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For two years, they learned theory and practiced with mannequins. Now it’s time for Stacey Barone’s students to treat patients
Erin Kesler, a third-year Boston College nursing student, puts on a yellow gown, latex gloves, and protective glasses. She steps into the room of a patient with a contagious staph infection. He also has an infected hip, which is why two intravenous lines drape from the crook of his elbow to drip bags hanging next to the bed. The catheters and tubes need to be flushed with saline water. Kesler, petite, tan, and a little unnerved, has never done such a thing.
Earlier, the patient snapped at Kesler when she took his vital signs. So she skipped listening to his abdomen with her stethoscope and left him in peace. Now she’s back, waiting for a nurse. The room, on the 11th floor of Beth Israel Deaconess Medical Center in Boston, is bright, with a view of an early fall blue sky. The patient channel-surfs his way through the midmorning television lineup as Kesler makes conversation.
“You had two breakfasts,” she says, glancing at his two trays on the windowsill.
“Uh-huh,” he answers.
At last, the nurse strides into the room. Her cheery confidence is a relief to Kesler. The nurse fills up a table with a medicine cabinet’s worth of swabs, syringes, and ampoules, arranging them just so. She points out which bits are slippery to hold, which caps are hard to get off. Each step comes with a caveat. Everything must be kept sterile.
Then the nurse flushes the IVs by removing the tubes from the plastic catheters in the patient’s arm and injecting the saline solution into the catheters. After everything is done, she writes the time and date on the clear plastic bandage that holds the catheters and IVs in place on the patient’s arm.
“You can do it next time,” she says turning to Kesler. The student’s safety glasses make her eyes look even bigger. She laughs nervously and murmurs, “There were like 50 steps.”
You can only learn so much about nursing in a lecture hall or by taking blood pressure using a medical mannequin. There comes a moment when student nurses must lay their hands on living patients. Erin Kesler is at that moment, along with 49 other juniors in the Connell School of Nursing. They are enrolled in the fall semester “laboratory” constituent of Adult Health II. Assigned to local hospitals, they will learn to insert catheters in sick patients, remove IVs, suction tracheas. It’s clinical experience—thus, the common shorthand for the class is “the clinical”—but the students will learn more than technical skills. Some will talk to distraught family members and dying patients. They will learn to expect the unexpected. “This is a big semester,” says Stacey Barone, the assistant professor who teaches the classroom portion of Adult Health II. Barone also oversees the clinical instruction and on Thursdays supervises one of the eight clinical groups. “If we reviewed how to read an EKG strip, then the expectation is that they can interpret one.”
Hands-on-training has always been central to nursing education. But nursing has become a more demanding profession. Advances in medicine keep terminal patients alive longer and have made diseases that were once a quick death sentence now chronic, complicated conditions. The typical hospital patient needs more care. As a result, the training required of student nurses, says Barone, “seems significantly more intense than what I did” in nursing training at Duke University in the early 1980s.
In their initial clinical experience last spring, these students worked more like nurses’ aides, giving baths, feeding patients, and taking vital signs. Now they also must measure out and administer medications, change dressings—and flush IV lines. While they are coping with Adult Health II, the students take an additional clinical class in a maternity ward. In the coming spring they will work in psychiatric units for one clinical and in pediatrics for another. Next year they will take clinical courses in community health and a specialty of their choice. Of all these, Adult Health II will give them experiences closest to what they will likely find in their first jobs. After graduating, most Boston College nursing students work on hospital floors with acutely ill patients, says Barone.
The juniors who meet for three hours every Wednesday morning in Cushing 212 for Barone’s lectures learn medical science—the side effects of drugs, the various ways the heart can malfunction—and the planning, treatment, and evaluation that comprise nursing care. They are tested often on what they’ve read and been taught—four times a semester, concluding with a 100-question multiple choice exam. And, once a week, in groups of six and seven, they report for shifts at one of four Boston hospitals: Beth Israel Deaconess, Massachusetts General Hospital, Brigham and Women’s Hospital, or Tufts Medical Center. The opportunity for hands-on clinical experience in major urban hospitals is what draws many prospective nurses to the Connell School, Barone says.
During any given semester about 300 Boston College undergraduate nursing students are involved in clinical work, according to Catherine Read, associate dean of the undergraduate nursing program. “They like to do the tasky things”—the technical procedures, the practical assists—Read says of the students, but that alone “is not what we are getting at.” The challenge is to get them to understand “it’s the big picture” that matters, Read explains—to learn to view a patient’s medical condition in relation to the individual’s emotional, familial, economic, and intellectual circumstances. Barone puts it this way: “Nurses are with patients 24 hours a day, seven days a week,” and the “opportunity to get to know them” is a valuable tool in their care. “I try to teach my students to take that opportunity and make astute assessments.”
