September 15, 2020

Episode 26: The state of critical care nursing

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Description

Critical care nurses have played a crucial role in the fight against COVID-19, and many have had a front row seat to how the virus has affected patients. Our guest, Megan Brunson, is a 20 year veteran of the ICU and the immediate past president of the American Association of Critical Care Nurses, which is the largest specialty nurses association in the US.

On this episode of The Handoff, Megan and Dan talk about everything from the health disparities she sees firsthand with COVID patients in the hospital she works in in Texas, why she thinks now is a good time for nurses to consider a career in critical care, and her advice to nurses and nurse managers on how to prevent burnout. 

Megan has been at the bedside for 23 years, with 20 of those in the ICU. She has worked the night shift for her entire career and is passionate about the role of sleep in keeping nurses mentally and physically healthy.

Links to recommended reading: 

Podcast

Transcript

Dan:
It's very exciting to have you on the show today, Megan.

Megan:
Thank you so much, Dan, for having me. I'm a little bit of a fan.

Dan:
I love it. It's fun to have a second season because people can actually listen to the first season. It's fun. Tell us a little bit about yourself. Where are you right now in the world and what roles are you playing in nursing?

Megan:
I am in Dallas, Texas, actually North Dallas, but I work in Dallas and I've been on the front lines a bedside nurse for the past 23 years. I almost feel like sometimes I have these two parallel lives. So I have my professional life that extends outside of the hospital and I'm very involved in American Association of Critical-Care Nurses and I'm the most immediate past president for the national organization. And then I also have my time at the bedside. I started out as a PCU nurse when I got out of nursing school here in the Texas area. Moved to Atlanta, couldn't find a PCU job, to be quite honest. And so I was thrown to working in the ICU, which ended up being a gift. Sometimes those things that come upon you don't expect end up being the biggest gifts, and I loved it. Of course, I married a Texan so I had to come back to Texas and I've been working in a CVICU here as a night shift supervisor, sometimes people call that an assistant manager, in different hospitals for the past, oh gosh, almost 12 or 13 years now.

Dan:
Wow. And so Texas, one of the States that has recently spiked in COVID, how has that been? What stuff are you seeing?

Megan:
Really, to be honest, it just crept up on us. I mean, with news being focused what's going on in the East and the West coast, Seattle and New York, obviously you know, have been seeing more and more evidence that there has just been different minority groups that have been disproportionately affected by COVID. And here in Texas, I'm seeing that significant amount of Hispanics and the Latina patients being effective. And like I said, it just creeped up on me. At first, you start looking at the patient manifest and you see some names and you start putting it together. But then we started noticing that there were whole families being admitted into the ICU.

Dan:
Wow.

Megan:
And then local news is coming out and supporting the fact that we're seeing 66% to 70% of our patient population being the Hispanic and Latino community. It's really heartbreaking, Dan, to be honest and it's very difficult for nurses because when you're caring for these whole families, I mean, generational impact. Grandparents and adult children in the same ICU, it just feels different being that weight on the nurse's shoulders when a whole family is in the ICU.

Dan:
Yeah, that's definitely a trend we're seeing here in Northern California as well where there's a ton of disparities. And now I just saw something as well with the infections in children are increasing. And, again, it's the same Latina and Black communities that are seeing much bigger upticks than others. From your perspective, what can nurses do to address those disparities?

Megan:
Before I mention that, I also would like to mention as well that the population of nurses who are in those minority groups are also equally affected by this and it's something that we need to consider. I don't know if you saw that recently there was that study in the Lancet with the University of Massachusetts, and also was in combination with U.K. about nurses. I mean, healthcare workers themselves have a three fold chance of getting COVID, but then if you're a minority, it's almost five fold, is what the study was showing. So I do think that we have a place to be concerned about our own co-workers too being affected if they're in that minority group. But as far as what nurses can do about disparities and health outcomes, I think that first we need to really look at communication and collaboration, also looking at perhaps if we even have our own biases and really be opening up and examining our own biases.

Megan:
Not to be punitive or not to think about where we may have done something wrong in the past but is this an opportunity for growth as us as a profession and as a person?

Dan:
Being an advocate as well, and like you mentioned, when we see trends, because we're there 24 hours a day, we see the trends across all of these populations, the patient, when you see families, entire families, come in that's the stuff that you may not see in the aggregated data. And those types of stories, I think nurses can step up and bring those stories to light and actually potentially make recommendations for changes in public health and other situations as well, or support for those families.

Megan:
Right, and I think it's very local to the community that you're in. So what would be going on in Texas might not be the same as Wyoming. I think that it's how it's affects your city, whether it's big or small or the middle of the desert and the Navajo nation to open country. So it really is specific to your community and making a conscious effort to be aware.

