Texas Nursing Student

APRIL 2007
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What’s Inside?
8 Do You Suffer From
NCLEX Anxiety?
On page 6, Methodist Health System’s Tony Paterniti discusses
how hypnosis may hold the key to a less stressful test experience.

Student Snapshot
On page 8, Baylor nursing student Tammy Trabosh (left) found
the field she loves while being precepted by DISD elementary
school nurse Regina Miller.

The Top 5 Questions

12 That Students Have
On page 10, student advisors Mindy Hutchison and Avis Musa
answer 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 a
transition from graduate nurse to critical care nurse. University of
Texas graduate Victoria Keen (left) went from intern to PICU

18
nurse in just 16 weeks at Medical City Children’s Hospital.

The Road Less Traveled

On page 18, Paula Faulk Maness reports why many nurses have
left the city to work in rural areas. Included are first person
accounts from rural nurses. Be sure to read Ed Price’s narrative
on the joys of living and working in Nacogdoches on page 21.
 publisher & editor

contributors Thomas Knight

associate editor
Kelly Rogers Ellenich
coNTRIBUTING EDITOR
Tony Paterniti, PhD, CCHt, RN Mindy Hutchison
Director, Department of Education copy editor
Methodist Health System Sheila Messman
executive producer
Tony Paterniti is a renowned nursing professional Jason Stoner
in the Dallas - Fort Worth area. After a long
traffic
career in clinical nursing, nursing management, Janet Foulks
and nursing education, Tony has spent the last website
few years helping graduate nurses intern at Rebecca Windham
Methodist Health System. He has helped many interns pass their media representative
NCLEX. If you are looking for a different kind of approach to handling Laura Griffin

the stress of NCLEX, read up on Dr. Paterniti’s ideas of help through

hypnosis. Tony used a hypnotist to help him finish his doctoral thesis
in 1992, and has since discovered that many graduate nurses – who
are good students, but do not do well on NCLEX – experience good
outcomes after hypnosis. His column begins on page six.
Paula Faulk Maness, MSN, RN
Nursing Faculty
Tarleton State University
Paula Maness is passionate about rural nursing.
She is an active member of the Texas Rural
Health Association, and teaches a course on the
Dimensions of Rural Health Care at Tarleton
State University (Stephenville, Texas). She
received her ADN from Odessa College in 1970; her BSN from Mary
COPYRIGHT © 2007 by Texas Nursing Student.
All rights reserved. Reprinting in whole or part
is expressly forbidden without the written
permission of the publisher.
Texas Nursing Student is published monthly,
except during June and August. Texas Nursing
Student is distributed free of charge to students
enrolled in ADN or BSN programs at 77 schools
of nursing in Texas. Magazines may be mailed
to the address of any student registered at a
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Nursing Student is printed in Fort Worth, Texas.
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Griffin, Media Representative at 972-481-8851.
For subscription information, visit the Texas
Nursing Student website located on the web at:
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Hardin Baylor University in 1975; and her MSN from Abilene Christian
To contact Texas Nursing Student write to:
University AISN in 1995. Paula has been a nursing faculty member
Texas Nursing Student
since 1991, and is the Learning Resource Coordinator for the Depart-
8918 Governors Row
ment of Nursing at Tarleton State. Paula lists her loves as patients, Dallas, TX 75247
Med-Surg nursing, Gerontology, rural nursing practice, and nursing
phone: 214-951-8100, ext. 17.
students. Read her article beginning on page 18. Fax: 214-951-8131.

