in the podcast area in iTunes.