On orientation day for the fall semester, Barone gathers her six clinical students, Erin Kesler among them, at the end of the hall on Beth Israel’s 11th floor. Since Barone began teaching this course seven years ago, her groups have worked here. She likes it because the patients are challenging, and the staff is helpful and welcoming of the students. The unit, which is called 11 Reisman, has the feel of a great, slow-moving ship. A milky gray light fills the hallways.
Two corridors merge into a single one, leading to a sunny solarium that comes to a neat point like a ship’s bow. Patients nap and idle away the time like passengers. This is the hospital’s medical oncology floor, yet it gets spillover from other departments. There are cancer patients in their forties as well as 80-year-olds with urinary tract infections and broken hips. Most people who land on this floor have multiple health problems.
Seated on a window ledge, framed by blue sky, Barone takes off her trim, red-frame glasses, pushes her blonde hair behind her ears, leans forward and asks the students who are seated around her to summarize their previous experiences.
Kesler, an Orlando, Florida, native who switched into the nursing program after volunteering at a hospital during her sophomore year at Boston College, says she hasn’t ever dressed wounds or put in catheters. Maria Cardiello, from Connecticut, who has an undergraduate fellowship assisting nursing professor Angela Amar in studies of violence toward women, says she’s given medications before. Cardiello and Jess Dever, who plays the mellophone in the marching band and is from Massachusetts, appear the most self-assured.
Rui Guan, a student from China, got little hands-on experience during last spring’s clinical because she was often drafted into translating for Chinese patients. Kathy Kim, a round-faced young woman from New Jersey with an easy sense of humor, has given one injection. Caroline Andrew, a lacrosse player from Vermont who is also a peer tutor at the University’s Connors Family Learning Center, perches on the edge of her chair and occasionally shifts her gaze nervously down the hall toward the patients’ rooms. “I don’t feel confident at all,” Andrew admits.
Barone has had students walk into a patient’s room and freeze or, worse, burst into tears. A jittery student nurse is more likely to make a mistake, so Barone wants to know if students are uneasy. Teaching in the hospital is a balancing act for Barone and the Connell School’s seven other Adult Health II clinical instructors. Their goal is to get the students to think for themselves, which means getting out of their way. Yet the teachers must make sure that no harm is done to patients. So in these early weeks, Barone will often tell the students what to do. As the semester wears on, she’ll say less and less, finally only speaking up if she sees that a student is about to make a mistake. “It’s like I’m wearing duct tape,” she says.
Students always work under the supervision of a licensed nurse. It is up to the instructor to determine the degree of that supervision, based on a hospital’s policies and a student’s skill level. Boston College tries to limit the size of clinical groups to between six and eight, though hospitals will allow as many as 10. To work with 300 students each semester, the University needs 35 to 40 clinical instructors.
Most are nurses who teach part-time. Barone brings more academic experience—she holds an MS degree in neurological rehabilitation nursing from Boston University and earned her Ph.D. in nursing from Boston College in 1993, joining the faculty full-time in 2002. (Her dissertation was on “Adaptation to Spinal Cord Injury.”) Still, keeping up on the ever-changing technology and science of nursing remains a challenge for her, as it will be for her students, who must learn “to feel comfortable being uncertain and asking questions,” she says. “There will always be something they won’t know.”
Just before 7:00 a.m. on a Thursday in mid-September, Barone’s clinical students, dressed in maroon scrubs, step off the elevator onto 11 Reisman for their first full day on the unit. They clutch their purses and jackets and head up one hallway and down another to find Barone. As they double back down the corridor, their gym shoes squeaking on the floor, a nurse in a darkened room calls, “All the lovely students.”
The students grab patient charts from a kiosk, pull up chairs at a small, round table, and begin turning pages. Each one has been assigned a patient for the day—a pattern that will be repeated throughout the semester, although the patients will change weekly. Cardiello pores over the scribbles of EKGs. Kesler pages through a weighty notebook. She stayed up until 12:30 in the morning researching the 22 medications her patient takes. Barone expects her students to come prepared.
By 7:30 a.m., Barone and the students start their morning meeting. They discuss their patients’ conditions, which include pneumonia, lung cancer, dementia, diabetes, and hypertension. That done, Barone sends them out on the floor to take vital signs. One student walks into a room just as her patient vomits and goes into respiratory arrest. All she can do is get out of the way. Another student finds her diabetic patient eating breakfast before he’s had his blood sugar tested. Not good. If his insulin level is too high, what he eats could make it worse. Maria Cardiello’s 93-year-old patient complains loudly in Portuguese. His temperature reading tops out at 95 degrees, which she believes must be wrong.