Email: editor@texasnursingstudent.com

Visit us on the web at

www.texasnursingstudent.com
2 ❘ Texas Nursing Student
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Hammer Toe Not
To Be Taken Lightly
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 toe
deformity. 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
hammer the top of the toe and becomes painful,
toe
most noticeably when wearing tight
shoes. There may be a bursa under the
corn or instead of the corn, depending on the
pressure. Most hammer toe symptoms are due to
pressure from footwear on the toe. There may
also be a callus under the metatarsal head at the
base 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 problem
is well established. However, there are several
things that can prevent hammer toe:
• Wear appropriate footwear. Allow toes to function without excessive
pressure. 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 correct
a hammer toe, usually as a day surgery procedure. TNS
4 ❘ Texas Nursing Student
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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 AT
SAN ANTONIO
Judith Wright Lott, DSN, RN, NNP, FAAN, Dean,
Louise Herrington School of Nursing,
BAYLOR UNIVERSITY
Pamela Martin, PhD, RN, Associate Dean for
Undergraduate 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 CENTER
SCHOOL 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
EXCITING
OPPORTUNITY
Apply Now For Student Advisory Position With Texas Nursing Student.
Job Summary: Essential Functions:
This position is the key liaison between 1) Report on stories, take or obtain
students at the attending school of pictures at local school events
nursing and Texas Nursing Student. and advise staff on publication.
Reports to: 2) Distribute magazine to students
Editor or Associate Editor of of nursing at attending school.
Texas Nursing Student Magazine
3) Orient successive student advisor.
Term:
August 2007 - May 2008
Contact: Tom Knight, Editor of
Compensation: Texas Nursing Student, if interested.
Pay for stories and photos, as well as editor@texasnursingstudent.com
a letter of recommendation for job or phone 214-951-8100, extension 17.
carried out to satisfaction of editor.
Do you Suffer
NCLEX Anxiety
Hypnosis may hold the key to a less stressful test experience
I had been working with GN’s on a regular basis. Having
taught in various nursing programs for more than 16 years,
I was familiar with the trials and tribulations of taking and
passing NCLEX.
I was especially concerned when one of the nurse
by Tony Pater niti, Phd, CCHt, RN, Dir ector, Depar tment of Education, Methodist Health System
As the nurse intern liaison in a large urban medical center,
interns 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 and
during the exam indicated that he most likely
suffered from a serious case of test anxiety.
He told me of his heart palpitations
before beginning the exam and his
shirt being covered in perspiration
when he took a break.
6 ❘ Texas Nursing Student
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?
from
He specifically remembered having greater and greater
difficulty concentrating as the number of questions grew from
75 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 to
advise him on how to better prepare for the next time.
I was aware that my customary advice wouldn’t work for
this nurse intern. It would do no good to tell him to practice
answering questions everyday. This wasn’t about getting the
right answers as his solid B record indicated he most likely
knew the content. This was about getting into
the right frame of mind so he could access
the information he already knew.
That evening, I remembered
how ten years earlier I had
great difficulty completing
the dissertation for my PhD.
I was certainly knowledge-
able about my topic, and I most
definitely had the technical skill
to 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