Dan:
And beyond the bedside, beyond the direct patient care, what are some ways that you and your association are helping raise awareness for this?

Megan:
Overall, I would say one of the core things that American Association of Critical-Care Nurses is, is that we really talk about healthy work environments and really that collaboration as a standard for the care that we provide, and that collaboration extends into that community and not only just with other colleagues that you've worked for. It's really becoming more aware because of the environment around us, but also I think that the discussion in healthcare is a more open dialogue now. And I think that we're trusting our own perspectives but also looking at the different cultures. For example, my daughter is studying French and it's very typical to kiss each other on the cheek. Well, now you would not do that in the sense of COVID. But so where do we have those discussions about the different cultures that were seeing and the importance of recognizing those and then teaching and educating, but then also appreciating the differences?

Dan:
That's a great example. And from a critical care nurse standpoint, I mean, ICU nurses are in high demand. I mean, in all the jobs on the Trusted Health Platform, ICU is number one, and there's not a big supply of them. As far as the workforce, from a critical care standpoint, are all available ICU nurses working just slammed and distributed throughout the world? What's going on from a trend standpoint there?

Megan:
I honestly say, first off, that one of the few bright rays of sunshine when it comes to this pandemic is that we really have shone a light on the current nursing workforce and really what a vocation it is, not only because it's the most trusted profession, but nurses are showing the value of what they're doing on a much larger scale, whether it be through the media or through social media and they're sharing the things that they're seeing. Not only just the compassionate stories, but their clinical skills. And so people are asking, "What is it that we do?" And I think when it comes to nurses, it does feel like they're being slammed just because now I think, to be honest, not only do we have the COVID patients but many of the hospitals are back open to having the typical surgeries. And then, Dan, I would even add a third layer to that and say, personally, that I've been seeing the non-COVID patients coming in and needing significant amounts of care because they have gone without because the world was on pause.

Megan:
And so they're coming in with their chronic medical conditions that have been under managed or perhaps even mismanaged. And then the other thing I would say is that we now are having patients who were COVID, went home, got better, and they're coming in with what I would say would be complications of COVID from cardiogenic shock to problems with their lungs and they're very, very, very sick. And that is a concern that I have going forward. And so, yes, I do feel like the nurses are, especially in the ICU, they're working, they're having travel nurses that are sharing the help around the country when these populations pop up and the censuses increase. But we need nurses now more than ever, and experts, clinicians at the bedside at that.

Dan:
And one thing I'm worried about too is the burnout. We did a study recently of about 1500 nurses. I know the ANA has done a study recently with several thousand nurses. And one of my fears is that the reason that hospitals are short is not only that there's an increased demand but that nurses want a break, and so I'm wondering what you see from your perspective on that.

Megan:
When it comes to burnout, we've been talking about burnout for years before even COVID happened. And you're right, there isn't a break. I mean, before you would go into work as a bedside nurse and you think, "Oh, I might have a good day or I might not have a good day," It was happenstance. But now you're going into work and you're fully aware that it is physically and mentally exhausting. I mean, your ability to cope is magnified because you're already knowing before you go in what kind of situation that you're in. And for me though, I do think that we have a role to shift the conversation from burnout to wellness, and we have been doing that, not only with the association, we also are collaborating with others in that wellness initiative through the American Nurses Foundation and ANA and ENA and the American Psychiatric Nurses too, on a front sense, preventatively give the wellness opportunity to nurses to think about how they're taking care of themselves on the front end.

Dan:
What are some of the things they can do on the shift when it's so crazy? I mean, you're in PPE all day long. You're in rooms for hours and hours. Breaks are a thing of the past. What are some of the things that nurses can do on hour three of their shifts to reset?

Megan:
First off, I think not only what they can do, but how they can support others, because you could be doing okay on your shift, but it's also being aware of your team as an overall and how they're doing. Some simple things, really. I think it's very hard to hydrate, Dan, to be honest, when you have the masks and you are sweating profusely in those gowns. And one of the nurses, she logs her water intake on an app, and I thought that was a really wonderful suggestion. Not to be annoying about it, but just to make sure that she's getting that adequate amount of hydration, because all of our stuff's put away, we don't have anything out at the nurses station. And the other thing is, I'll tell you, there's nothing wrong with sneaking a quiet moment in that supply room. I have done it multiple, multiple times.

Dan:
I know. It's so true.

