A New Normal: Graduate Nursing Students Paying for Clinical Rotations

by Patrice Brown | July 2016

Aspiring advanced practice nurses enter their prospective graduate programs each semester with the good faith of excelling at their course work and practicum. Unfortunately, that notion may be tarnished by the misfortune of not finding a clinical site. In some instances, unwarranted cancellations by a preceptor occur. Leaving the pupil to hastily find another preceptor. Consequently, if the student is unable to obtain a new preceptor their graduation is postponed for months or sometimes years.
With the advent of online advanced nursing education, the demand for preceptors has skyrocketed. Many students spend months calling around for a preceptor to no avail. Plenty of primary care clinics are, booked full of students, a year or two in advance. To offset the demand some practices and health care practitioners have begun charging students for time spent precepting in their clinics. Thus, herein lies “an elephant in the room”: is it ethical for clinics to require payment for nursing practicums? Sadly, there is no straightforward answer to this question; yet among students there are two schools of thought.
One school of thought: “It’s unethical to pay for a clinical rotation. Why would I pay for something that a person should do out of the goodness of their heart?”
Central to any health profession is service. This act of unselfish kindness and generosity bears meaning to one’s career and, above all, sustain and dignify the future of others. In this instance, a pupil in need of mentoring isn’t too lowly for the time and attention necessitating growth. Unselfish service is marked by giving freely without expecting anything in return, as explained within an excerpt from the Hippocratic Oath, “To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract…”
Second school of thought: “You’re paying for your education just as you would in a classroom environment.”
Some clinics are charging a minimum of $200 per week for a practicum experience. Which translates into $1,600 – $2,000 for an eight to ten week session. However, not all clinical sites are created equally. Some preceptors allow the pupils to independently see patients and afterwards they confer to execute a treatment plan for the individuals. Alternatively, other preceptors adopt a “hands off” approach and throw the student “out to the wolves” with little to no experience. How can schools of nursing solve this burgeoning problem?
Graduate nursing clinical rotations should be regulated by an accreditation body, such as the Commission on Collegiate Nursing Education (CCNE). Program effectiveness, assessment, and achievement of program outcomes are addressed within CCNE’s Standards for Accreditation. Presumptive regulation of graduate nursing clinical sites should be addressed under section IV – B, “program completion rates demonstrate program effectiveness”. How effective is the nursing program if students are not graduating due to sparse clinical sites? The school of nursing should be held accountable to help their students find practicum placement. If a large percentage of pupils are unable to complete the program of study due to insufficient assistance with securing a preceptor, a mandate should be place upon the school of nursing to provide a written explanation and analysis along with a plan of action for improvement before re-accreditation is approved for the graduate nursing program.

Patrice Brown

Ms. Brown is an Atlanta-based professional nurse who has worked on various inpatient units. She also has experience as a float pool and travel nurse. Ms. Brown hails from Milledgeville, Ga, a small town 90 miles southeast of Atlanta, Ga. In December 2009, Ms. Brown graduated from Mercer University with a Bachelor of Science in nursing degree. Currently, she is enrolled at Chamberlain College of Nursing obtaining her Masters of Science in nursing degree. Ms. Brown is a proud member of Zeta Phi Beta Sorority, Inc. Advocacy and writing are two of Ms. Brown’s passions. To satisfy her desires of writing and advocacy “Musings of a Bedside Nurse” a healthcare blog was created by Ms. Brown to initiate an open dialogue about issues within healthcare that affect other nurses. She is active within several professional nursing organizations.

What You Need to Know About Shift Work Disorder

by Nachole Johnson, MSN, APRN, FNP-BC

 

Millions of people work hours other than the standard 9 to 5, Monday through Friday and, unbeknownst to them, their health may be severely affected because of it. Shift work (defined as working anything other than the traditional 9 to 5) was designed to cover industries that operate twenty-four hours per day. Hospitals fall into that category and need staff coverage at all times, leading to employees that are more prone to a condition known as shift work disorder (SWD).
Although mainly an issue for those who work overnight shifts, SWD can cause problems for those who regularly work longer than eight hours per day, too. Working twelve hours at a time, day or night, can cause problems for some people. Nurses are particularly affected by SWD due to the nature of hospital working conditions.