period of time the self doubt would
begin, followed by uncomfortable feel-
ings and repeated thoughts of, “What’s
the use?”
My ability to concentrate would
fade quickly and I would abort the
attempt, which I am certain reinforced
my doubt and lack of confidence.
I smiled as I recalled how
I overcame all that resistance. I
saw a hypnotist! My friend, who had
stopped smoking with the help of one,
suggested I give it a try.
I remember not knowing a thing
about hypnosis, but being willing to
attempt it.
I made an appointment and went
to the first session. I sat in a recliner
chair, closed my eyes and listened to
the hypnotist as he talked about relax-
ing each part of my body. I visualized
writing the dissertation, but beyond
that, I cannot recall the content of
the first session nor the second, which
occurred a week later.
Although we had agreed on three
sessions, I never made it to the third.
I was too busy writing my dissertation!
Four months after my hypnosis
sessions, the dissertation was at the
typist being prepared and I had sched-
uled my final defense which occurred
one month later. Hypnosis had helped
me remove whatever barriers I had so
that I could write the dissertation.
Needless to say, I asked the nurse
intern if he was willing to see a hypno-
tist to help him deal with the feelings of
anxiety. He agreed to do so and after
three visits with a hypnotist, he took
and passed the NCLEX exam.
Within a period of two weeks, two
other GN’s requested information about
REPEATED ATTEMPTS
<
hypnosis for test anxiety. I also referred
those GN’s to hypnotists and they both Number of Candidates
passed their second attempt. Taking NCLEX Examination
Since our internships are large, and Percent Passing, by Type
between 75-150 nurse interns, and are
offered twice annually, the number of RN 2006 Totals
nurse interns requesting hypnosis grew Type of Candidate # %
as well as the number requesting infor- First Time, US Educated
mation about hypnosis. During the Diploma 3,810 89.5
past seven years, I have referred about Baccalaureate Degree 41,349 88.3
40 nurse interns for hypnosis related to Associate Degree 65,390 88.0
their difficulty in passing the NCLEX Invalid or Special Program 164 73.2
exam. I am aware of 34 of them having Total First Time, US Educated 110,713 88.1
successfully passed their second attempt
Repeat, US Educated 22,474 54.2
at the exam after having between one
First Time,
and three sessions with a hypnotist. Internationally Educated 25,908 61.2
Two of the interns who I referred Repeat,
Internationally Educated 17,992 28.3
had failed the exam twice before seeing
a hypnotist and both passed on their All Candidates 177,017 73.8
third attempt. I had an opportunity Statistics courtesy of the National Council of State
to talk to about 75% of the 34 nurse Boards of Nursing (NCSBN) NCLEX® Examinations
interns and they consistently described
the re-taking of the NCLEX as being
a much calmer experience for them as
compared to their first experience.
It’s important for me to emphasize
here that in no way did I conduct
“ I asked the nurse intern
if he was willing to see a
research related to NCLEX, anxiety, hypnotist to help him
and hypnosis and that I am not reporting deal with the feelings
this information with any particular of anxiety about NCLEX.
claim about its cause and effect. He agreed, and after
I simply reacted to a request for
three sessions with a
help by a nurse intern; remembered I
had been helped by a hypnotist, and
hypnotist, he took and
passed NCLEX.
made the referral. During the past year,
we have begun sending nurse interns –
who are at risk for failure because of – Tony
”
anxiety – instead of waiting for them Paterniti
to fail the NCLEX exam. The point
to be made here is that you should be
open to non-traditional ways of solving
some of the more traditional problems.
If it works, then why not? TNS
Texas Nursing Student ❘ 7
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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
8 ❘ Texas Nursing Student
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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
the

TOP[5] Questions
that students have
By Mindy Hutchison and Avis Musa

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

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

Colleges offer general nursing programs that give a broad overview of patient
care for all ages. Once you graduate, you can apply to work in a specific
area 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 get
related 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 solve
problems 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 you
want to be a pediatric nurse, you can choose psychology or anthropology
courses on child growth and development. If you want to serve a certain
demographic population like Latin immigrants, you might want to brush up
on your language skills. You may even find language courses from continuing
education or community groups. Don’t forget the power of Google… OK, the
campus library, then. Start researching nursing journals now to build that
foundation in your desired area.

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

Advanced practice in nursing requires experience and a working knowledge clinical experience working as a registered nurse in specific settings to
of the needs of patients. This knowledge builds from clinical care of patients properly prepare for master’s level courses. Since nursing is practical and
in real-life settings – something you can’t find in a book! theoretical, it’s important to have patient care and multidisciplinary team
Many nursing programs recommend or require one to two years of experiences to draw upon when researching best practices.

