By Jennifer Thew, RN
Originally appeared in HealthLeaders.
About three-and-a-half years ago, Jennifer David, BSN, RN, MHA, associate vice president of client relations at Avant Healthcare Professionals, a Florida-based recruitment and staffing firm specializing in international healthcare employment, saw something that unnerved her.
She had visited a hospital client where three of the agency's international nurses would be working on long-term contracts.
There were 70 infants in the neonatal intensive care unit, and 28 of them had been born to mothers addicted to opioids. The infants were experiencing symptoms of withdrawal known as neonatal abstinence syndrome.
"If you've never seen that before, which I had not, it took me back. I had tears in my eyes," she recalls. "These babies never stopped crying. They just scream and they shake and they're in pain and they're going through withdrawal."
This was before the opioid crisis had made national headlines, and David was certain that the international nurses had seen nothing like what she witnessed.
"When I got back [from the hospital visit] and met with my instructors, I said, 'We're going to have to prepare these nurses. I'd rather them go through the shock here where they have the support."
David met with the three nurses who were headed to the NICU, and her hunch about their familiarity with opioid addiction and NAS was confirmed.
"I wanted to find out if they knew anything about neonatal abstinence syndrome and if they knew anything about the opioid issue in the United States, and they did not," she says.
As a result, Avant put in place a program to train and support all its nurses in caring for patients with opioid addiction.
Here are the three elements of the program to support nurses.
David first began the support program with the nurses working in the NICU. They discussed how the opioid crisis began in the U.S., and shared statistics on deaths related to opioid overdoses. The group also learned about NAS.
"We had them watch videos because that shows what an NAS baby is going through," she says.
They also learned how to care for and support the infants clinically.
"My nurses' reactions [to the education]? They were in tears, and some of us were as well," she says. "But we realized we had to get them ready for where they were going."
A few months later, while on a site visit at a different hospital, David realized the program needed to be delivered to more of Avant's nurses.
"I was in the ER, and at this hospital, in any given shift, they would have two to four overdoses," she says. "I was there at 11am and they already had three."
Because patients with opioid addiction could end up on any unit in a hospital, the program has become part of the core training given to all of Avant's nurses, no matter where they are going on contract.
During the training, they cover topics such as categories of opioids, withdrawal symptoms, and management and treatment of withdrawal.
Recently, Avant did a survey to gage the effectiveness of the opioid training and support program. They surveyed 48 nurses who were on assignment and found:
- 81% said they knew nothing about opioid addiction before coming through the program
- 67% said the program improved how they viewed and cared for their opioid-addicted patients
- 79% indicated they felt comfortable managing the pain opioid-addicted patients experience
David recommends hospitals and nurse leaders be proactive in developing programs that provide training and emotional support to nurses caring for opioid-addicted and overdose patients.
"If you do have a unit that has a large amount of this [patient population], talk about it with your team and absolutely debrief," she says. "Circle back to do pulse checks, and if they need more support, then get them to somebody."
If a nurse manager notices a high number of call-ins, that should raise a red flag that nurses may be struggling.
"I think the awareness is what needs to happen," she says. "We're so busy taking care of the patients, I think the next wave is we've got to take care of the healthcare providers."
2. Pulse Checks
The program goes beyond educating the nurses and sending them off to their assignments.
"In the last three or four years, we've been taking care of a [larger volume] of these patients, but we've kind of forgotten about the nurses," David says. "So, the other piece of our program, besides just giving them all this knowledge, is doing 'pulse checks.' "
During the nurses' orientation at the facility, which is between two to four months, David and her team have weekly calls with the international nurses.
In addition to checking to see how the nurses are doing with their clinical skills, they are also asked if they have had patients who have overdosed or if they've cared for an infant with NAS.
"We ask them because many times they don't know how to handle it the first time," David says.
David also talks with the nurse managers before the nurse begins his or her contract.
"I let them know ahead of time that we're giving [them] an international nurse, and this may be the first time they've ever seen [opioid addiction or overdose] so they may want to debrief with them afterwards," she says.
After the nurse completes orientation, the pulse-check calls continue biweekly for the first year of the contract. After the first year, there are monthly classes for the remainder of the assignment, which last about two-and-a-half years.
David also checks in with the nurse managers every two weeks during orientation and every month for the length of the assignment.
3. Coping Skills
During the pulse checks, David also asks how the nurses are coping with caring for this population of patients.
"On the psychological side, we have to [understand] those issues that nurses feel and help them through them," she says.
"I had a nurse call me about six months ago. She was a single mom of young kids and she had two or three overdoses in the ER every shift and she had nobody to talk to about this," David says.
Constantly caring for patients who overdose can wear on the entire nursing staff.
"At [some of] the hospitals I've spoken to, when they do RN engagement surveys they found many nurses were calling off or even leaving the hospital thinking it was going to be brighter at another hospital because of all these overdoses," she says. "They were calling off because they couldn't sleep. Or they were having challenges and they just didn't want to go back for another shift."
David recommends that hospitals provide debriefing with a crisis intervention team for nurses immediately after an overdose.
"Do it during a shift. Don't wait until the next day," she says.
If one of the Avant nurses reports he or she cared for a patient with an opioid overdose, David asks the clinician some of the following questions:
- Was this your first overdose patient?
- What was your role in caring for that patient?
- Did the hospital have a crisis intervention or support teams?
- Do you have any questions?
- How are you feeling?
If the nurse says he or she is struggling, Avant will put the clinician in touch with its employee support team.