The American Academy of Sleep Medicine (AASM) identifies those who work early morning, evening, overnight, and rotating shifts as the ones most affected by SWD. Aside from excessive sleepiness, shift work can lead to difficulty falling asleep or staying asleep, decreased energy, difficulty concentrating, headaches, and poor mood and irritability.
Dianne Jones, RN, has experienced the effects of working odd hours firsthand. “When I worked 3 pm – 3 am in my first ER position, I had difficulty sleeping,” she says. “It was made worse by the next job when I worked 7 pm – 7 am.”

Jones’ problem is all too common among those who work overnight shifts. The human body has a natural circadian rhythm that sets sleep and wake patterns over a 24-hour period—and working the overnight shift disrupts that cycle since the normal circadian clock is set by a light-dark cycle. Jones describes the feeling of this disruption after working a night shift as follows: “Once my eyes were exposed to daylight as I left work, I felt as if I became almost manic…my body was telling me it was time to be awake and active.”

Those who work dayshift can also be affected by SWD, not necessarily because of working a non-traditional shift, but mainly because of quick returns. Quick returns, or working back-to-back shifts, are a practice all too common among nurses. A study on nurses who worked various shifts found that quick returns of day shift nurses were just as strongly correlated with SWD as those who worked strictly night shift. Quick returns—just like shift work in general—cause disruptions in the circadian rhythm. The mismatch in the natural circadian rhythm eventually leads to sleep/wake disturbances and internal desynchronization.

Jones noticed that the amount of time she slept varied with the length of her shift and the stress associated with her job at the time. “When working twelve-hour shift in the ER, I slept about 5 hours max. With an eight-hour shift at a less stressful job, I slept about 7 or 8 hours.”
Jones, who has worked nearly every shift imaginable as a nurse, has finally settled into a day shift position after spending a considerable amount of time working evening and overnight shifts in her 10-year nursing career. She believes that nurses who work 12-hour shifts in high acuity areas can burnout over time: “I think most nurses can maintain a high level of stress on the body and mind for a while, but it does begin to take a toll and may lead to errors, substance abuse issues, or burnout.”
Shift work can cause many health issues, some with longstanding effects. The AASM attributes SWD to work disturbances such as work-related injuries, vehicle accidents related to drowsy driving, and substance abuse (to improve sleep). Many serious medical conditions, including hypertension, diabetes, obesity, and an increased risk of breast and bowel cancer have also been attributed to SWD.

Certain risk factors can predispose some people to developing SWD when working alternative shifts. Those who are older, have comorbidities, drink alcohol, smoke, or have had previous sleep issues in the past are at highest risk.
There are ways to combat the symptoms caused by SWD, but for some, a change in schedule may be necessary to reverse them altogether. Here are four recommendations for those who may be affected by SWD to help alleviate any sleep issues:

1. Have a consistent room temperature
Sleep experts recommend a room temperature of 68 degrees Celsius to help promote sleep, as it’s easier to sleep with cooler temperatures.

2. Keep the room dark
If working nights, using a blackout curtain during the day can dramatically improve sleep. Use eye shades if the room cannot be darkened enough for sleep. Along the same lines, wearing dark sunglasses on the drive home in the morning can blunt the impact the sun has on making you feel alert once sunlight hits your eyes.

3. Reduce noise
Reducing noise before bed and limiting screen time with the TV, computer, and cellphone will help your brain “wind down” for sleep. Silence your cellphone and unplug any landlines before you lie down. Heavy carpeting and drapes in the bedroom can also help dampen noise. Lastly, ask family members to respect your sleep time if others are awake when you plan to be asleep by limiting noise in the home.

4. Avoid large meals and caffeine shortly before bed
Large meals can cause indigestion and make it hard to sleep when your stomach is full. Avoid large meals at least 2 hours before bedtime. Ingesting caffeine can keep you amped up when it’s time to sleep.

Other ways to decrease SWD include working less shifts in a row, shortening your work commute by finding another job closer to home or moving closer to your job, and taking naps when possible. Another possible solution that may help some nurses is to switch from working twelve-hour shifts to eight-hour shifts. Symptoms related to working an alternative work schedule need to be present for at least 3 months for an official diagnosis of SWD, so it’s imperative to be evaluated by a provider if sleep issues are still a problem after implementing recommendations.

Nachole Johnson, MSN, APRN, FNP-BC

Nachole Johnson is an FNP who specializes in Health and Wellness and is the author of You’re a Nurse and Want to Start Your Own Business? The Complete Guide, available on Amazon. Visit her ReNursing blog for more ideas on how to reinvent your career.