10 ❘ Texas Nursing Student

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3 I need help paying for college. Where can I get money?
With the cost of tuition, fees, books, and living expenses rising, many
students have a difficult time budgeting for college, even when they
have supportive family members. The FAFSA (Federal Application for
Student Aid) is your first step to determining if you’re eligible for
grants, scholarships, or loans from the government and your institu-
tion. Most universities also offer general scholarships based on
financial need or academic merit. Many students may work part-time
or as work studies if they can properly balance study time and work
time. If you need more help, or have a special circumstance, contact
4 My spouse or significant other had a job relocation and I am moving to your area.
Can I transfer to your nursing program?
Sometimes nursing students may have a family situation that causes
them to move across the county, state, or country with half of their
nursing credits in tow. With a shortage of nurses, usually there are not
many spaces open to transfer, but students may be deployed or delay
completion of their program, opening up a spot in school. Check with
each nursing school to see its transfer policy, application deadline, and
5 How do I get an “A” in this class? Can you tell me what’s on the test, or what to study for?
Sometimes nursing school is overwhelming and students wish for a
way 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 any
easier! 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 ask
questions. Read and study your textbooks and prioritize what you think
is important – don’t just ask for the page numbers where the exam
answers are! Professors will ask you to apply your new knowledge to
? Okay Aris and Mindy, those answers were all well and good, but you still didn’t answer my particular
question! Will you answer it for me?
If you attend UT Arlington, you may e-mail us at: nursing@uta.edu.
If you attend another school, it might be best to contact your academic
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 are
available 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 involvement
on 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.
material requirements. Most schools require a letter of good standing
from your previous school with no ‘’D’s or “F’s” in nursing courses.
Unfortunately, the chance of failing one bachelor’s degree program and
transferring to another is slim. You may also need to provide academic
transcripts and sometimes course descriptions or even course syllabi to
see if you took the same course in your previous school.
scenarios, and use critical and analytical thinking skills to answer
important 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 professor
won’t be standing over your shoulder with the answer when a real life
patient has a difficult problem or a big decision has to be made.
If you’re having difficulty with a particular concept, meet with
your professor after doing some reading, studying, and research on your
own. Skimming your notes from class will not suffice. Be prepared to
manage your time well and work hard to get your “A.”
advisor, or, you can always email: editor@texasnursingstudent.com
for advice from an unbiased source. TNS
Texas Nursing Student ❘ 11
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 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

