texas nursing student

APRIL 2007

Texas Nursing Student

Do You Suffer FromNCLEX Anxiety?On page 6, Methodist Health System’s Tony Paterniti discusseshow hypnosis may hold the key to a less stressful test experience.

Student SnapshotOn page 8, Baylor nursing student Tammy Trabosh (left) foundthe field she loves while being precepted by DISD elementaryschool nurse Regina Miller.

The Top 5 Questions That Students HaveOn page 10, student advisors Mindy Hutchison and Avis Musaanswer five questions most commonly asked by nursing students.

Is Critical Care Nursing For You?On page 12, nurses from all over Texas discuss how to make atransition from graduate nurse to critical care nurse. University ofTexas graduate Victoria Keen (left) went from intern to PICUnurse in just 16 weeks at Medical City Children’s Hospital.

The Road Less TraveledOn page 18, Paula Faulk Maness reports why many nurses haveleft the city to work in rural areas. Included are first personaccounts from rural nurses. Be sure to read Ed Price’s narrativeon the joys of living and working in Nacogdoches on page 21.

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publisher & editor

Thomas Knight

associate editor

Kelly Rogers Ellenich

coNTRIBUTING EDITOR

Mindy Hutchison

copy editor

Sheila Messman

executive producer

Jason Stoner

traffic

Janet Foulks

website

Rebecca Windham

media representative

Laura Griffin

COPYRIGHT © 2007 by Texas Nursing Student.All rights reserved. Reprinting in whole or partis expressly forbidden without the written permission of the publisher.

Texas Nursing Student is published monthly,except during June and August. Texas NursingStudent is distributed free of charge to studentsenrolled in ADN or BSN programs at 77 schoolsof nursing in Texas. Magazines may be mailedto the address of any student registered at a Texas certified school of nursing for $3.75 peryear. Cover price is $4.95 per issue. TexasNursing Student is printed in Fort Worth, Texas.

For advertising information, contact LauraGriffin, Media Representative at 972-481-8851.

For subscription information, visit the TexasNursing Student website located on the web at:http://texasnursingstudent.com.

To contact Texas Nursing Student write to:

Texas Nursing Student8918 Governors RowDallas, TX 75247

phone: 214-951-8100, ext. 17.Fax: 214-951-8131.

Email: [email protected]

Visit us on the web at www.texasnursingstudent.com

Tony Paterniti, PhD, CCHt, RN Director, Department of Education Methodist Health System

Tony Paterniti is a renowned nursing professionalin the Dallas - Fort Worth area. After a longcareer in clinical nursing, nursing management,and nursing education, Tony has spent the lastfew years helping graduate nurses intern at

Methodist Health System. He has helped many interns pass theirNCLEX. If you are looking for a different kind of approach to handlingthe stress of NCLEX, read up on Dr. Paterniti’s ideas of help throughhypnosis. Tony used a hypnotist to help him finish his doctoral thesisin 1992, and has since discovered that many graduate nurses – who are good students, but do not do well on NCLEX – experience goodoutcomes after hypnosis. His column begins on page six.

Paula Faulk Maness, MSN, RNNursing Faculty Tarleton State University

Paula Maness is passionate about rural nursing.She is an active member of the Texas RuralHealth Association, and teaches a course on theDimensions of Rural Health Care at TarletonState University (Stephenville, Texas). She

received her ADN from Odessa College in 1970; her BSN from MaryHardin Baylor University in 1975; and her MSN from Abilene ChristianUniversity AISN in 1995. Paula has been a nursing faculty membersince 1991, and is the Learning Resource Coordinator for the Depart-ment of Nursing at Tarleton State. Paula lists her loves as patients,Med-Surg nursing, Gerontology, rural nursing practice, and nursing students. Read her article beginning on page 18.

contributors


As a new nurse, you will be on your feet much more than you were as a student. Keep an eye out for one of many problems like hammer toe.

Hammer toe is a term commonly used to describe any type of toedeformity. With hammer toe, the deformity usually exists in one toe at the proximal inter phalangeal joint. The base of the toe points upward

and the end of the toe points down.The symptoms of a hammer toe are usually

first noticed when a corn or bunion develops on the top of the toe and becomes painful,most noticeably when wearing tightshoes. There may be a bursa under the

corn or instead of the corn, depending on thepressure. Most hammer toe symptoms are due topressure from footwear on the toe. There may also be a callus under the metatarsal head at thebase of the toe. Initially a hammer toe is flexible,but can become more rigid over time.

Some have a family history of hammer toe.Others simply have weaker muscles in their feet.

Preventing hammer toe can be difficult, as symptoms do not usually start until the problemis well established. However, there are severalthings that can prevent hammer toe:

• Wear appropriate footwear. Allow toes to function without excessivepressure. Shoes should be one-half inch longer than your longest toe.

• Treat any corns or calluses immediately.

• Use padding to get pressure off the toe.

• Use hammer toe crests and hammer toe splints.

• Get gel toe shields and gel toe caps.

If conservative treatments are not successful, surgery may be used to correcta hammer toe, usually as a day surgery procedure. TNS

STATE EDITORIAL ADVISORY BOARD

Betty Adams, PhD, RN, Dean, College of Nursing,PRAIRIE VIEW A&M UNIVERSITY

Virginia Brooke, PhD, RN, Nursing Faculty,THE UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON

Paulette Burns, PhD, RN, Dean,Harris College of Nursing & Health Sciences,TEXAS CHRISTIAN UNIVERSITY

Anita Coyle, PhD, RN, CHES, Assistant Professor,MIDWESTERN STATE UNIVERSITY

Eileen Deges Curl, PhD, RN, Chair, Department of Nursing,LAMAR UNIVERSITY AT BEAUMONT

Lori Ferguson, MSN, RN, Nursing Faculty,TARLETON STATE UNIVERSITY

Bunny Forgione, PhD, RN, CNS, Associate Dean,College of Nursing and Health Sciences,TEXAS A&M UNIVERSITY - CORPUS CHRISTI