Megan:
Everyone says that they can't find certain supplies, but I think there's some of us that say that because we want to go in there and just have a 30 second, one minute breather. And I fully, fully support that. I mean, if it takes you a little longer to find something in the supply room, go for it. And then the other thing is, is that, depending on the flow of the shift, I do think it's okay to support your coworkers if they're spending that extra five or 10 minutes taking that break or taking that lunch. If you know that the unit is handled and the unit is okay, give them that time because they'll give it back to you.

Dan:
That's a good segue. In your current role as a nurse leader on a unit, what are some strategies you would give to other nurse leaders to make sure that their staff is taken care of both physically and mentally?

Megan:
One of the things that I think is imperative as a nurse leader and being part of the team is really looking at how nurses are scheduling themselves, I would say. I think that we often want to fill those holes where we feel that's short-staffed, but when you really look at it and step back, do you have a nurse that's working six, seven, eight shifts in a row? And what can you do to say, "Hey, I've noticed that you're signing up for a lot of shifts. Is there a way to break this up to give you a break or is this something that you intended to do and are you okay with it?" And they might be okay with it but it's that acknowledgement that you have that concern. And I think the other thing too as a nurse leader is to, I honestly say all the time, just know your staff. Everything from the name of their dogs to the fact that they liked Diet Mountain Dew. I think that those are some of those things that are meaningful to them, especially if you're in charge of a large team.

Megan:
I myself am on a smaller team so that's a little bit easier, but those small things to create dialogues that they will open up when they actually are having hardships and difficulties allow for you to have that trust as a leader.

Dan:
And the staff have trust and so, like you said, when they take that 15 minute break or they get the 30 minutes for lunch or whatever, if they have trust in the leadership and their team then they can actually decompress. But if they're worried about that stuff throughout the shift, then there's no downtime, right?

Megan:
Right, exactly, and I think that they want to. It starts superficially when you build trust and then it will become deeper. And then in the same turn as a leader it helps you because they will come forward with problems but also solutions that they might be seeing to barriers to care. So it definitely is a win on both sides.

Dan:
That's that culture of innovation that you want, I think, and it starts with that relationship with the leadership and the trust there. And then you do, you have people coming up with, they feel safe to bring up ideas, they feel safe even discussing the workarounds they figured out as a source of innovation and a way to maybe do something better.

Megan:
Right.

Dan:
One of the other things that you mentioned and you're passionate about is the role of sleep as well. And so I would love to hear your thoughts on the impact of sleep on being your best self as a nurse and providing the best care.

Megan:
I think I've been so interested in sleep since the first time I ever did on a night shift 27 hours ago.

Dan:
Since your first nap.

Megan:
Yeah, exactly. And I, like most people, was thrown into the night shift just because it was that rite of passage that supposedly you were supposed to do it. But I ended up loving it. But, at the same time, I noticed that this discussion of fatigue is a huge part, not only of wellness, but to how we take care of our patients and give optimal care. And there's the typical tricks, Dan. I mean, from the blackout blinds to the wax in your ears, to the no blue light, we've heard all of those tricks of the trade, if you will. But some of the things that I like to highlight, especially people who are new to coming on to night shift, is really mapping out your sleep, really looking at a given week, and blocking it out on your calendar if you're sleeping during the day. Not accepting as it to be common that you would have a dentist appointment at two in the afternoon, because you wouldn't have one at two o'clock in the morning, right?

Dan:
Right.

Megan:
And I actually, when Fitbit's first came out, I clocked my sleep, not my steps. And that's how I got interested in really being slapped in the face with how poor my sleep was. And I think I mentioned another one just as a leader that scheduling, having a real keen eye on checking on people when they have shifts, but also looking at your peers around you, you have a nurse that's sitting in a nurses station and they're nodding their head. I call it those micro sleeps where you just want to close your eyes for 10 seconds, really have that discussion with them. Again, not punitive, but just say, "I'm concerned because you look like you're fatigued. What exactly can we do for you?" Perhaps there is an opportunity to send them home early or perhaps they could come in late the next day and really look and see if there's a way that you can help them out as a co-worker.

Dan:
I think that's something that we take for granted is, we look for the other things like errors in care or helping with some sort of task, but we don't tend to assess our coworkers for how awake they are or how present they are necessarily. And I think more and more data's coming out about how sleep does impact the error rate and performance of nurses and so it's another thing that peer support, like you said, not punitive, but, "Hey, you're looking tired. Let's figure this out," because at the end of the day it hurts patients.