12 ❘ Texas Nursing Student

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There was a time…
not too long ago when a graduate
nurse interested in the specialty of
critical care would hear some varia-
tion of this advice: “Do at least two
years of Med/Surg, get your basic
skills down, your confidence up,
then come talk to us.”
Those days are gone, thanks to
innovative internship and preceptor
programs that pair eager young grads
with seasoned nurses in one-on-one
relationships to help guide them
safely into the exciting world of
critical care.
“It all came about because there’s
a nursing shortage, particularly in the
PICU and NICU environment,” says
Laura Massey, RN, nurse manager
of the PICU unit at Medical City
Children’s
Hospital in
Dallas. “We
had to do
something
because
nursing
schools were
not putting
Laura Massey, RN out ICU
Medical City Children’s nurses.”
That “something” turned out
to be a whole new way of putting
together the training for critical care
nurses. Hospitals all over Texas have
launched Internship and Preceptor
programs designed to give young
graduate nurses the high-tech train-
ing and friendly support they need to
become great critical care specialists.
Training includes classroom time
as well as hands-on work at the bedside
on all the advanced new equipment
that is now used to monitor and
resuscitate critical patients. Additional
training is given in the medications
used for day-to-day care and CODE
CRITICAL CARE NURSE
situations. It’s a lot to learn, but
>
Nursing Shortage More
most critical care nurses are happy Pronounced in Critical Care
to take it all in.
“It’s an extremely exciting field The growing nursing shortage is especially
of nursing,” says Linda Stephens, RN, acute in specialty nursing. The overall nursing
the Chief shortage in Texas exceeds 10%, according to
Nursing Dr. Janet Allan, former Dean of the School of
Officer Nursing, UTHSC San Antonio. The number of
at West requests for temporary and traveling critical
Houston care nurses to fill staffing gaps has skyrock-
Medical eted in every part of the U.S., and these
Center. “In requests were most noticeably in adult critical
addition to care units, pediatric and neonatal ICUs, and
the nursing emergency departments. Hospitals are com-
piece of it, Linda Stephens, RN, CNO pelled to offer critical care nurses attractive
West Houston Medical Center incentives, including sign-on bonuses, reloca-
it’s dealing
with all the new skills and technol- tion bonuses, reimbursement for continuing
ogy; it’s the collegiality you have education and certification, and other invit-
with your co-workers. You’re ing benefits. In addition, many hospitals use
so dependent on each other, and the critical care orientation and internship pro-
doctors are dependent on you to make grams to prepare newly- licensed nurses to
acute observations and convey infor- work in critical care.
mation on to them so they can make
>
their decisions. Everybody has each Number of Critical Care
Nurses in the United States
other’s back and you’re never alone.”
Melissa McCarty, a young critical According to the Department of Health and
care nurse at West Houston Medical Human Services, there are 403,527 nurses in
Center, says the U.S. who care for critically ill patients in
she actually a hospital setting. Of these, 201,833 spend at
looks for- least half their time working in an intensive
ward to care unit; 70,241 spend at least half their time
coming to in a step-down or transitional care unit; 94,912
work each spend at least half their time in an emergency
day. “You department; and 36,541 spend at least half
are the link their time in post-operative recovery. Critical
between care nurses account for an estimated 31% of
(continued next page) the total number of nurses working in the
Melissa McCarty, RN
West Houston Medical Center hospital setting.
Texas Nursing Student ❘ 13
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What Critical Care Nurses Do
>
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.
14 ❘ Texas Nursing Student
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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 emotional
attachment with them.”
Mary Womack, RN, the Critical Care Manager at the Medical Center
of McKinney, says it’s important that hospitals keep training good critical
care nurses. “They’re building new hospitals and ICUs every day, and every
time they open a unit they’ve got some new technology we all have to
learn. So there’s an ongoing need for the type of training you don’t get in
schools. Internships are designed to provide that.”