Charlotte Green, MLA, BSN, RN, Associate Dean,Associate Degree Nursing,EL CENTRO COLLEGE

Jill Hayes, PhD, RNC, Assistant Dean for Students,THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER ATSAN ANTONIO

Judith Wright Lott, DSN, RN, NNP, FAAN, Dean,Louise Herrington School of Nursing,BAYLOR UNIVERSITY

Pamela Martin, PhD, RN, Associate Dean forUndergraduate Programs,THE UNIVERSITY OF TEXAS AT TYLER

Lori Millner, PhD, Director,DFW AREA HEALTH EDUCATION CENTER

Caryl E. Mobley, PhD, RN, CPNP, Associate Dean and Professor,TEXAS WOMAN’S UNIVERSITY

Donna C. Owen, PhD, RN, Chair of Undergraduate Nursing,TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTERSCHOOL OF NURSING

Elizabeth Poster, PhD, RN, Dean of Nursing,THE UNIVERSITY OF TEXAS AT ARLINGTON

Diane Rankin, MSN, MACE, RN, Clinical Faculty,THE UNIVERSITY OF TEXAS AT EL PASO

Helen Reyes, MSN, RN, Undergraduate Coordinator,College of Nursing and Health Sciences,WEST TEXAS A&M UNIVERSITY

Gayle Timmerman, PhD, RN, CNS,Assistant Dean for Undergraduate Programs,THE UNIVERSITY OF TEXAS AT AUSTIN

Glenda Walker, DSN, RN, Director of the School of Nursing,STEPHEN F. AUSTIN STATE UNIVERSITY

Sally Harper Williams, Workforce Center Director,DALLAS-FORT WORTH HOSPITAL COUNCIL

hammer toe

Hammer Toe Not To Be Taken Lightly

EXCITING OPPORTUNITY

Apply Now For Student Advisory Position With Texas Nursing Student.

Job Summary:This position is the key liaison betweenstudents at the attending school ofnursing and Texas Nursing Student.

Reports to:Editor or Associate Editor of Texas Nursing Student Magazine

Term:August 2007 - May 2008

Compensation:Pay for stories and photos, as well as a letter of recommendation for job carried out to satisfaction of editor.

Essential Functions:

1) Report on stories, take or obtainpictures at local school events and advise staff on publication.

2) Distribute magazine to studentsof nursing at attending school.

3) Orient successive student advisor.

Contact: Tom Knight, Editor of Texas Nursing Student, if interested.

[email protected] phone 214-951-8100, extension 17.

?NCLEX AnxietyAs the nurse intern liaison in a large urban medical center,I had been working with GN’s on a regular basis. Havingtaught in various nursing programs for more than 16 years, I was familiar with the trials and tribulations of taking andpassing NCLEX.

I was especially concerned when one of the nurseinterns told me he had never earned a grade less than a “B” during four years of college and that he had failed the NCLEX exam.

When I asked him to recount his experience, his recollection of the time immediately prior to andduring the exam indicated that he most likelysuffered from a serious case of test anxiety.He told me of his heart palpitationsbefore beginning the exam and hisshirt being covered in perspirationwhen he took a break.

He specifically remembered having greater and greaterdifficulty concentrating as the number of questions grew from75 to more than 150. He described feeling almost panicky,and wishing he could just get up and walk out. Of course, all this was relayed to me in hopes that I would be able toadvise him on how to better prepare for the next time.

I was aware that my customary advice wouldn’t work forthis nurse intern. It would do no good to tell him to practiceanswering questions everyday. This wasn’t about getting the

right answers as his solid B record indicated he most likelyknew the content. This was about getting into

the right frame of mind so he could accessthe information he already knew.

That evening, I rememberedhow ten years earlier I hadgreat difficulty completingthe dissertation for my PhD.

I was certainly knowledge-able about my topic, and I most

definitely had the technical skillto do the writing but I was lacking

in confidence. I remembered sitting at my desk

and beginning to piece the informa-tion together, and within a short

Do Sufferyou from

by Tony Pater niti, Phd, CCHt, RN, Dir ector, Depar tment of Education, Methodist Health System

Hypnosis may hold the key to a less stressful test experience


period of time the self doubt wouldbegin, followed by uncomfortable feel-ings and repeated thoughts of, “What’sthe use?”

My ability to concentrate wouldfade quickly and I would abort theattempt, which I am certain reinforcedmy doubt and lack of confidence.

I smiled as I recalled how I overcame all that resistance. I saw a hypnotist! My friend, who hadstopped smoking with the help of one,suggested I give it a try.

I remember not knowing a thingabout hypnosis, but being willing toattempt it.

I made an appointment and wentto the first session. I sat in a reclinerchair, closed my eyes and listened tothe hypnotist as he talked about relax-ing each part of my body. I visualizedwriting the dissertation, but beyondthat, I cannot recall the content of the first session nor the second, whichoccurred a week later.

Although we had agreed on threesessions, I never made it to the third.I was too busy writing my dissertation!

Four months after my hypnosissessions, the dissertation was at the typist being prepared and I had sched-uled my final defense which occurredone month later. Hypnosis had helpedme remove whatever barriers I had sothat I could write the dissertation.

Needless to say, I asked the nurseintern if he was willing to see a hypno-tist to help him deal with the feelings ofanxiety. He agreed to do so and afterthree visits with a hypnotist, he tookand passed the NCLEX exam.

Within a period of two weeks, twoother GN’s requested information about

hypnosis for test anxiety. I also referredthose GN’s to hypnotists and they bothpassed their second attempt.

Since our internships are large,between 75-150 nurse interns, and areoffered twice annually, the number ofnurse interns requesting hypnosis grewas well as the number requesting infor-mation about hypnosis. During thepast seven years, I have referred about40 nurse interns for hypnosis related totheir difficulty in passing the NCLEXexam. I am aware of 34 of them havingsuccessfully passed their second attemptat the exam after having between oneand three sessions with a hypnotist.