Megan:
Exactly. The other thing I would say too, is that I don't think we as nurses listen to our own body. And you may be thinking, "Oh, I got eight hours of sleep," but it's also the quality of that sleep. If your dog was barking and the doorbell was ringing and you were woken up 20 times, especially now since kids are home with virtual learning. But I will say that we don't really say, "Hey, am I closing my eyes one too many times during the night? Where is my accountability? I didn't take a good nap before I came in," to really think about that being a situation where I need to be accountable. And another layer on that is a lot of other industries really support the research and the accountability as it relates to fatigue. My husband is an airline pilot and it's a big conversation on accountability for airline pilots, and that's just another example of an industry that really looks at fatigue and how much of a clinician and 100% of yourself you're bringing into work.

Dan:
Yeah, I was going to mention. Pilots aren't allowed to fly more than X many hours a day, truck drivers aren't allowed to drive X many hours a day, but nurses, we're celebrated if we worked the 16 hour shift and then we do it three more times in a week and pick up overtime, an extra shift after that. And I think that's one of the perks of the job are the 12 hour shifts and it's also one of the detriments to the profession too, I think. And I would love to figure out how we can potentially fix that aspect of it or stop celebrating the fact that you can work five 12s in a row, because it's not safe.

Megan:
Right, and it's a culture shift. And right now, unfortunately, we're particularly vulnerable to falling into the easy thing and saying, "Oh sure, I'll work that fifth shifts," when really you should pause and say, "It's not for me right now. I have not slept really well the past five or six days." And the evidence is showing, subsequent shifts in a row, you actually have less and less sleep as those subsequent shifts go on. But a study in our favor is now they're also showing that you can "catch up" on sleep. So if you have a day off and you want to crash for 18 hours, there is some school of thought that, that does help. But definitely, don't count on that as being an easy fix to do all the time.

Dan:
Yeah, I know. When I was at my past organization, when we mentioned eight hour shifts, nurses balked really quickly because they want the four off. I mean, that is one of those things is. It's just kind of built into the culture of the profession.

Megan:
Yes, I will say, I'm a little spoiled with that myself. I definitely have to admit it. But, again, the eight hour shifts, when you look at the evidence, really support us being 100% when we come to our job. So there's definitely more discussion there and we have to be honest with ourselves as a profession of where we're going to give the best care and how we're going to do that as it relates to fatigue.

Dan:
That's a great focus for us as a profession. I want to shift a little bit and talk about your role in the CVICU. I think from a COVID perspective, there's been this theory all along that it's actually potentially a cardiac disease, that it's really damaging vessels in the heart and things. So I wonder, from your perspective, what trends are you seeing around the COVID patients in the CVICU?

Megan:
Well, I don't know if many people know about CVICU, but we love our toys and have lots of equipment. And I will tell you, it's a sad thing to say that we're seeing lots and lots of more toys and equipment at these patients' bedsides. The cardiogenic shock, not only when a patient comes in positive for COVID, but like I started to mention earlier on in our discussion, is the patients that either have put their care on pause because of the pandemic or had COVID, did okay, are at home, now swabbing negative, but did have COVID or have the antibodies, and now coming in very, very sick with right-sided, I see mostly right-sided failure, but coming in with heart failure. And I think, again, I'm not a data person and I don't remember numbers at all. I'm bad at it.

Megan:
But I think as a trend and what I've seen anecdotally, it's going to be six, eight months, we're going to start putting these pieces together and we're going to see where COVID has been a concern in the cardiac population, those who already had cardiac disease and then those who have shifted into being heart failure patients now because of COVID.

Dan:
Yeah, so it's kind of a double whammy, right?

Megan:
Yes.

Dan:
The deferred care and also the disease itself is impacting things. Yeah, it'll be interesting. I think the effects long term are going to be really interesting to see how this becomes a chronic disease.

Megan:
Right. And one thing I would say, again, those little tiny, bright rays of sunshine when it comes to the pandemic is, what a wonderful time to get into nursing because you are going to see everything. I mean, just everything. And the experience that the nurses who are new to the profession, the types of clinical patients they're going to see, infectious disease to team collaboration during this time, I just think it's going to be wonderful for them. They're going to be excellent clinicians and experts before they know it.

Dan:
Yeah. I think this is the time that nursing shines and I hope that it rallies a bunch of people to join our profession. One of the things that we've been focusing on are student nurses and new graduates, giving them some career tools and things so that they can pick their specialty and that kind of thing. We actually just put out a specialty guide. One of the ones that people talk about is critical care nursing, whether it's PICU, NICU, ICU, whatever. What advice would you have for nursing students or new grads to pick or consider critical care nursing as their chosen specialty?