By definition, critical care nurses take care of the most seriously ill or
injured patients. That means their patient load is smaller, usually one
patient to one nurse as opposed to five to seven patients per nurse on a
Med/Surg, or other unit.
“It’s intense. You really have to think on your feet,” says Shawna
Darland, an RN who works at the Medical Center of Lewisville.
Darland hasn’t been out of nursing school for a year, but she already
knows critical care is where she wants to stay. “I liked always having some-
body work with me during my preceptorship,” she says, “watching me grow
and making me think for myself. It built my confidence very quickly.”
Shandra Hogan-Robinson, an RN who works
at Spring Branch Medical Center, says she came
to critical care nursing by a somewhat different
route. “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 functioning
at a stable level and then sending them on to a Shandra Hogan-Robinson
Med/Surg floor or even home.”
Spring Branch Medical Center
Mary Casarez, an RN at Southwest
General Hospital in San Antonio, really
likes how critical care nursing gives her the
opportunity to work closely with doctors on
patient care. “We are their eyes and ears,”
she says. “The whole critical care team knows
what’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 at
Mary Casarez, RN
Southwest General Hospital
Southwest General Hospital, also likes the close contact with the medical
staff. “It makes you feel like you’re part of the team. The doctors trust you
and your assessments of their patients, and it feels good to know they’re
taking your word on the patient’s condition. When we (continued on page 16)
Critical Care Internships
When Laura Massey, RN, first became
an LVN, she had no idea she would
one day end up as the manager of the
PICU unit at Medical City Children’s
Hospital, in Dallas. “I continued my
education and training – increasing
my skill and knowledge level – which
allowed me to be a successful PICU
nurse,” she says. Massey also benefited
from the supportive environment at
Medical City Children’s.
Medical City Children’s offers two
16-week internships in their PICU.
The program has been in place for
more than 10 years. “We realized that
the traditional way of doing things,
sending graduate nurses to Med/Surg
for two years, was not giving us what 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).
we needed,” Massey says. “When
nurses came onto critical care units because she loves kids, but the skills just the right way to make you a good
from Med/Surg, they weren’t used she learned during her internship at critical care nurse.”
to the fast pace and life and death Medical City Children’s took her to Keen says a lot of young nurses
situations, and it could be very heights she never dreamed she could get nervous about coming into critical
overwhelming and intimidating conquer. “I learned there’s a lot you care. “They say, ‘Oh my goodness!
for them.” don’t learn in school,” Keen says. “I The ventilators! The drugs!’ but the
Massey says a lot of nurses left like the fast pace and the fact that internship really brings everything
critical care to go back to Med/Surg you can take somebody from being together and teaches you how to handle
or on to some other specialty. critically ill to watching them fully any situation. And if you don’t have
Hospitals all over the country were recover. That’s very rewarding.” the answers, someone more experienced
struggling to fill their critical care Keen says she liked the internship is always just a few steps away.”
jobs, so they basically decided to because her instructors knew which Keen is a preceptor now, teaching
“grow their own” ICU nurses. skills she needed to work on. “They younger nurses how to handle the
“We give them very intensive make sure you get the right experiences pressures of a PICU and interact with
didactic training and put them at the in order to survive working in a PICU,” patient’s families. “I love my job,” she
bedside with a trained preceptor. That she says. “In school you learn about declares. “When you’re a young nurse
has worked very well. We turn out a lot disease processes. In the internship, you have a lot of zeal. I hope I can
of very good nurses in this program.” you learn how to care for patients who continue to do this. I hope at the end
Massey says Victoria Keen, RN, is have the disease. You get very specific of the day when I get in my car and
a perfect example of how the program instructions. Coming straight from ask myself if I did the best I can, the
works. Keen wanted to go into PICU school, they are able to mold you in answer will always be yes.” TNS