Two of the interns who I referredhad failed the exam twice before seeinga hypnotist and both passed on theirthird attempt. I had an opportunity to talk to about 75% of the 34 nurseinterns and they consistently describedthe re-taking of the NCLEX as being a much calmer experience for them ascompared to their first experience.

It’s important for me to emphasizehere that in no way did I conductresearch related to NCLEX, anxiety,and hypnosis and that I am not reportingthis information with any particularclaim about its cause and effect.

I simply reacted to a request forhelp by a nurse intern; remembered Ihad been helped by a hypnotist, andmade the referral. During the past year,we have begun sending nurse interns –who are at risk for failure because ofanxiety – instead of waiting for themto fail the NCLEX exam. The point to be made here is that you should beopen to non-traditional ways of solvingsome of the more traditional problems.If it works, then why not? TNS

<

REPEATED ATTEMPTS

Number of Candidates Taking NCLEX Examinationand Percent Passing, by Type

RN 2006 Totals

Type of Candidate # %

First Time, US Educated3,810 89.5

41,349 88.365,390 88.0

164 73.2

Total First Time, US Educated 110,713 88.1

Repeat, US Educated 22,474 54.2First Time,

Internationally Educated 25,908 61.2Repeat,

Internationally Educated 17,992 28.3

All Candidates 177,017 73.8

Statistics courtesy of the National Council of State Boards of Nursing (NCSBN) NCLEX® Examinations

DiplomaBaccalaureate Degree

Associate DegreeInvalid or Special Program

I asked the nurse internif he was willing to see a

hypnotist to help him deal with the feelings

of anxiety about NCLEX.He agreed, and afterthree sessions with a

hypnotist, he took andpassed NCLEX.

“

”– TonyPaterniti

Texas Nursing Student ❘ 7texasnursingstudent.com

Tammy Trabosh is learning all about the field she loves: School

nursing. Tammy will graduate in May from the Baylor University Louise

Herrington School of Nursing. Currently, she is being precepted by

Regina Miller, RN, BSN, at the Jerry Junkins Elementary School in far

north Dallas.

“I have discovered I want to be a school nurse,” Tammy says. “I love

kids and I’ve always known I wanted to work with them. School nursing

not only gives me an opportunity to do that, it also gives me the chance

to perform community nursing at its most core level.”

“As a school nurse, you begin with patients who are young and

you monitor their health needs as they grow cognitively and develop-

mentally along the way,” Tammy explains. “You don’t always get to

develop these types of relationships in a hospital setting.”

Tammy’s preceptor, Regina Miller, previously worked in the burn

unit and at the emergency room for Parkland Health & Hospital System.

She took a brief hiatus from nursing to raise her children. When she

contemplated a return to nursing as a school nurse her thinking was,

“How hard can it be? You put a band-aid on them and send them on

their way, right?”

“I should have known better,” Regina now says.

During the last few years, the Dallas Independent School District

(DISD) has become better equipped to educate students with major

medical problems. The DISD provides unique classrooms where sick

children receive an education, occupational therapy, and whatever

medications or special equipment they require.

“These kids deserve the same education as any other kid in the

public school system,” Regina explains, “So my clinical skills are just

as important as ever.”

Assessment is another big part of school nursing. “It’s the hardest

part of my job,” Tammy says. “You start from scratch and figure out

what’s causing the illness. I’m not just fixing them up, I’m looking at

their psycho-social care and the whole environment surrounding them.

That’s not an aspect you normally get time for in a hospital.”

Tammy is so excited about becoming a school nurse she has already

applied for a position with the Dallas Independent School District. Regina

hopes that Tammy and others like her will pursue their dream of becoming

a school nurse if it’s what suits them.

“I get my rewards when I see the

results,” Regina says. “When the kids get

the help they need and the parents show

a sincere appreciation, it makes it all

worthwhile. It’s nice to get hugs.” TNS


Regina Miller, School Nurse, Junkins Elementary School


5[ ]TOPthe

that students haveQuestionsBy Mindy Hutchison and Avis Musa

We questioned University of Texas at Arlington School of Nursing faculty and staff to discover what questions nursing studentsask their professors and advisors the most. After a thorough investigation, we bring you some answers to the top five questions.

I want to specialize in a certain area of nursing. Can I major in pediatrics as an undergraduate?

I want to become a nurse practitioner. Can I go straight into the master’s program after my BSN?

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Colleges offer general nursing programs that give a broad overview of patientcare for all ages. Once you graduate, you can apply to work in a specificarea in a hospital setting. Typically, master’s programs offer more special-ization in areas of nursing such as pediatrics or adults. But how do you getrelated experience as an undergraduate? To specialize in a certain area, students may apply for nursing internships or find summer jobs as nurse techs in hospitals.

Each school offers a curriculum that covers basic courses to prepare students’ skills to form arguments, understand human cultures, and solveproblems in mathematics and science. While there is a set of required

coursework, usually each program is flexible enough to provide options.For students who want to specialize, there are specific nursing electives

or other courses on their campuses to start them on the right track. If youwant to be a pediatric nurse, you can choose psychology or anthropologycourses on child growth and development. If you want to serve a certaindemographic population like Latin immigrants, you might want to brush upon your language skills. You may even find language courses from continuingeducation or community groups. Don’t forget the power of Google… OK, thecampus library, then. Start researching nursing journals now to build thatfoundation in your desired area.

Advanced practice in nursing requires experience and a working knowledgeof the needs of patients. This knowledge builds from clinical care of patientsin real-life settings – something you can’t find in a book!

Many nursing programs recommend or require one to two years of

clinical experience working as a registered nurse in specific settings toproperly prepare for master’s level courses. Since nursing is practical andtheoretical, it’s important to have patient care and multidisciplinary teamexperiences to draw upon when researching best practices.


Okay Aris and Mindy, those answers were all well and good, but you still didn’t answer my particularquestion! Will you answer it for me?

I need help paying for college. Where can I get money?3

My spouse or significant other had a job relocation and I am moving to your area. Can I transfer to your nursing program?4

How do I get an “A” in this class? Can you tell me what’s on the test, or what to study for?5

?