Interesting Facts about the Health of Minority Women by Nicole Thomas, RN, MSN, CCM, LNC

Health is defined as the state of being free from illness or injury. Health is what keeps all individuals in a state of harmony and balance because when our health is good, we are good. However, the state of being free from illness or injury is not equal across all spectrums of the human species. Some of you may deal with health related issues on a daily basis, occasionally, or rarely. Despite your frequency, it’s doubtful time allows you to look up interesting facts and figures on this topic. For instance, did you know that black women have a shorter life expectancy than White women by 5 years, 50% higher all-cause mortality rates, and death rates from major causes such as heart disease, cerebrovascular diseases, and diabetes that are often 2 to 3 times higher than those for Caucasian  women? Knowledge is power, so here are a few interesting facts and figures about the health of minority women that make you go hmmm.

• Caucasian women are more likely to develop breast cancer than African American women. But African Ameri- can women are more likely to die of this cancer because their cancers are often diagnosed later and at an advanced stage when they are harder to treat and cure. There is also some question about whether African American women have more aggressive tumors.
• African American women between the ages of 35-44, have an increased breast cancer death rate of more than twice the rate of White women in the same age group—20.02 deaths per 100,000 com- pared to 10.2 deaths per 100,000.
• Black women develop high blood pressure earlier in life and have higher average blood pressures compared with white women. About 37 percent of black women have high blood pressure.
• About 5.8% of all white women, 7.6% of black women, and 5.6% of Mexican American women have coronary heart disease.
• A 2011 Journal of Women’s study indicated that 57 percent of Latina women, 40 percent of African American women, and 32 percent of white women had three or more risk factors for having a heart attack.
• According to the article published by the Diabetes Sisters, the prevalence of diabetes is at least 2-4 times higher among African American, Hispanic/Latino, American Indian, and Asian/Pacific Islander women than among white women.
• One in four African American women over 55 years of age has diabetes.

So, which fact do you find most interesting?

References:
Breast Cancer: A Resource Guide for Women. (2009). Retrieved from:http://minorityhealth.hhs.gov/assets/pdf/checked/bcrg2005.pdf
Pryor, David. Diabetes in African American Women. Retrieved from:http://www.blackwomenshealth.com/blog/diabetes-in-african-american-women/.
Women of Color Have More Risk Factors for Heart Disease. (2012). Retrieved from:http://www.hhs.gov/ash/news/2012/20120206.html.
Women and Diabetes. (2012). Retrieved from:https://diabetessisters.org/women-diabetes.

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Nicole Thomas, RN, MSN, CCM, LNC

Founder and Registered Nurse at Impact Nurse Consulting, LLC

Nicole Thomas, RN, MSN, CCM, LNC, the founder of Impact Nurse Consulting, LLC.,is a Masters prepared Registered Nurse licensed by that state of Louisiana who has 10 years of extensive clinical nursing experience. Her multi-faceted nursing background consist of medical-surgical nursing, home health care, certified case manager, pre-certification, utilization management, managed care, nurse educator, and legal nurse consultant.

Report Finds Heart Disease Risk Decreases After Night Shift Work Stops by Julia Quinn-Szcesuil

Night shift nurses have long known their schedules can cause health problems, but a recently published study offers hope that the impact isn’t forever.
In April, “The Association Between Rotating Night Shift Work and Risk of Coronary Heart Disease Among Women,” confirmed the risk between heart disease and shift work, but noted when you stop night shift work, the risk for coronary heart disease decreases.
The report, published in the Journal of the American Medical Association, evaluated the work and lifestyle habits of more than 189,000 healthy nurses who participated in the Nurses Health Studies. 

Lead by Celine Vetter, PhD, of Brigham and Women’s Hospital and Harvard Medical School the study looked at their rotating night shift work in 1988 and 1989 and evaluated the findings with their body weight, physical activity, diet quality, and whether or not they smoked.
According to the report, the longer the nurses worked a rotating night shift, the higher the risk of coronary heart disease. Researchers noted up to an 18 percent increase over women who didn’t work a night shift if the shift work lasted more than 10 years. The nurses who reported the rotating shifts worked at least three night shifts over the course of a month in addition to other day and evening shifts.

In a video reporting her findings, Vetter noted one finding that was significant enough to warrant more studies. Even if nurses worked many years of rotating shift work, thereby upping their risk of disease, the findings showed that when the rotating shift work stopped, the risk started to decrease. The longer the time passed from when the night shift ended, the greater the decrease in risk.
The finding itself is worth looking into, says Vetter, to see if any other other factors could contribute to the decrease or not.

