A Salute to Combat Nurses: You Go, Girls and Guys

We all remember Margaret “Hot Lips” Houlihan from the popular television series M.A.S.H.

Sometimes ditzy in the social arena, she was a highly skilled and knowledgeable nurse when it came to performing in the battlefield OR during the Korean War. She and the surgeons sometimes had to operate under perilous conditions, and while the show was a sit com, it made some strong points about the morality of war and the sacrifices these M.A.S.H. surgical teams had to make.

Military nurses of every age and time deserve a lot of credit and recognition, especially in today’s theaters of war. I’ve known and interviewed a few of these nurses, and read about others in books and in their blogs and emails. The work combat nurses do and the things they experience are unlike anything most nurses will ever know. Those who work near the battlefield are often asked to do the impossible.

The experience of one nurse working in Afghanistan was recently chronicled on a Web site for nurses. Army Capt. Michelle A. Racicot, RN, who is currently stationed in September at Brooke Army Medical Center in San Antonio, wrote about her experiences:

“I had an interesting moment one day when I was filling out an application for a master’s degree program,” she wrote. “One question asked, ‘Briefly describe your experience working with cultures other than your own.’ Before I could type my response, I was asked to fly with the medevac team to evaluate three pediatric patients hit with shrapnel from a rocket propelled grenade.

“We flew to a remote FOB (forward operating base),” she continued, “and I was greeted by one of the Polish medics who attended my classes. One of the children had an eviscerated bowel and was having shortness of breath and nausea. While I was covering his wounds and drawing up medication to give him, he would not let me let go of his hand. I later learned that he did not survive.

“It was a reminder that even with all we can offer with medicine and surgery, sometimes it isn’t enough.”

Pretty heart-wrenching stuff and something that will no doubt remain with Racicot for a long time – if not forever.

Not all nurses are reactive; some are proactive.

Take Col. Susz Clark, RN, the second-in-command of the Army Nurse Corps and the former top Army nurse in Iraq, recognizes that medical care in the field needs revamping.

Currently, members of combat care teams first meet after they are deployed to the combat zone. Clark thinks this should change. She calls for “small, interdependent groups of professionals” whose members would work and train together regularly from the beginning of their careers. She believes doing it this way would create fast and adaptable teams that are highly proficient and ready to roll the minute they arrive in the combat zone.

“In a counterinsurgency environment, such as Iraq or Afghanistan, medical care must occur ‘curbside to combat,’ ” Clark told a reporter.

Seems totally sensible and obvious, but it took a nurse to see it.

Kicking the Habit: Let Them Know Nurses Care

The Great American Smokeout is just around the corner. This year the event happens on Nov. 19.

The Great American Smokeout has been coming around annually on the third Thursday of November since 1976, but its origins date to 1971. That’s when a man in Massachusetts asked people to give up smoking for one day and donate the savings to a local high school. I’m not sure whether he was thinking more about raising money or getting people to quit smoking – or maybe it was both – but he wasn’t the only one with this idea.

That same year, a Minnesota newspaper editor created the first “D Day” (Don’t Smoke Day) and the idea began to spread. In 1976, the California chapter of the American Cancer Society encouraged people to stop smoking for a day. A year later, the society took the event nationwide.

Today, nearly everyone knows about the Great American Smokeout. It has become as much a part of our culture as smoking has become a cultural no-no. I never could’ve envisioned such a turnaround when I was growing up in the 1950s. Anyone who complained about having to breathe smoke-filled air 50 years ago was considered a pariah, a party pooper, a whiner.

When I entered nursing school, maybe 20 percent of the students smoked. When we graduated, more than half did. I can’t forget all those late nights in the dorm when we’d study together, play bridge or watch television in the lounge. Cigarettes were as integral to the scene as popcorn and soda pop. On any given night, you’d find a layer of smog in our living quarters. By today’s norms, it was appalling.

I can still smell the uniforms of the hospital nurses I worked with – all that white nylon and acetate reeking of foul odors after they returned to the floor following a few minutes in the break room. Our so-called break room was actually an oversized closet; get five or six nurses smoking in there and it was like entering a toxic soup.

Maybe even worse was the odor I remember when being cared for by a nurse who was a smoker. I can still smell her cigarette-tainted uniform as she bent over my body to turn me.

I know a lot of nurses and I can’t think of one who still smokes. Caring for patients with COPD made a lot of nurses quit. They didn’t want to be looking at their futures in their patients.

