The new Nightingales

by Matthew Cyr

Jenifer Sant      Elizabeth King      Ellen O'Donnell      Connie Dinning      Josh Bourgeois      Martha Curley      Mimi Bernardin

Jenifer Sant, RN, BSN

16 years as a nurse; the last 13 on Children’s Neurosurgical unit

What kind of patients do you take care of?
Children with epilepsy make up the biggest part of the program, but we deal with seizures of all types. We also care for kids with hydrocephalus, which is accumulation of cerebrospinal fluid in the brain, and children with brain tumors, back injuries, closed head injuries and other neurological disorders.

Do adults and children recover differently from brain injury?
Definitely. An adult with a closed head injury, stroke, aneurysm or traumatic brain injury is often left neurologically devastated. But since the brain isn’t fully developed in children for many years, their brains can reprogram themselves. We’ve seen children with the same diagnoses as adults come in after extensive rehab walking and talking. We do a surgery here for kids with severe seizures called a hemispherectomy where up to half of the brain may be removed, and it’s amazing to watch them recover. Unless you’re a neurologist or a neuroscience nurse you may not know that they had such major surgery.

What have you learned about nursing that you can’t learn in school?
To highly value and act on what parents say. There have been several times when a child just doesn’t look right when I walk into the room and I can’t put my finger on what’s wrong, so I’ll ask the mother “aside from fact that your child is in hospital, are you really worried about him right now?” If she says yes, then I get worried.

Do you worry about getting too emotionally involved with patients?
You need to get involved with your patients, but you have to cut yourself off a little bit when your emotions get involved. If you’re upset it doesn’t do anyone any good. You need to be an advocate for that child and present yourself as a professional to the rest of the care team. If they sense you’re getting too emotional they may not listen to you as they should.

As a clinical coordinator, what do you miss about bedside nursing?
Just walking into the room and saying, “I’m going to be your nurse today.” I try to pick up extra shifts here and there when I can be at the bedside, because that’s what I do best and I would really miss it if I wasn’t able to do it.

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Elizabeth King, RN, BS

Staff Nurse III on 8 East, a general medical floor

What do you do on a daily basis?
I function in a variety of roles, including taking care of patients and families, teaching and training new nurses, and being the charge nurse.
I also work on special projects to assess and improve the overall system, and serve as a mentor and resource to new staff on the unit. My job is different from when I was a Staff Nurse I because of my clinical expertise and accountability. I try to improve the unit and bring new nurses to their own level of expertise.

Have you enjoyed your evolution into a mentorship role?
It’s been a gradual process. Over the years as I’ve developed as a nurse, I grew slowly from doing strictly patient care, to improving the unit and eventually to system-wide changes. As my clinical expertise grew, I was able to seek out and embrace new challenges and responsibilities both on the unit and in the nursing profession.

What’s the hardest thing for a new nurse to learn?
The organizational component of the job. As a nurse, you need to be able to juggle competing demands. There might be a crying baby in one room, a child needing pain medication in another, and a third who needs to go to a test, and you have to decide in 30 seconds which is the priority. Over time the clinical expertise will come, but if you haven’t learned to organize your day, it can be really difficult to function adequately.

How is nursing different than you thought it would be?
When I started 13 years ago, I thought of it as just a job. Now it’s more than that. It’s part of my life. I’m really glad to be in a profession where I make a difference every day. Life is too short not to feel like you’ve made a mark in this world.

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Ellen O'Donnell, MSN, PNP

Has been a nurse for 32 years; got her Pediatric Nurse Practitioner degree in 1996

What's the difference between a nurse and a nurse practitioner?
I was a nurse for over 24 years, then decided to get a Master's Degree in Nursing and become a pediatric nurse practitioner. That has helped me expand my nursing skills to the point where I look at the entire continuum of care, both outpatient and inpatient. I do things nurses do like health histories, physical examinations, diagnosis, and disease management, but I also order lab tests, prescribe medications, and counsel and educate patients and families on long-term care.

What do you do in the General Surgery clinic?
I work with the surgeons to evaluate patients before surgery, educate and teach, and answer questions about things like long-term management of complex surgical problems. I also help create educational materials for patients and families, perform research projects and publish articles.