With the cost of tuition, fees, books, and living expenses rising, manystudents have a difficult time budgeting for college, even when theyhave supportive family members. The FAFSA (Federal Application forStudent Aid) is your first step to determining if you’re eligible forgrants, scholarships, or loans from the government and your institu-tion. Most universities also offer general scholarships based onfinancial need or academic merit. Many students may work part-timeor as work studies if they can properly balance study time and worktime. If you need more help, or have a special circumstance, contact

your school’s financial aid counselor.Once you’re in an upper division nursing program, usually depart-

mental scholarships from the nursing program and private donors areavailable to reward high achievement or help with financial need.Alumni associations, campus departments, and other charitable organi-zations often provide scholarships for community service or involvementon campus. You never have to pay an application fee for a scholarship.In this case you don’t have to spend money to get free money. Also,many, many employers have tuition reimbursement programs.

Sometimes nursing students may have a family situation that causesthem to move across the county, state, or country with half of theirnursing credits in tow. With a shortage of nurses, usually there are notmany spaces open to transfer, but students may be deployed or delaycompletion of their program, opening up a spot in school. Check witheach nursing school to see its transfer policy, application deadline, and

material requirements. Most schools require a letter of good standingfrom your previous school with no ‘’D’s or “F’s” in nursing courses.Unfortunately, the chance of failing one bachelor’s degree program andtransferring to another is slim. You may also need to provide academictranscripts and sometimes course descriptions or even course syllabi tosee if you took the same course in your previous school.

Sometimes nursing school is overwhelming and students wish for away to that easy “A.” In freshman level compulsory courses, instruc-tors may have provided detailed study guides or course outlines to help students acclimate to college level discourse. Nursing school is a different story – it was competitive to get in, and it doesn’t get anyeasier! You may be very smart, but a grade is a measure of class per-formance, not intelligence, knowledge, or common sense.

Participate in class regularly, pay attention, take notes, and askquestions. Read and study your textbooks and prioritize what you thinkis important – don’t just ask for the page numbers where the examanswers are! Professors will ask you to apply your new knowledge to

scenarios, and use critical and analytical thinking skills to answerimportant questions.

A nursing professor is your resource to the field of nursing – and he or she can help guide you in your preparation. But the professorwon’t be standing over your shoulder with the answer when a real lifepatient has a difficult problem or a big decision has to be made.

If you’re having difficulty with a particular concept, meet withyour professor after doing some reading, studying, and research on yourown. Skimming your notes from class will not suffice. Be prepared tomanage your time well and work hard to get your “A.”

If you attend UT Arlington, you may e-mail us at: [email protected]. If you attend another school, it might be best to contact your academic

advisor, or, you can always email: [email protected] for advice from an unbiased source. TNS


Critical Care used to

be reserved for experienced

nurses, but innovative new

programs have opened the

field to graduate nurses

fresh out of school.

by Patricia B. Smith

not too long ago when a graduatenurse interested in the specialty ofcritical care would hear some varia-tion of this advice: “Do at least twoyears of Med/Surg, get your basicskills down, your confidence up, then come talk to us.”

Those days are gone, thanks toinnovative internship and preceptorprograms that pair eager young gradswith seasoned nurses in one-on-onerelationships to help guide themsafely into the exciting world of critical care.

“It all came about because there’sa nursing shortage, particularly in thePICU and NICU environment,” saysLaura Massey, RN, nurse manager of the PICU unit at Medical City

Children’sHospital inDallas. “We had to dosomethingbecausenursingschools werenot puttingout ICUnurses.”

That “something” turned out to be a whole new way of puttingtogether the training for critical carenurses. Hospitals all over Texas havelaunched Internship and Preceptorprograms designed to give younggraduate nurses the high-tech train-ing and friendly support they need tobecome great critical care specialists.

Training includes classroom timeas well as hands-on work at the bedsideon all the advanced new equipment

that is now used to monitor and resuscitate critical patients. Additionaltraining is given in the medicationsused for day-to-day care and CODEsituations. It’s a lot to learn, butmost critical care nurses are happy to take it all in.

“It’s an extremely exciting fieldof nursing,” says Linda Stephens, RN,the ChiefNursingOfficer at WestHoustonMedicalCenter. “Inaddition tothe nursingpiece of it,it’s dealingwith all the new skills and technol-ogy; it’s the collegiality you havewith your co-workers. You’re so dependent on each other, and thedoctors are dependent on you to makeacute observations and convey infor-mation on to them so they can maketheir decisions. Everybody has eachother’s back and you’re never alone.”

Melissa McCarty, a young criticalcare nurse at West Houston Medical

Center, saysshe actuallylooks for-ward tocoming towork eachday. “Youare the linkbetween

Linda Stephens, RN, CNOWest Houston Medical Center

Melissa McCarty, RNWest Houston Medical Center

Laura Massey, RNMedical City Children’s


Nursing Shortage More Pronounced in Critical Care

The growing nursing shortage is especially

acute in specialty nursing. The overall nursing

shortage in Texas exceeds 10%, according to

Dr. Janet Allan, former Dean of the School of

Nursing, UTHSC San Antonio. The number of

requests for temporary and traveling critical

care nurses to fill staffing gaps has skyrock-

eted in every part of the U.S., and these

requests were most noticeably in adult critical

care units, pediatric and neonatal ICUs, and

emergency departments. Hospitals are com-

pelled to offer critical care nurses attractive

incentives, including sign-on bonuses, reloca-

tion bonuses, reimbursement for continuing

education and certification, and other invit-

ing benefits. In addition, many hospitals use

critical care orientation and internship pro-

grams to prepare newly- licensed nurses to

work in critical care.

Number of Critical Care Nurses in the United States

According to the Department of Health and

Human Services, there are 403,527 nurses in

the U.S. who care for critically ill patients in

a hospital setting. Of these, 201,833 spend at

least half their time working in an intensive

care unit; 70,241 spend at least half their time

in a step-down or transitional care unit; 94,912

spend at least half their time in an emergency

department; and 36,541 spend at least half

their time in post-operative recovery. Critical

care nurses account for an estimated 31% of

the total number of nurses working in the

hospital setting.