We all know that smoking costs society in many ways, but the actual numbers are pretty eye-popping. The Campaign for Tobacco-Free Kids states that smokers cost the economy $97.6 billion a year in lost productivity. Even if it is half that amount, it’s enough to make you choke.

An additional $96.7 billion is spent on public and private health care due to tobacco use, and every American household spends $630 a year in federal and state taxes because of smoking.

According to Centers for Disease Control and Prevention, smoking causes about 440,000premature deaths in the United States and about $157 billion in health-related economic losses annually. This includes the more than 35,000 people who die due to second-hand smoke.

Additionally tragic are the babies who die every year because their mothers smoked during pregnancy: about 600 boys and 400 girls. How terribly sad is that?

Smoking is a powerful addiction and the addicted must want to quit. According to research, smokers are most successful in kicking the habit when they have support. It can be a nicotine patch, prescription meds, counseling, Web-based programs, guide books, support groups and encouragement of family and friends. Probably a combination of these is best.

What can nurses do?

If you know a smoker on a personal or professional basis who is considering quitting, give him or her all the support and encouragement you can. Let them know that you understand giving up smoking is one of the hardest things they’ll ever have to do and that you really care about their health and happiness.

I think when a nurse cares, it means a little more.

H1N1: Creating Dilemma On All Sides

The swine flu and vaccine are presenting some problems for nurses.

In New York state, nurses are threatened with job termination if they don’t get vaccinated against H1N1. The state health department is telling all people who work directly with patients and those with whom they come in contact that they must be vaccinated for both the seasonal flu and the H1N1 virus.

At least one nurse doesn’t like being told that the vaccine is mandatory.

“It's just that we're being forced to take this against our will, without proof that the vaccine will even be effective," Sara L. Rombough, RN, told the Watertown Daily Times. Rombough is a 25-year veteran nurse who works at Massena Memorial Hospital in Massena, N.Y. She says she’ll lose her job in November if she refuses to get vaccinated.

The New York State Nurses Association is taking her side. A spokesman said the association encourages nurses to get the vaccine, but doesn’t think it should be mandatory.

According to the Watertown Daily Times, smaller rural hospitals in New York state may not be able to fire nurses who don’t want the vaccine because dismissing them will cause staff shortages.

The state health department defends its stand on mandatory immunization, saying it wants “herd immunity,” and to achieve that, 95 percent of populations need to be vaccinated. Officials also say that hospital patients need to be protected.

Out West, 16,000 union nurses in 39 hospitals in California and Nevada plan to strike because they say that their employers are not providing enough protections against the swine flu.

The union contends that hospitals should supply disposable N95 respirators to nurses who care for people with swine flu, but there is debate about whether this should happen. One view is that because N95 respirators must be custom-fitted, they are impractical. The Society for Healthcare Epidemiology of America says the masks are not necessary.

The other opinion, fostered by the Centers for Disease Control and Prevention, is that giving N95s to health care workers should be a priority.

A spokeswoman for the California Association of Hospitals said most hospitals would be glad to give N95s to their staff, but the masks are in short supply and many hospitals can’t get them.

In August, a California nurse died of H1N1 because of a severe respiratory infection, according to the California Department of Health Services. The department also reports that more than 3,000 people have been hospitalized in the state because of swine flu; 200 have died.

Should nurses and other health care workers who care for patients with H1N1 be forced to receive the vaccine?

Are nurses who refuse to take the vaccine doing the right thing?

Should hospitals do whatever it takes to protect their medical staff, regardless of cost?

Tell us what you think.

Cancer Screenings: What Should Nurses Say?

I know that, because I’m a nurse, I’m going to be asked by more than one person what I think of the American Cancer Society’s new stand on the benefits and problems of screening for some cancers.

According to a story by the New York Times, the society is “quietly” preparing a statement that will say that the benefits of screening for prostate and breast cancers may have been overrated. I suppose the “quietly” part is an effort not to cause a major public uproar or freak-out. After all, we Americans have had it drilled into our heads the importance of screening for breast and prostate cancers and catching these diseases early. We consider screening a right.

However, the statistics on cancer outcomes make the experts not-so-sure anymore about the wisdom of screening.

According to an analysis recently published in The Journal of the American Medical Association, there has there been a 40 percent increase in the diagnosis of breast cancer, but only a 10 percent decrease in the breast cancers that metastasize. A large increase in early cancers should be balanced by an equal decrease in late-stage cancers, which is what has occurred with screening for colon and cervical cancers.