What do you like about working with children?
Children are so honest and open and tell it like it is. They are so much fun. People ask how I can work with sick kids, but I tell them that children are the most courageous people I know. They give anyone they come in contact with an inner strength, a "special" something of themselves. It's hard to describe, but being able to connect with them in some small way is really important to me.

What's the best part of your job?
I love meeting new patients and families, staying connected to the long-term patients and families and making a difference. Sometimes you don't even know you're making a difference until they come back and tell you how something you said or did helped them understand or get through their procedure, test, or intervention. It's great to know that I have somehow touched these families, but they have touched me a whole lot more than they know. There are a lot of special patients and families who take a little piece of your heart with them, but then you know there is someone else coming who will fill that space.

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Connie Dinning, RN, BSN, BA

Chemotherapy Order Entry system administrator; was a direct-care nurse for 20 years

What is COE?
It’s the Pediatric Chemotherapy Order Entry system, which is a computer system for doctors to prescribe chemotherapy more safely for oncology patients, and for nurses and pharmacists to review and work with those orders. It was developed jointly by Children’s and the Dana-Farber Cancer Institute.

How does it work?
The system identifies the patient’s treatment plan, and includes a drug dictionary, order prescribing and template building capabilities. The treatment plans are used for many types of cancer and chemo regimens, and for pediatric patients of all ages. Patients on the same treatment plan who are due to get the same chemo regimen will have a standardized set of orders, which vary only by dosing for patient size or age, or unique patient needs.

How does COE make chemo delivery safer?
It requires the necessary components of an order, does the math and standardizes orders. There’s no ambiguity because treatment plans are reviewed intensively by nursing, pharmacy and medicine prior to being given to patients. The result is that orders can’t get through without being complete and well thought out. COE allows us to track the fact that there are fewer changes to chemotherapy orders, which often translates into saving potential errors in patient care.

What do you do as the COE administrator?
I create templates for COE, test the system and troubleshoot clinical and computer problems related to chemo orders. I also train new COE users, and help determine the best content for the templates and COE. I didn’t have a technical background when I took the job six years ago, but I’ve learned a tremendous amount about computers and how systems work.

What has surprised you about nursing?
I got into it because I wanted to work with patients and families, but I’ve been surprised that there are a variety of opportunities for growth and a lot of satisfaction in other roles. When this job came around, they needed someone with clinical expertise and it sounded like the type of work that might be interesting. I just started a master’s degree program and can see how it’s helpful to have a broader knowledge of systems and management. Working with COE has made me much more interested in the broader level of clinical care. It’s really created a nice career path.

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Josh Bourgeois, RN, BSN

5 years as a nurse in the Cardiac Intensive Care Unit

The CICU is a very intense place. What drew you to it?
I love the acuity of it. A lot of the babies have heart defects of varying severity, from holes in the heart to hypoplastic left heart syndrome, which is a congenital syndrome involving several abnormalities of the heart and blood vessels. We’re the only pediatric heart center in New England that deals with HLHS, and the only pediatric heart transplant center in the northeast. We do over a thousand open heart surgery cases a year on patients from around the country and the world.

Is it hard to take care of such sick children?
It’s important to remember that underneath all of the technology there is someone’s child that you’re caring for and that makes it easier to deal with. It’s such an exact science here that it usually goes the way you expect. On the other hand there are kids who are very complex and I deal with them and their parents longer. It gets a little harder the more time I’ve spent with the family, but we have the lowest mortality rate in the country, so the vast majority do well.

How is your experience taking care of these patients different than that of a doctor?
I usually have only one or two patients at a time so I’m with the child constantly. I see nuances that could lead to complications. There are 22 other patients on this unit who are just as sick as the one I have so I have to tell the doctors what’s going on. The physicians rely on the nurses and our experience to assist them in the care of these patients.

What challenges do you face in your job?
One thing people always ask me about is death and dying. We deal with that, but not on a daily basis. When it happens, our job goes from taking care of the baby to taking care of the family. You really have to take your cues from the parents about what they need. And that’s not just with the death of a child. People deal with illness differently so we have to adjust our style to help them see past all this equipment. A big part of helping them is non-verbal actions to make them realize everything is going okay.

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Martha Curley, RN PhD, FAAN

A nurse researcher on in the Medical/Surgical ICU

How did you end up as a nurse researcher?
When I was a staff nurse and a clinical nurse specialist, I was constantly challenged with what was the best way to provide nursing care. I felt it was important to get a PhD in nursing research in order to systematically answer those questions.