There was a time…

(continued next page)

CRITICAL CARE NURSE>>


what’s going on with the patient and the family. They come in and see all the tubes and wires and it’s overwhelming. We get to interact with them,settle their fears, and answer their questions. You form an emotionalattachment with them.”

Mary Womack, RN, the Critical Care Manager at the Medical Centerof McKinney, says it’s important that hospitals keep training good criticalcare nurses. “They’re building new hospitals and ICUs every day, and everytime they open a unit they’ve got some new technology we all have tolearn. So there’s an ongoing need for the type of training you don’t get inschools. Internships are designed to provide that.”

By definition, critical care nurses take care of the most seriously ill orinjured patients. That means their patient load is smaller, usually onepatient to one nurse as opposed to five to seven patients per nurse on aMed/Surg, or other unit.

“It’s intense. You really have to think on your feet,” says ShawnaDarland, an RN who works at the Medical Center of Lewisville.

Darland hasn’t been out of nursing school for a year, but she alreadyknows critical care is where she wants to stay. “I liked always having some-body work with me during my preceptorship,” she says, “watching me growand making me think for myself. It built my confidence very quickly.”

Shandra Hogan-Robinson, an RN who worksat Spring Branch Medical Center, says she cameto critical care nursing by a somewhat differentroute. “I was a respiratory therapist before, so I was already very comfortable with ventilators.When I was in school doing my rotations, I found I was most comfortable in critical care units. I like being able to get a patient functioningat a stable level and then sending them on to aMed/Surg floor or even home.”

Mary Casarez, an RN at SouthwestGeneral Hospital in San Antonio, really likes how critical care nursing gives her theopportunity to work closely with doctors onpatient care. “We are their eyes and ears,” she says. “The whole critical care team knowswhat’s going on with all the patients, so we can take advantage of everybody’s skills to provide the best patient care possible.”

Jennifer Acosta, RN, who also works atSouthwest General Hospital, also likes the close contact with the medicalstaff. “It makes you feel like you’re part of the team. The doctors trust youand your assessments of their patients, and it feels good to know they’retaking your word on the patient’s condition. When we

Mary Casarez, RNSouthwest General Hospital

Shandra Hogan-RobinsonSpring Branch Medical Center

(continued on page 16)

Critical care nurses practice in settings

where patients require complex assessment,

high-intensity therapies and interventions,

and continuous nursing vigilance. Critical

care nurses rely upon a specialized body of

knowledge, skills and experience to provide

care to patients and families, and create

environments that are healing, humane, and

caring. Foremost, the critical care nurse is a

patient advocate. The American Association

of Critical Care Nurses defines advocacy as

respecting and supporting the basic values,

rights, and beliefs of the critically ill patient.

In this role, critical care nurses:

Respect and support the right of the

patient or the patient’s designated

surrogate to autonomous informed

decision making.

Intervene when the best interest of the

patient is in question.

Help the patient obtain necessary care.

Respect the values, beliefs and rights

of the patient.

Provide education and support to help

the patient or the patient’s designated

surrogate make decisions.

Represent the patient in accordance

with the patient’s choices.

Support the decisions of the patient or

designated surrogate, or transfer care to

an equally qualified critical care nurse.

Intercede for patients who cannot

speak for themselves in situations that

require immediate action.

Monitor and safeguard the quality of

care the patient receives.

Act as a liaison between the patient,

the patient’s family and other health-

care professionals.

>

>>>>

>>

>

>>

What Critical Care Nurses Do>


When Laura Massey, RN, first becamean LVN, she had no idea she wouldone day end up as the manager of thePICU unit at Medical City Children’sHospital, in Dallas. “I continued myeducation and training – increasing my skill and knowledge level – whichallowed me to be a successful PICUnurse,” she says. Massey also benefitedfrom the supportive environment atMedical City Children’s.

Medical City Children’s offers two16-week internships in their PICU.The program has been in place formore than 10 years. “We realized thatthe traditional way of doing things,sending graduate nurses to Med/Surgfor two years, was not giving us whatwe needed,” Massey says. “Whennurses came onto critical care unitsfrom Med/Surg, they weren’t used to the fast pace and life and deathsituations, and it could be very overwhelming and intimidating for them.”

Massey says a lot of nurses leftcritical care to go back to Med/Surg or on to some other specialty.Hospitals all over the country werestruggling to fill their critical carejobs, so they basically decided to“grow their own” ICU nurses.

“We give them very intensivedidactic training and put them at thebedside with a trained preceptor. Thathas worked very well. We turn out a lotof very good nurses in this program.”

Massey says Victoria Keen, RN, isa perfect example of how the programworks. Keen wanted to go into PICU

because she loves kids, but the skillsshe learned during her internship atMedical City Children’s took her toheights she never dreamed she couldconquer. “I learned there’s a lot youdon’t learn in school,” Keen says. “Ilike the fast pace and the fact that you can take somebody from being critically ill to watching them fullyrecover. That’s very rewarding.”

Keen says she liked the internshipbecause her instructors knew whichskills she needed to work on. “Theymake sure you get the right experiencesin order to survive working in a PICU,”she says. “In school you learn aboutdisease processes. In the internship,you learn how to care for patients whohave the disease. You get very specificinstructions. Coming straight fromschool, they are able to mold you in

just the right way to make you a goodcritical care nurse.”

Keen says a lot of young nurses get nervous about coming into criticalcare. “They say, ‘Oh my goodness!The ventilators! The drugs!’ but theinternship really brings everythingtogether and teaches you how to handleany situation. And if you don’t havethe answers, someone more experiencedis always just a few steps away.”

Keen is a preceptor now, teachingyounger nurses how to handle thepressures of a PICU and interact withpatient’s families. “I love my job,” shedeclares. “When you’re a young nurseyou have a lot of zeal. I hope I cancontinue to do this. I hope at the endof the day when I get in my car and ask myself if I did the best I can, theanswer will always be yes.” TNS

Critical Care Internships at Medical City Children’s Hospital give new nurses like Victoria Keen (left),the opportunity to flourish in PICU, the department managed by Laura Massey, RN (right).