“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Otis Brawley, chief medical officer of the cancer society, told the Times. “We never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ”

The hard and scary reality is that medical science still doesn’t know which types of cancer have the ability to invade aggressively and which types could or should be left alone. Treating slow-growing cancers can cause more harm than good, but when we hear the word “cancer,” we want to shout, “Take it out!”

We know that many men who have been diagnosed with prostate cancer choose the “watchful waiting” option, and rightly so. They often die of some other cause before the prostate cancer becomes a problem. In addition, the PSA test is far from the exact science we once thought it to be.

When it comes to breast cancer, though, I’ve never heard of a “watch and wait” option. Imagine the outrage at any physician who advised a woman to “watch the lump” for awhile. It’s fair to say that many women consider getting yearly mammograms as routine and important as preventive visits to the dentist or taking a daily vitamin.

I often have to remind myself and others that there is still a lot we don’t know about the body, cancer and treating disease. There are so many stories every week about new discoveries, research and promising drugs and other treatments that it’s easy to get caught up in the hype and jump to conclusions. But as nurses, we need to remind patients and anyone who asks that there are no magic bullets or one-size-fits all when it comes to conquering disease.

What will I say when asked about continuing with screenings for prostate cancer and breast cancer?

I’ll encourage women to continue to get those mammograms, and for men, the digital exams and PSA (with the caveat that the numbers can be deceiving) until somebody really proves that the harm done really outweighs the good.

What do you think?

Multi-State Licensure Compact - Is It Time?

When I graduated from nursing school oh-so-many years ago, there was no National Council Licensing Exam.

Every state devised its own nursing boards, and states differed on what were passing grades. I sat for my boards in Missouri – a multiple choice test for which we used a pencil to fill in those little bubbles. The exam was a five-parter, taken over two days, and students had to travel to the state capital, Jefferson City, to take the exam.

We drove from St. Louis – four and five senior nursing students per car – and quadrupled-up in motel rooms to save money. We got little sleep the night before the first test. We had studied for weeks for the boards, but still stayed up way too late, quizzing each other for Part I, II and III. The rest of the process is a bit of a blur, but I remember returning home and dreading the three-to-four-month wait for the results.

Finally, the letter from Missouri’s board of nursing arrived; I had passed all parts. Most of my classmates were as successful, but a few had to re-test on one or two parts, and they had to wait another few months before returning to Jeff City. In the meantime, they couldn’t collect that boost in pay that we “full-fledged” nurses received as soon as we recorded our notice of passing with our employers.

A year later, I was off to California, which recognized Missouri licenses, but only if the nurse’s passing scores met a certain minimum, which was higher than Missouri’s minimum scores.

Fortunately, I qualified. I gratefully paid what was a hefty fee for those days because it saved me from taking the California boards.

Then along came the NCLEX, which was a really good idea. Physicians take national exams; why not nurses? I’m all for simplifying, and shouldn’t nurses be held to a uniform standard of skills throughout the United States?

I think the obvious next step should be license reciprocation among all of the states – or multi-state licensure – but politics, power and money are the big stumbling blocks.

In some cases, the problem lies with the state boards of nursing, and sometimes it’s the state nursing associations that are holding out joining the Nursing Licensure Compact (NLC). These organizations don’t want to relinquish control and/or the income that license applications generate. And some state nursing organizations feel that multistate licensure will make it much easier to replace striking nurses.

So far, 23 states (and one pending) have joined the NLC.

For those nurses who obtain their original licenses in compact states and who want to work in another compact state, life is easy; no applications and no waiting to practice. This can be pretty important when nurses are needed at a disaster site, and certainly removes the dilemma for telehealth nurses who work in one state and advise patients who live in another.

But for nurses who take their boards in non-compact states, there is waiting and expense. And for telehealth nurses, there is confusion about the law. It’s bound to get even murkier as technology makes patient care from a distance a more common occurrence.

One expert I spoke with had what I think is an excellent model of practice: the driver’s license.

Drivers with valid licenses can operate a vehicle in any other state without charge, but they are expected to observe the laws of each state. When drivers establish residency in another states, they must apply for a new license.

We are a mobile society and our technology takes us to places electronically that we never envisioned going. How do you feel about multi-state licensure? Is now the time for nurses to get in the driver’s seat and push for multi-state licensure? Please, share your thoughts.

Survey Shows the Changing Face of Nursing

California is often called a bellwether state because trends are likely to begin here and that’s important because it has more than 10 percent of the country’s population. So it was with great interest that I read the results of the recently published California Board of Registered Nursing 2008 Survey of Registered Nurses.