Texas Nursing Student ❘ 15

texasnursingstudent.com
Critical Care Certification
>
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.
16 ❘ Texas Nursing Student
texasnursingstudent.com
tell a doctor he needs to get to the hospital, he knows he needs to get to
the hospital.”
“You’re the patient’s early warning system,” Shelly Collins says. Shelly is
an RN working at Medical Center of McKinney. “You have to stay on your
toes; you can’t get lazy. But when you
really 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 where
she now works in critical care. “You get
a better idea of the reality of the job by
Shelly Collins (center) with daughters,
working in the field while you’re going Hailey (left), and Carley (right) works
to school,” she says. “I knew I wasn’t at Medical Center of McKinney.
wasting my time in critical care because
I 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 fast
pace and have nerves of steel to work in critical care. Not many nurses
have that when they go in, but the intensive training provided in intern
and preceptorship opportunities helps young nurses
develop the calm and focus they need to be
effective in life or death situations.
“I definitely recommend internships,” says
Stephanie Chen, an RN working at Medical Center
of McKinney. “They provide good preparation for
the real world of nursing.” Just make sure you find
the right program for you.
Sharon Dixon, RN, BSN, says an internship
Stephanie Chen, RN
made all the difference for her. “The program I did Medical Center of McKinney
was very structured,” she says. “I worked one-on-one
with a preceptor and over three months, I went progressively from the least
critical patients to the most critical. I also got the chance to work in Trauma
and 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 really
stressful and it takes a lot out of you,”
Mary Womack concludes. “But you
get to make a difference. You get to
save lives. Most nurses don’t ever
leave critical care because it gets in
your blood.” TNS Sharon Dixon, RN
Memorial Hermann The Woodlands
 Is Critical Care Do you like
the feel of an
“adrenaline rush”
Are you good at noticing
subtle signs and symptoms
and knowing when and

Nursing for You? during a code

situation?
what to report
to a doctor?
This easy quiz will help determine
whether or not you would enjoy ❑ Yes ❑ Yes
Critical Care Nursing. There are no
“right” or “wrong” answers, so just ❑ No ❑ No
mark the first answer that comes to
mind, then check your results.