Critical Care InternshipsCritical Care Internships


tell a doctor he needs to get to the hospital, he knows he needs to get tothe hospital.”

“You’re the patient’s early warning system,” Shelly Collins says. Shelly isan RN working at Medical Center of McKinney. “You have to stay on yourtoes; you can’t get lazy. But when youreally get something right it feels good.”

Shelly encourages student nurses to work in the field while they’re still in school. She says she started as a unit secretary on the same floor whereshe now works in critical care. “You geta better idea of the reality of the job byworking in the field while you’re goingto school,” she says. “I knew I wasn’twasting my time in critical care becauseI already loved it from working there two years as a secretary.”

One thing most all critical nurses agree on is you have to like a fastpace and have nerves of steel to work in critical care. Not many nurseshave that when they go in, but the intensive training provided in internand preceptorship opportunities helps young nursesdevelop the calm and focus they need to be effective in life or death situations.

“I definitely recommend internships,” saysStephanie Chen, an RN working at Medical Center of McKinney. “They provide good preparation for the real world of nursing.” Just make sure you findthe right program for you.

Sharon Dixon, RN, BSN, says an internshipmade all the difference for her. “The program I didwas very structured,” she says. “I worked one-on-onewith a preceptor and over three months, I went progressively from the leastcritical patients to the most critical. I also got the chance to work in Traumaand the surgical ICU during my training, and that helped me, too.”

So is critical care nursing for you? Take our quick quiz on the next page and find out if it’s something you might be ready for.

“Critical care nursing is reallystressful and it takes a lot out of you,”Mary Womack concludes. “But you get to make a difference. You get tosave lives. Most nurses don’t ever leave critical care because it gets inyour blood.” TNS

Shelly Collins (center) with daughters,Hailey (left), and Carley (right) works

at Medical Center of McKinney.

Sharon Dixon, RNMemorial Hermann The Woodlands

Although certification is not mandatory for

practice in critical care, many nurses choose

to become certified. Certification examina-

tions test critical care knowledge primarily

at the application/analysis level, which

indicates strong critical thinking abilities.

A required number of clinical hours in the

specialty are also an examination prerequi-

site. Certified nurses validate their

continuing knowledge of current practices

in critical care nursing through a renewal

process every three years, which includes

meeting extensive continuing education and

clinical experience requirements. Certified

critical care nurses (CCRN) must have been

in critical care practice for a minimum of two

years to be eligible for the examination.

An advanced practice certification for clinical

nurse specialists who care for patients who

are acutely or critically ill was introduced in

1999. Because of the availability of Medicare

and managed care reimbursement to clinical

nurse specialists, a growing number of

employers are requiring advanced practice

certification. Additionally, as state boards

of nursing attain statutory authority to issue

advanced practice nursing licenses, nurses are

often being required to pass a nationally

recognized certification examination. The

CCNS examination administered by the AACN

Certification Corporation is an example of

the type of certification that is required for

advanced practice licensure status.

Stephanie Chen, RNMedical Center of McKinney

Critical Care Certification>


Is Critical CareNursing for You?

Are you good at noticing subtle signs and symptoms and knowing when and what to report to a doctor?

Do you like a goodchallenge?

Can you handle stress?

If you had seven or more “Yes”

answers, then you probably

have the type of personality

that would be well-suited

for Critical Care Nursing.

Do you like the feel of an “adrenaline rush” during a code situation?

Do you welcome the challenge of educating patient families about their loved one’s illness?

Are you comfortable working around a critically ill patient who might die at any moment?

Do you enjoy an ever-changing atmosphere where every day is different and you never know what’s going to happen next?

Do you prefer a fast-paced work environment?

Do you enjoy learning aboutnew technology?

Would you like to work more closely with doctors and other nurses on patient care?

This easy quiz will help determinewhether or not you would enjoy

Critical Care Nursing. There are no“right” or “wrong” answers, so justmark the first answer that comes to

mind, then check your results.

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

Manyof those whoare new to nursing have set their sightson a future career in a big city hospital.Houston, Austin, San Antonio, El Paso,Lubbock, and the Dallas-Fort Wortharea all have attractive things to offerbesides huge facilities with the latest in technology.

But a select few – those whooften take the road less traveled –send resumes to hospitals in ruralareas, accept jobs there, and findsomething they weren’t quite prepared for: Quality of life.

Researchers have mademany attempts to classify ruralnursing by location, popula-tion density, or the distancerequired to travel or com-mute to an urban area.

However, rural nursingmay be best defined by thosewho actually do it. In thisstory they will answer the ques-tion, “Why is a nursing job inRural, Texas, so satisfying?

But first, let’s be pragmatic about comparisons. Rural areas payless than urban settings. However,the cost of living is significantlyhigher in urban areas.

Lifestyles may also differ radicallyfrom rural to urban settings, but beingable to leave your car unlocked, yourwindows open at night, and your chil-dren playing safely in the front yard arejust a few of the many advantages ruralliving has to offer.

Yes, there may be fewer shoppingmalls, the grocery may not be open 24hours a day, and the nearest sushi barmight require an overnight stay. Butnurses say there are bigger differences.

Patricia Hoffman, BSN, RN, hasan interesting take on rural nursing asshe saw it in Brownwood, Texas. Shefeels the training nurses receive in arural setting better prepares them for afuture at an urban hospital. “My rural

experience prepared me to use criticalthinking skills,” Patricia says. “To lookat the patient first – not the equipment– and be a patient advocate.

Sherry Clements, BS, RN, a nurs-ing administrator who went from a busyurban Houston hospital setting to arural health care facility in Eastland,Texas, says her strategy for recruitingnurses and encouraging them to main-tain a high standard of practice can beexpressed in one word: Resources.

The standards of care do not changefrom urban to rural settings, but theavailability of resources does. Fundingdifferences between urban and ruralareas often require rural nurses to be more innovative, self reliant, andcrafty in order to accomplish the samepatient outcomes.