But if someone told me when I started nursing 30 years ago that I would have my PhD and would be a nursing scientist at Children’s, I would have said you’re totally out of your mind because that wasn’t in the cards for me at all. The only reason I went into nursing was because my father told me I couldn’t marry my husband unless I made something of myself, and I could finish a nursing program in three years rather than go to a university for four. We got married a week after I graduated from nursing school and we’re still together 30 years later. All I wanted to do was get married, but my father wanted me to be self-sufficient. It was good advice.

How do you go from helping individual patients to asking questions that affect all patients?
Once you become proficient in bedside patient care you realize that there are parents around and they need as much help from nursing as the patients. They come to the intensive care unit and it’s a strange environment and a strange experience to see their child critically ill. The nurse is the singular person with those parents eight or 12 hours a day who can help them understand what they’re feeling and show them how best to help their child. As nurses we help them succeed as “good” parents in that situation.

We may not be able to influence the outcome of every child who comes here, but we can influence how a family experiences their child’s illness.

Early on, I developed the Nursing Mutual Care Participation Model of Care, and one of my initial studies was how nurses work with families on how to parent a critically ill child. We found that the care model significantly reduced parent stress in regard to the intensive care environment. And once we started showing that nursing intervention makes a huge difference to parents, I got hooked on how to take care of patients better.

How does your research differ from that of physician researchers?
The science of nursing is separate from other disciplines. The American Nurse Association talks about nursing practice as caring relationships that facilitate healing, so we look at both the subjective and objective experience of illness. For example, we look at what it’s like to be the parent of a sick child, but also study how to position patients with acute respiratory failure so they heal the best. The best outcomes happen when you have the best medicine, surgery, radiology, nursing, physical therapy and social work.

What does your current research focus on?
Right now I’m doing a multi-site research study on the effect of prone positioning in patients with acute lung injury. Many patients come into the ICU in respiratory failure, and by tradition nurses have cared for them in the supine position, which is on their backs. We did a phase one trial and found that about 80 percent of children had an improved level of oxygenation when placed on their stomachs. We then asked whether that level of oxygenation improves the clinical outcome. Is it worth turning someone who is heavily instrumented on their stomachs for 20 hours a day? To find out I’m enrolling 180 patients in more than 12 sites around the country to determine whether the clinical outcomes are better when treating children in the prone position.

In this kind of work, one thing feeds into another. When patients are kept prone for 20 hours a day they are more likely to get pressure ulcers. So in order to learn how to best prevent those, I worked with my colleague Sandy Quigley to predict, manage and prevent them. On top of all that, in order to assure patient comfort we had to consistently evaluate and manage their sedation, so we developed the nurse-implemented sedation algorithm. You ask one question and it gets bigger.

Do you miss direct patient care?
There’s still a lot of the clinical nurse specialist in me, and for me being a researcher has everything to do with being a nurse. Most doctorally prepared nurses work in an academic setting and don’t have the clinical connection that I do. My office is here on the ICU and I wouldn’t give that up for anything. I can walk out of my office, touch a human life, then walk back in here and crunch the numbers.

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Mimi Bernardin, RN, BSN

What do you do in the ED?
Depending on the day, I may be the charge nurse, the triage nurse, or a staff nurse. As the triage nurse, I’m the first person to see patients when they come into the ED. I perform a physical assessment, which includes taking vital signs, determining level of acuity for each patient and prioritizing care accordingly. On an average day we see about 200 kids, and treat everything from traumas and psychiatric issues to gastrointestinal and respiratory problems.

Have you always worked in the ED?
No, when I started at Children’s about six years ago I worked on 9 East and 10 East, which are general pediatric units.

What’s different about working in the ED?
Although I take care of patients with a broader range of illnesses in the ED, the time spent with each patient and family is much shorter. An ED nurse has to have quick assessment and clinical decision making skills. Sometimes within minutes of meeting a patient, an IV has to be placed and medications administered. Prioritizing care quickly and effectively is essential.

What do you like most about your job?
I really enjoy the patient and family interaction I get as a staff nurse. Despite the fast pace, I can develop a relationship with patients and help them through their ED visit. We all want to make a difference, and in the ED you only have a short time to do it. So I try to recognize the unique needs of each patient and make the ED visit as smooth as possible.

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