Do you prefer a Do you welcome Do you like

fast-paced work the challenge a good
environment? of educating challenge?
patient families about
their loved one’s
illness?
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No

Do you enjoy Are you comfortable Can you

learning about working around a handle

new technology? critically ill patient stress?

who might die
at any moment?

❑ Yes ❑ Yes ❑ Yes

❑ No ❑ No ❑ No

Would you like to work Do you enjoy an

more closely with ever-changing atmosphere If you had seven or more “Yes”

doctors and other where every day answers, then you probably

nurses on is different have the type of personality

patient care? and you never know that would be well-suited

what’s going to for Critical Care Nursing.

❑ Yes happen next? ❑ Yes

❑ No ❑ No
Texas Nursing Student ❘ 17
texasnursingstudent.com
18 ❘ Texas Nursing Student
texasnursingstudent.com
Many of those who
are new to nursing have set their sights
on a future career in a big city hospital.
Houston, Austin, San Antonio, El Paso,
Lubbock, and the Dallas-Fort Worth
area all have attractive things to offer
besides huge facilities with the latest
in technology.
But a select few – those who
often take the road less traveled –
send resumes to hospitals in rural
areas, accept jobs there, and find
something they weren’t quite
prepared for: Quality of life.
Researchers have made
many attempts to classify rural
nursing by location, popula-
tion density, or the distance
required to travel or com-
mute to an urban area.
However, rural nursing
may be best defined by those
who actually do it. In this
story they will answer the ques-
tion, “Why is a nursing job in
Rural, Texas, so satisfying?
But first, let’s be pragmatic
about comparisons. Rural areas pay
less than urban settings. However,
the cost of living is significantly
higher in urban areas.
Lifestyles may also differ radically
from rural to urban settings, but being
able to leave your car unlocked, your
windows open at night, and your chil-
dren playing safely in the front yard are
just a few of the many advantages rural
living has to offer.
Yes, there may be fewer shopping
malls, the grocery may not be open 24
hours a day, and the nearest sushi bar
might require an overnight stay. But
nurses say there are bigger differences.
Patricia Hoffman, BSN, RN, has
an interesting take on rural nursing as
she saw it in Brownwood, Texas. She
feels the training nurses receive in a
rural setting better prepares them for a
future at an urban hospital. “My rural
There are 254 counties
in the State of Texas. They are
classified 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.
experience prepared me to use critical
thinking skills,” Patricia says. “To look
at the patient first – not the equipment
– and be a patient advocate.
Sherry Clements, BS, RN, a nurs-
ing administrator who went from a busy
urban Houston hospital setting to a
rural health care facility in Eastland,
Texas, says her strategy for recruiting
nurses and encouraging them to main-
tain a high standard of practice can be
expressed in one word: Resources.
The standards of care do not change
from urban to rural settings, but the
availability of resources does. Funding
differences between urban and rural
areas often require rural nurses to
be more innovative, self reliant, and
crafty in order to accomplish the same
patient outcomes.
“The challenge for me,” Sherry
says, “is to make sure my nurses know
how important their contribution is
to the community at large. It is
like the adage about a pebble
[being] thrown into the water.
Rural areas are such [little]
ponds that even a small
pebble creates tidal waves.”
Sherry says in the city you
wouldn’t know your patients
outside the hospital. “But in
a rural setting, you work
together, worship together,
shop together, laugh together
and grieve together. One life
affects another.”
DeVonna McNeill, MSN, RN,
has worked as the OB supervisor in a
rural hospital, as a faculty member at
Tarleton State University, and as an
in-service educator at a large urban
hospital. “Having worked in both large
urban hospitals and the small rural
hospital in the town where I grew up
taught me to value some experiences
in a different way. There is a lot to be
said for knowing your patients as friends
and neighbors. Familiarity, and a sense
of family and community, are some of
the greatest differences between urban
and rural nursing. Caring for people
you knew in school, or their kids or
parents, or the person who teaches
your kids lends a (continued next page)
Texas Nursing Student ❘ 19
texasnursingstudent.com
different sort of character to nursing
that I did not feel in my big city
hospital experiences.”
The consideration of a nursing
practice in a rural setting is something
every nurse must explore for them-
selves. This exploration should
include what motivates an individual
about nursing, their expectations of
co-workers and themselves, and their
goals for the future – both personally
and financially.
The community surrounding
any hospital will define a nurse’s
experiences. Therefore, the environ-
ment where a nurse works will affect
their outlook on life, and this is
perhaps one of the most difficult
things for an ambitious young nurse
to contemplate when considering a
career in rural Texas.
Although it is not for everyone, a
nurse who practices in a rural setting is
certain to gain something special from
it. The rewards are many, and further-
more, the demand is high. TNS
o strengths, their weaknesses and their entire family
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
20 ❘ Texas Nursing Student
texasnursingstudent.com
FROM THE FIELD
A 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 Tracy Emmons
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
history. It makes you learn to respect and trust each
Shirley Wylie
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
Valerie Cady Hudgens
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.
Peace
for a Price
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 able to see the stars; no Orion Constellation, no Milky Way, just
would interview. I went to Redding, California where I fell in love the lights of the city. We missed the stars.
with the area (plus they offered double the pay), and hired on as We met a lot of people in Dallas through our work, church,
Director of the Emergency Room. Then I was promoted to Assistant and socially; they were nice, but it was like a crowded party. You
Chief Nursing Officer, and later, Chief Nursing Officer. After that, I walk around and see a lot of people, but you don’t truly know
was offered a position at the Tenet Corporation Headquarters in anyone. Casual interaction, they know nothing of you or your family.
Dallas as the Senior Director of Nursing Operations. When people talk of Dallas the conversation always centers
on all the things you can do. What they don’t mention is the
How did I get to Nacogdoches Medical Center? process involved in planning activities. If you want to go eat at
I met and married my wife in California. She had never been to a restaurant, it depends upon traffic, is it North or South of you?
Texas or my home state of Louisiana. True story, before marrying What time of day is it? You might end up spending more time in
me I had to promise her I would never move us to Texas or Louisiana. traffic getting to the restaurant than actually dining. Most week-
But when I was offered a position at Corporate Headquarters in days it was hard to be spontaneous, you had to stay close to home
Dallas, we agreed as a family to accept the position and move, but or go later in the evening when the traffic is less intense.
only after she reminded me of my promise. We moved to Dallas Dallas is humbling – there were always lights in the night
and lived just north of it, in Allen. Dallas is nice. It’s big and there’s skies, always the hum of the traffic, and the wailing of sirens. I
lots of “stuff” to do. We did a lot of “stuff,” the malls, the movies, the never could just be by myself.
theatres that serve a meal with the movie, wonderful restaurants, My first time in Nacogdoches Medical Center was in October
that sort of thing. It is true there is a lot of “stuff” to do in Dallas. 2006. Part of my duties as the Senior Director is to “fill in” as CNO
However, there are other things about life in the big city beyond until a permanent one is hired. When I would come home for the
“stuff.” When home, my wife and I would often sit on our balcony weekends I would tell my wife just how nice this town was. What a
and listen to the traffic. We would look up at night and not be wonderful and friendly small town Nacogdoches (continued next page)

Texas Nursing Student ❘ 21

texasnursingstudent.com
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
22 ❘ Texas Nursing Student
texasnursingstudent.com
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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