There’s a lot of interesting information in this 218-page report, which contains lot of easy-to-understand tables and graphs. (I confess; I didn’t read the entire thing, but if you’re interested, visit http://www.rn.ca.gov/pdfs/forms/survey2008.pdf.

This is the sixth time the survey has been conducted – the previous one was conducted just two years ago – and about 56 percent of California’s nurses responded to the survey. That’s a huge response rate in a pollster’s world.

Like the 2004 & 2006 surveys, the 2008 survey targeted two populations:
• RNs with active California licenses living in and outside California.
• RNs with inactive status since 2006.

The survey found that there have been some major changes within the California nursing community since that first survey in 1990.

• In the last 18 years, the average age of working RNs rose from 42.9 to 47.1 years.
• More than 14 percent of nurses are men.
• In 1990, more than three-fourths of nurses were white; now that number is about 58 percent. Filipinos represent 18 percent of the RN workforce and Hispanics 7.5 percent . About 4 percent are Black/African American. The remaining 12 percent are non-Filipino/Indian Asian, Pacific Islander, American Indian and mixed ethnicity.
• In 1990, about a third of all nurses received their initial education in a diploma program; that has dropped to about 14 percent.
• Nurses new to the job with baccalaureate or master’s degrees rose from about 29 percent in 1990 to 39 percent in 2008.
• Nurses today average 27 years old at graduation and 12 percent have earned a master’s or doctoral degree.

What about the money?

It’s better. Incomes for nurses in California have risen dramatically in the last 18 years. In 1990, the average annual income was $31,504. By 2008, it was $81,428. A fifth of respondents reported earnings of more than $100,000.

Most working nurses get benefits, too. Nearly 85 percent of nurses received retirement benefits and health insurance, and nearly 9 out of 10 received dental insurance.

Why do nurses do what they do?

The survey found that it’s because they like the interactions with patients, feel that their work is meaningful and that they have job security. Most also are happy with their work schedule.

What gets under nurses’ skin?

Definitely the paperwork and other non-nursing tasks. Many also are not happy with administration and management decisions – complaints that have not changed much since the 2006 survey.

Technology: Can't Live With It; Can't Live Without It

Nurses must embrace technology every day. If they don’t embrace it, they at least must deal with it, so it bodes well to stay on its good side. Pretend technology is your friend.

Until the late 1960s, hospital technology was pretty basic. I remember how excited I was in 1968 to learn how to read EKGs, and I worked in one of the first telemetry units in the country. What a great idea, I thought, but as it turned out, we nurses in this new step-down unit spent most of our time dealing with problems that ate up untold hours.

Things have vastly improved since then, but every time one thing is perfected, something else appears on the scene that demands de-bugging and a large learning curve.

I was dragged kicking and screaming into the computer age, and now, of course, I can hardly live without one. Heck – I’ve got a computer on my phone now, but some days I think my brain is going to explode. Technology seems to be getting away from me regardless of how fast I peddle.

How did we get here?

At the risk of sounding like one of those irksome “remember-the-days” emails, I,m going to ask the question anyway: Remember the days when all we had to know was how to use the telephone (it was attached to the wall), a typewriter and an electric can opener?

Remember the days before you had to take a course on how to use a microwave and program a clock?

Remember the days when it took only one knob to turn on the TV?

OK, I admit; I’m not sorry that someone invented the remote, nor do I regret having email. I’m excited about the prospect of online, Internet-based medical records, and most nurses would never give up their PDAs.

But it’s scary to think about how much we depend on technology.

For instance, I recently took my computer into one of those big-box tech stores for diagnosis and treatment last week. Nine days later, I was told that no one had even looked at it. I drove to the store, pulled my tower out of the clinic and went to the Internet (on my backup laptop) to find a compassionate geek who makes house calls.

I found Gregory. He arrived at the door with a Bluetooth on his ear, talking to his father.

“I’m helping him set up his Blackberry,” he whispered as he entered the house.

Eureka! I had purchased a Blackberry the week before and needed help with that, too.

While I watched and tried to learn something, Gregory discovered my computer had contracted 46 viruses. With his right hand on the keyboard, he fixed the problem. With his left hand, he set up email and Internet access on my Blackberry – all while instructing his father on how to do the same.

Glory be. Could I bottle this guy’s DNA and sell it?

When it comes to fixing tech problems, I do what I can, then search for someone like Gregory. Every nurse could use a miracle worker like him close at hand – or at least a phone call away.

Now if I can just quit trying to turn on the television with our portable phone…