“The challenge for me,” Sherrysays, “is to make sure my nurses knowhow important their contribution is

to the community at large. It islike the adage about a pebble

[being] thrown into the water.Rural areas are such [little]ponds that even a smallpebble creates tidal waves.”

Sherry says in the city youwouldn’t know your patientsoutside the hospital. “But ina rural setting, you worktogether, worship together,

shop together, laugh togetherand grieve together. One life

affects another.”DeVonna McNeill, MSN, RN,

has worked as the OB supervisor in arural hospital, as a faculty member atTarleton State University, and as an in-service educator at a large urbanhospital. “Having worked in both largeurban hospitals and the small ruralhospital in the town where I grew uptaught me to value some experiencesin a different way. There is a lot to besaid for knowing your patients as friendsand neighbors. Familiarity, and a senseof family and community, are some ofthe greatest differences between urbanand rural nursing. Caring for peopleyou knew in school, or their kids orparents, or the person who teachesyour kids lends a


There are 254 counties in the State of Texas. They areclassified as urban, urban/rural,

rural, or frontier. Although a majority of Texans live in urban areas, over one half the counties in Texas are considered rural.

According to the U.S. Bureau of the Census, 196 of the 254 counties are non-metropolitan.Approximately three million people or 16% of

the population live in rural areas.



To the extent that money is the answer, rural

areas have reflected the greatest proportional

increase in nursing salaries, but remain third

to suburban and urban nursing salaries.

Between 1996-97 and 2000, nursing salaries

in rural areas increased by 33% from $42,000

to $55,987; suburban nursing salaries increased

from $53,746 to $62,550; an increase of 16%;

and nursing salaries in urban areas increased

from $55,418 to $65,330, an increase of 18%.

Despite the larger percentage increase,

the average rural nursing salary in 2001

remained $9,343 lower than the average

urban nursing salary, and $6,563 lower

than the average suburban nursing salary.

Pulcini, Vampola, and Ward, 2001

different sort of character to nursingthat I did not feel in my big city hospital experiences.”

The consideration of a nursingpractice in a rural setting is somethingevery nurse must explore for them-selves. This exploration shouldinclude what motivates an individualabout nursing, their expectations ofco-workers and themselves, and theirgoals for the future – both personallyand financially.

The community surrounding any hospital will define a nurse’sexperiences. Therefore, the environ-ment where a nurse works will affecttheir outlook on life, and this is perhaps one of the most difficultthings for an ambitious young nurseto contemplate when considering acareer in rural Texas.

Although it is not for everyone, anurse who practices in a rural setting iscertain to gain something special fromit. The rewards are many, and further-more, the demand is high. TNS

o

FROM THE FIELDA city girl who married her rural sweetheart

had a strong motivation to explore the joys of

rural nursing at Eastland Memorial Hospital.

Tracy Emmons, RN, BSN explains it this way.

“It is rewarding when patients recognize you in

the community, or stop you in the hall and tell

you that they appreciate what you did for them

or their family. I will probably stay in rural nursing

until I retire. I’m not sure what is most appealing

to me about rural nursing, but I know this is where

I belong. It’s pretty ironic since I’m originally a

‘city-girl.’”

Shirley Wylie, RN, BSN, a public health nurse in

rural Stephens County who started her career in a

small rural hospital says, “I believe rural nursing

should have a certification of its own. A rural nurse

can truly say he or she is a jack-of-all-trades, and

a master of “some.” A few years ago, I left rural

nursing for bigger money in the Dallas-Fort Worth

metroplex. I lasted thirty days! In a rural facility, it

is like working in a family. You know everyone, their

strengths, their weaknesses and their entire family

history. It makes you learn to respect and trust each

other on a daily basis, because the resources are more difficult

to secure out here, but the personal rewards are worth the effort.

One novice nurse who entered nursing later

in life described her experiences at Palo Pinto

General Hospital in Mineral Wells. Valerie Cady

Hudgens , RN, BSN, says,“Many hugs occur

throughout the day in a small hospital. Lives

are shared, be it in joy or sorrow. As a new

nurse, just out of college, finding a gentle place

to land was important to me. Working with a

dying patient and his family, I also realized that I

have grown strong emotionally, and that I have

small pieces of myself that I can afford to give

away. I have an emotional cup that is filled as quickly

as it is being emptied. Rural nursing is the place for me.

Tracy Emmons

Shirley Wylie

Valerie Cady Hudgens


My name is Ed Price and I am the CNO at Nacogdoches Medical

Center, a rural community hospital. I am 52 years old and have I

been a nurse for 25 years.

My first RN job right out of nursing school was in a level II ER.

Two months into it I was the 3-11 charge. I worked in the ER for 2

years then decided to join the Air Force. My duties in the Air Force

included Staff Nurse-Multiservice Unit, Assistant Charge-Cardiac

Unit, Team Leader-ER, Director of Nursing-Armstrong Laboratory

Hyperbaric Unit, Education and Training Officer. In my military

career, I have been to Japan, Korea, Canada, Germany and England.

I retired just under 10 years ago and began my civilian career

as DON of a Dialysis unit, then as a Clinical Supervisor for a Level I

Trauma Center at LSU-HSC in Shreveport.

One day I got a call from a head hunter asking if I would move

to California. I first told him no. He kept calling until I finally said I

would interview. I went to Redding, California where I fell in love

with the area (plus they offered double the pay), and hired on as

Director of the Emergency Room. Then I was promoted to Assistant

Chief Nursing Officer, and later, Chief Nursing Officer. After that, I

was offered a position at the Tenet Corporation Headquarters in

Dallas as the Senior Director of Nursing Operations.

How did I get to Nacogdoches Medical Center?

I met and married my wife in California. She had never been to

Texas or my home state of Louisiana. True story, before marrying

me I had to promise her I would never move us to Texas or Louisiana.

