Providing Support for Overnight Teams

Oct 06, 2021

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There's more work than anyone can do in one shift, but it seems like it always gets done. It is done well when people rely on each other, ask each other questions, trust each other and help each other out.

James Myers

For James Myers, ACNPC-AG, 2020 was a year of transition as he graduated from nurse practitioner (NP) school, passed his exams, became certified and was hired as a nocturnist NP. However, an ideal transition does not include starting a new career in a pandemic.

Nonetheless, Myers had previous emergency medical services (EMS) and military training, which prepared him for the pandemic crisis response at his hospital in Round Rock, Texas. Over the past year, he’s also learned to use a mix of technology, education and perseverance to handle the waves of the COVID-19 surges.

What are you seeing in your hospital as the pandemic continues?

The patients that we have are very ill, especially the patients with COVID-19. I don't even know what's normal, because I started during the pandemic. There are a lot of rapid responses for hypoxia and a lot of codes for adults arresting from respiratory problems. It just seems it's overwhelming, but it's also what I trained for. I have a background in the ICU and EMS, and doing codes and dealing with airway and breathing problems is very familiar. So, on the one hand it's an overwhelming disaster, but on the other hand, there's a problem and we've been trained to solve it, and you can solve it. It's comforting and horrifying all at the same time.

What is the sense you get from the pandemic’s mental and emotional toll on nurses?

People are just overwhelmed and it's emotional, and you definitely see people crying or freezing up, or just having a completely flat affect. There are a lot of dysfunctional reactions to a bizarre situation.

I also see a lot of intellectual dysfunction. There is a lot of information coming in, and it's difficult to process it. You see people freezing up doing advanced cardiovascular life support (ACLS). That's not because they haven't done it before or that they haven't been trained. It’s that they've had to do it multiple times per shift. There’s a cognitive struggle and it’s from being overwhelmed. The other night NPs and myself came in to help out with that cognitive load and deal with some of the more complex things. It's basically like phone a friend. I see people being overwhelmed, but there's a number they can call for someone to come help them out, and that's the nocturnists, the night NPs. I see it there. I feel it myself.

How have you adapted your practice to treat patients with COVID-19?

Using ultrasound technology has been immensely helpful. I did a fellowship with Ultrasound Leadership Academy from July last year to July of this year. Most of the ultrasound for nurses is just doing an ultrasound IV. In some of that, most of the NP ultrasound is to do central lines and some of the invasive procedures that they do. I often use ultrasounds for diagnostics. For the most part, you can't use a stethoscope on a patient with COVID-19. The typical way that you assess patients, like with a stethoscope, is kind of removed for COVID-19. So, you need another thing, a lung ultrasound, cardiac ultrasound, looking at the IVC, that's helped so much and helped me risk stratify some of the patients. I can tell if their lungs are inflamed. I can tell if there's fluid building up. I can actually assess to see if we need to give them fluid so they don't go into shock versus no fluid and just prevent their lungs from swelling from fluid or infection.

Using ultrasound has helped immensely, but it's just not widely adopted. I think it's because the training is not there. If there's no training, no one will use it. I had to start somewhere, and this is where I started. But, I had a lot of ultrasound training during my NP training.

How did you get into nursing?

It seemed like a logical progression from EMS. I got into EMS out of college, and I became a paramedic. Then, it made sense for me to go to nursing school after being a paramedic. Then, as a nurse, I went toward the ICU. Once I was in the ICU, I eventually worked toward being an NP. I mean, I like helping people. I like solving difficult problems, and that sort of put me on that path. It seems like nursing is in a continuum with EMS.

What have you liked most about this position – specifically working nights – since you started?

It is all medicine and no bureaucracy, I guess. Working at night, you're just there to assist with troubleshooting with the nurses, admit patients, do rapids, do codes. That's it. During my shift, I don't have to attend meetings. I'll do Zoom meetings on the off-week for the group when I need to. But, it's just being an NP, and that's it. It's a wonderful situation, because 100% of my training is going into 100% of my job.

How have you adapted to working nights, and do you have any advice for new nurses working overnights?

Oh, yes. I work seven on, seven off. So, I work seven 12s, and then I have seven days off. That is a huge help, because I don't have to flip between the day and the night. My wonderful counterpart who works the other week at night, she's OK with doing seven on, seven off. But other places will do four-four-six or whatever amounts to get their shifts during the month. I think those flips between day and night, we've reduced those, and I think that helped me. Drinking a lot of coffee obviously helps, but then not doing that when I'm off. When I'm off, I'm not trying to stay awake all night.

Other things like exercise and recharging with friends and family help while I’m on. I mean, adjusting to the night, it's just not flipping over, and then restoring yourself when you're not working. I see how burnout happens. I've seen it in different careers and different jobs, and I see it in this one. If you're just working a ton, there's no time to restore yourself. So, working full-time for now without taking on additional jobs is enough for me. That helps out immensely. It's been helping for a year and a half so far.

What are some things that people should know about nursing that they don't?

Right now, I see two real issues that nurses face – trying to stay calm during this crisis and the growing amount of violence.

It's so difficult to stay calm and think right now. It's very, very hard to do that, because there's an acute crisis of just people not breathing. At the same time, there's also a chronic crisis of people not believing in what's going on, which results in a lot more admissions, because they don't get vaccinated. It's really hard to stay calm when all these things are going on. That's such a vital skill.

The other thing people don't know about nursing is nurses get assaulted all the time. You wouldn't believe how violent it can be. I can see how this happens in the emergency room – people come in drunk or on drugs, and that can cause violence. That's why they usually have a police officer in many EDs. But, it also happens on the floors, the ICUs and other areas. Many patients get delirious in the middle of the night and just basically assault nurses. I get multiple calls a night of patients getting delirious, ripping out their IVs and swatting at the nurses. That happens so frequently. I realize it’s due to altered mental status, but it can still be emotionally damaging to the nurse.

What advice do you have for other nurses who are still facing COVID-19 surges in their units?

When I’m assisting the nurses in my hospital, I typically tell them two things: "You don't rise to the occasion; you fall to your training. And, rely on your pod mates, your colleagues."

When you take an ACLS class, or you take one of the alphabets, BLS, TNCC, those classes teach you how to respond in an emergency. However, those skills are perishable. If you don't train and practice them in a practical and high-fidelity simulation, you're going to lose them. Thorough training is so important.

Second, rely on your colleagues, because the whole is greater than the sum of its parts. There's more work than anyone can do in one shift, but it seems like it always gets done. It is done well when people rely on each other, ask each other questions, trust each other and help each other.

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