Megan:
That's a really good question because myself, I actually was kind of scared of it, to be honest, I was on a step down unit for many years and I had no intention of going to the ICU. And I think a lot of that was just what I had preconceived notions of what I thought critical care was until I actually got there. So I would suggest there's no harm in asking to shadow, to go and watch a critical care team, or go to an ICU and ask the nurses that work in that unit. But one of the rewards of working with critically ill patients is each specialty has their reward. But I think with critical care is that intense level of expertise that you need. But it's not individual that you have sometimes on a shift 10, 15 experts that are all coming together and collaborating to take care of this patient that you can see in some instances go from very critically ill to within three to five days, "Oh my gosh, they're walking down the hall."

Megan:
Or perhaps it's a patient that is more longterm and has been with you for 90 days and you're still so rewarded by, "Oh my gosh, everybody took care of this person and they are walking down the hall." And I think, to me, I love critical care because of that lifelong learner that you have to be. I think every part of nursing, you have to be that lifelong learner. But in the sense of COVID, we're all in this together. We didn't know anything, but the nurses were willing to say, "Hey, you know what? I have these resources. I'm willing to do it. I have zero hesitation. Let's figure it out together."

Dan:
That's great advice. And I ask because I'm an ER and trauma nurse and I had a playful banter with my ICU colleagues.

Megan:
I'm sure. I'm sure.

Dan:
That's a fun little rivalry that exists within the profession, and so I would say, those are all the type-As up there.

Megan:
Right.

Dan:
And at the same time said, setting them up like some of the sickest patients on the planet and in minutes having those patients ready and stable and tucked in and everything lined up.

Megan:
All in clean sheets.

Dan:
And clean sheets. I set my patients up with a glass from the car accident like, "I don't have time for this. I'm busy. ICU will just figure it out." And I have so much respect for that.

Megan:
Yeah.

Dan:
No, that's great. And, yeah, we need more, like I said, ICU nurses, nurses in general. I think it's such a wonderful profession and we're in the limelight right now and it's so great to see how our profession is stepping up to care for the world right now. And I'm just so excited and happy to be part of that profession.

Megan:
Our association this year's theme is, "All in. This is our moment. All in," and it really is what I'm hearing from the nurses. They're all in. No, it's not going to be easy and they know it's in collaboration with their communities to social distance and mask, but they're all in to be those different makers when those patients come into the hospital. They're passionate about it.

Dan:
Yeah. It's all in, and we ran a campaign recently called "Step up, not back." And yeah, the ability for nurses to put their safety to the side and step up is just amazing. And now we need to take care of each other because it's one thing to do it in a short term crisis, but now the pandemic's in week, whatever 18 or whatever we're in, and it's not sustainable to be a hero for 18 weeks. And so we need to take care of ourselves using the wellness, sleeping, looking out for each other, and just rallying around the cohort of nurses that we are.

Megan:
Right. I think the saying goes, "It's a marathon, not a sprint." I feel like this is quite a long marathon.

Dan:
Yeah, this is an ultra.

Megan:
Exactly.

Dan:
Well, Megan, one of the things I like to do here is hand off information to the audience. I would love to hear what you have to hand off to our listeners.

Megan:
Sure. Well, first off, I just want to say thank you personally to all the listeners for making me a better nurse. I mean, nurses inspire nurses. I am always in awe at nurses' strengths, the innovation, and the compassion that I every day, every minute. But I'll keep it simple for you, Dan. Really, I just am courage nurses and nurse leaders to share their story, share the story of them personally of being a nurse or share the story of your team that you work with. Share your story of failure and success, hardship and joy, and those wins and those losses. And by doing that, you grow the profession by letting people know what you do. Not just how you care for patients and what those stories are, but really that clinical expertise that's needed, that expert knowledge that's needed, at the bedside. So there you go, Dan, just share your story.

Dan:
I love it, yeah, and nurses love that, I think. So we need to share more of our stories and that's great advice. Megan, where can we find you? If listeners want to get ahold of you, learn more about what you're up to, what's the best place to do that?

Megan:
Me, personally, I am on Twitter and Instagram. My handle, if you will, funny story behind that, is called Nurse Noodles. My dad called me that all through nursing school so it just stuck many years ago. So I've kept with it. So Nurse Noodles on Instagram or on Twitter. And then of course the association, American Association of Critical-Care Nurses, also has a Facebook page, an Instagram, and also a Twitter, and invariably you'll see me on there as well.

Dan:
Love it. Thanks so much for being on the show. Love the insights and I'm hoping that we have some takeaways for leaders and frontline nurses to take better care of themselves and continue the fight to keep our population safe.

Megan:
Thank you, Dan. You too.

Thank you and welcome to the Trusted Community!
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