But when I was offered a position at Corporate Headquarters in

Dallas, we agreed as a family to accept the position and move, but

only after she reminded me of my promise. We moved to Dallas

and lived just north of it, in Allen. Dallas is nice. It’s big and there’s

lots of “stuff” to do. We did a lot of “stuff,” the malls, the movies, the

theatres that serve a meal with the movie, wonderful restaurants,

that sort of thing. It is true there is a lot of “stuff” to do in Dallas.

However, there are other things about life in the big city beyond

“stuff.” When home, my wife and I would often sit on our balcony

and listen to the traffic. We would look up at night and not be

able to see the stars; no Orion Constellation, no Milky Way, just

the lights of the city. We missed the stars.

We met a lot of people in Dallas through our work, church,

and socially; they were nice, but it was like a crowded party. You

walk around and see a lot of people, but you don’t truly know

anyone. Casual interaction, they know nothing of you or your family.

When people talk of Dallas the conversation always centers

on all the things you can do. What they don’t mention is the

process involved in planning activities. If you want to go eat at

a restaurant, it depends upon traffic, is it North or South of you?

What time of day is it? You might end up spending more time in

traffic getting to the restaurant than actually dining. Most week-

days it was hard to be spontaneous, you had to stay close to home

or go later in the evening when the traffic is less intense.

Dallas is humbling – there were always lights in the night

skies, always the hum of the traffic, and the wailing of sirens. I

never could just be by myself.

My first time in Nacogdoches Medical Center was in October

2006. Part of my duties as the Senior Director is to “fill in” as CNO

until a permanent one is hired. When I would come home for the

weekends I would tell my wife just how nice this town was. What a

wonderful and friendly small town Nacogdoches

Peace for a Price



is; I could even see the stars in heaven at night. Each week, I would

bring back the newspaper or chamber of commerce brochures. The

hospital staff seemed to like me, and they asked what it would take

to recruit me to Nacogdoches. I told them about the promise I had

made to my wife; they had to recruit her to recruit me. The old

saying,“please the wife and the husband will follow” came true.

From the minute we arrived, our visit to Nacogdoches

seemed like we were visiting family, just like coming home.

Everyone was as friendly as in Dallas, but these people really

wanted to know about us. Why were we visiting? Why were we

in town? We would tell them we were thinking of moving here.

Everyone – and I mean everyone from the barber to the waitress –

would say how wonderful it is to live here. Each would end by

saying,“We would love for you to move here.” Eventually, it

was my wife’s idea to move. She told me she would live in

Nacogdoches with, or without me.

There isn’t all the “stuff” to do in Nacogdoches that there is

in Dallas. No large malls, no NBA team, but the first week in our

house, my wife and I watched the sun rise as we sat on our front

porch and listened to birds. We didn’t talk, we just held hands.

We knew we were home. Neighbors have dropped in just to say

hello, and yes, most of them brought food. We didn’t have any

experiences like that in Dallas.

At night we can see the stars; bright and crisp. Downtown,

when you drive around the square you hear the strings of guitars,

banjos and fiddles as local musicians play on the sidewalks. Try

the local Blueberry and Jalapeño Jam. It’s great on a hot biscuit!

Did you know Nacogdoches is the Blueberry capital of Texas?

My life is different now; my job in Dallas was 17 miles away.

On a good day it took 45 minutes to drive it one way. My worse

day was two hours during a traffic jam. Now I live three minutes

from work. My first day driving home, I called my wife and told her

traffic was really bad, it would take me an extra 15 seconds to get

home. I now spend more time with my kids, instead of driving the

car to and from work.

The choices in homes are different – and cheaper. While

looking for a house in Dallas, my wife searched and searched for a

home with one mature tree in the yard. That was her motivation,

to have a tree the kids could play under. In Nacogdoches we have

obtained a bigger house at a cheaper price. Our home here has

four acres, and too many trees to count. I do need a bigger

lawnmower, though.

I didn’t know just how different life would be here. Our first

weekend, we woke up to three cows in our front yard. My four

year-old kept talking about how we should have a pet cow, and

could she keep the one that had spots?

Is nursing here different than any other place else I’ve been?

Yes and no. The people – their quality and competency – are the

same as the “big city,” we just don’t have as many services as a

larger hospital. However, Nacogdoches Medical Center offers

the same menu of patient care: Cardiac, OB, GYN, and Pediatric

services with an 11-bed ICU.

Everyone knows everyone in and out of the hospital. My son

comes home from high school asking if I know this person or that

person. I tell him,“Yes, why?” He beams,“Because I go to school

with their son (or daughter).” When Nacogdoches High School’s

football team was traveling by bus to their first playoff appearance

in years, their route took them right by the hospital. To show

support, most of the staff (including me) was out by the street

waiting for the bus to drive by. Many were dressed in black and

gold, the colors of the Golden Dragons of Nacogdoches! Most had

made signs. All of us were shouting when the bus went by. It was

something as spontaneous as a hospital family involved in our

community. As others drove by, they were honking their horns or

yelling their support, too. I felt at home, this is the place I want to

share with my wife and raise my children in. Many graduates love

working at Nacogdoches Medical Center. But why?

Aside from the reasons I’ve talked about, Nacogdoches

Medical Center offers an 18-week residency program for new

graduates. We offer “looping” to other areas, which means if you

work Med/Surg, you will also orient in other areas that your patient

may come from, for example, the OR, ER, or Critical Care Unit. In

each area, a preceptor will be assigned to you who can teach you,

question you, and support you. We also provide a mentor for each

graduate in our residency program. This mentor is an experienced

nurse who will be your friend, someone you can talk to.

Our goal is to help you become successful, with the least

amount of stress. We want you to be part of our family, to know

the names of our kids, our pets, and our friends. Do you want to

know who your co-workers are? Do you want to look up at night

and see the stars?

We are looking for co-workers who won’t settle for second

best, who believe that competent, friendly patient care is the “right

thing” to do. We want nurses who like to laugh, who don’t mind

joking with the patients. Nothing is more gratifying than hearing

a patient laugh. If you are interested in our internship program,

give us a call. I promise, you’ll be glad you did. TNS

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