Overall, the findings show that rotating night shift work causes enough of a disruption to cause a small, but statistically significant, increase in coronary heart disease. And while there were nearly 11,000 cases of coronary heart disease recorded, that still means that 178,000 nurses didn’t have that correlation.

If you work a rotating night shift (and even if you don’t), it’s a good idea to take special care of yourself with heart-healthy habits. Get enough exercise for stress reduction, heart health, and weight control. Eat a heart-healthy diet with lots of fruits and vegetables and keep the saturated fat to a minimum. Get enough rest (even if you have to fit in a nap or two in your crazy schedule) and don’t smoke. And be heartened that even as your risk is increased the longer your rotating shifts go on, that same risk also decreases during the years after you return to a regular schedule.

Julia Quinn-Szcesuil

Julia Quinn-Szcesuil

Full-time Nurse in Every School

Medscape Medical News

AAP Calls for a Full-time Nurse in Every School

Marcia Frellick

 

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A new policy statement by the American Academy of Pediatrics (AAP) calls for a minimum of one full-time registered nurse in every school and a school physician in every district.
The statement, published online May 23 and in the June 2016 issue of Pediatrics, replaces the 2008 guidance, which supported ratios of one school nurse to 750 students in the healthy student population, and a 1:225 ratio for populations who need daily nursing assistance.
As previously reported by Medscape Medical News, according to a 2007 study, only 45% of public schools had a full-time nurse on site, whereas 30% had one working part time.
 
Role Has Expanded
Since the first school nurse was hired in 1902, the role has become increasingly complex. Now, the school nurse role includes surveillance, emergency preparedness, health education, chronic disease management, and behavioral health assessment.
They also liaise between schools and the public health arena, facilitating immunization, obesity prevention, smoking cessation, and substance abuse and asthma education.
"School nursing is one of the most effective ways to keep children healthy and in school and to prevent chronic absenteeism," Breena Welch Holmes, MD, a lead author of the statement and chair of the AAP Council on School Health, said in an AAP news release. "Pediatricians who work closely with school nurses will serve all of their patients better."
School nurses and pediatricians working together are a prime example of team-based care, the authors write. Nurses can connect students and their families to the medical home and can foster coordination of care.
Pediatricians can include school nurses as key team members in delivery of care and in the design of integrated care, such as school-based health centers.
The AAP also recommends that pediatricians ask their patients school-related questions, such as whether health problems are leading to chronic absenteeism; include school contact information within the student's electronic health record; and share relevant health information with the school nurse.
 
More Learning or Behavioral Problems
Some of the changes prompting the new AAP guidance are medical. Survival rates of preterm infants have increased to more than 90% of infants born after 27 weeks' gestation, resulting in more children with moderate to severe disabilities and learning or behavioral problems.
In addition, chronic illness is increasing: Food allergy prevalence in children younger than 18 years jumped from 3.4% in 1997 to 1999 to 5.1% in 2009 to 2011. And in 2010, 215,000 people younger than 20 years in the United States had type 1 or type 2 diabetes.
About 1 in 10 school-aged children has asthma, which contributes to more than 13 million missed school days a year, and the percentage of kids aged 6 to 11 years with obesity increased from 7% in 1980 to nearly 18% in 2012, the authors note.
"One in ten children and adolescents has a mental illness severe enough to cause some level of impairment; yet, in any given year, only about 12% of children in need of mental health services actually receive them," they write.
 
Legal and Societal Demands
There are legal and societal changes as well. Federal and state laws demand adherence to privacy regulations and compliance with rights and accommodations for the disabled and people needing additional services.
The authors note some research has shown cost savings as well for full-time school nurse staffing. "In 1 study," the authors write, "for each dollar spent on school nurses, $2.20 was saved in parent loss of work time, teacher time, and procedures performed in school rather than in a more costly health care setting."
Yet, with tightening budgets, school nurse staffing has been inconsistent. And using a nurse-to-student ratio to determine the necessary number of nurses no longer works to fill increasingly complex needs, the AAP says.
"[G]ood health and strong education cannot be separated," the authors conclude.
All authors have filed conflict of interest statements with the AAP. Any conflicts have been resolved through a process approved by the Board of Directors.
Pediatrics. Published online Mary 23, 2016.