Barone calls the students back to the solarium at 10:00 and demonstrates how to flush IVs and how to use a handheld glucose machine. Before Cardiello leaves the solarium, Barone asks her what she should watch for in her patient, who appears to have an as-yet-undetermined blood disorder. “That he might bleed a lot,” Cardiello answers.
Cardiello’s patient is a big man with a square forehead and greenish pallor who has swaddled himself in blankets, tucking them under his chin. His mood has improved because his daughter has arrived. Even better, the daughter can translate his Portuguese for Cardiello, who plops the glucose machine on his bed and tells the daughter, “I need his hand,” which the daughter relays. His thick hand emerges from under the pile of sheets and blankets.
Cardiello fumbles with the beeping machine, pushing buttons as she tries to clear the last reading. When the machine is ready, she quickly pricks the patient’s index finger with a small lancet. She has to squeeze his finger two, three, four times to get enough blood on the thin test strip for a reading. She inserts the blooded strip into the machine and reads the set of numbers that flash on its small screen. The patient needs insulin.
Cardiello can’t find the staff nurse, so she tracks down Barone, who suggests she give the shot. She agrees to, though she’s surprised to be giving a shot on her first day. They retreat to a small room near the central desk. There Barone observes as Cardiello sticks the short needle of a syringe into a vial and draws the clear liquid out very slowly, watching closely to see when she has loaded two units, or less than a quarter of a teaspoon. The student’s hands tremble ever so slightly. “You’re doing fine,” Barone says.
The two stride down the hall and into the darkened room and find that the patient’s daughter, still seated in a chair next to her father, is crying. A doctor was just here, she tells them, her voice breaking. Her father has terminal cancer. The patient stares blankly at the TV. Barone sits down on the patient’s bed and takes the daughter’s hand. Cardiello pulls up a chair. The woman sobs. Last night, she had a premonition that he would die. This is her fault, she says. “I shouldn’t have come today,” the daughter cries.
“He totally lit up once you got here,” Cardiello tells her.
After about 10 minutes, Barone, who’s done most of the consoling, wraps up the conversation as gracefully as she can. She shows Cardiello where to give the patient the injection on his upper arm, a spot without any bruising, and the student gives him the shot matter-of-factly. The patient doesn’t turn his eyes from the TV. Cardiello rechecks his vitals, his temperature is still low, and she leaves the room. In the hall, she sighs. “I’ve never been in a situation like that,” she says. “I didn’t know what to do.”
At the end of each clinical day, around 2:00 p.m., Barone holds a debriefing for her group, usually in the solarium, where the green walls of Fenway Park are visible in the distance. Each week, Barone focuses on a different subject, often drawing from the highs and lows of the day just concluded. “What worked for you today?” she’ll ask. “Why?”
If a patient has passed away, she may turn the focus toward death and dying. The subject could be pain management and the nurse’s role as a patient’s advocate. Or the discussion might dwell on coping strategies for the “noncompliant patient.”
It’s the third week in the semester, another early Thursday morning, and the students are noticeably more at ease. Seated in the solarium, they sip coffee and compare notes on when they went to bed. At 7:15, they rise to look at the charts. As they flip pages, a soft cry comes from a nearby room. It grows louder. Cardiello checks to see which room the sounds are coming from. She reads the room number out loud.
“That’s my patient,” says Rui Guan, looking up. The cries fade, and Guan returns to examining her thick notebook. Her 88-year-old patient has non-Hodgkin’s lymphoma and delirium. Ten days ago her heart fluttered uncontrollably. Another cry, this one sharp and loud, sounds. Guan looks up again. “It’s scary,” she says.
Guan is the quietest in the group. She has broad cheeks, a small puckered mouth. and a head full of straight black hair she pulls into a no-nonsense knot. She speaks with a heavy accent and tends to over-enunciate to help people understand her, which can make her sound brusque. Because English is not her native language, she says, she spends twice as much time studying as the other students.
Her parents managed to moved their family from a small town in Southern China to Boston five years ago so Guan and her brother could attend American universities. In high school in China, Guan planned to work for the government. Once she arrived here, nursing struck her as a practical career, given the pay and job opportunities. Then, while gaining clinical experience last spring, she realized that as a bilingual nurse she has a way to be of extra help and comfort to her fellow immigrants.
Guan’s patient today has a deeply wrinkled face and smooth, bald head. The student finds her asleep, covered in a colorful blanket with the large image of a floppy-eared dog woven into it. Guan calls her name loudly to wake her up. The patient moves but keeps her eyes closed. Guan jostles the patient’s shoulder lightly, calling her name again. The patient cracks open one then the other of her blue eyes and squints up at Guan, who introduces herself.
“I’m going to take your vital signs,” Guan says. The patient smiles and murmurs, “Adorable.”
The student reaches for her patient’s arm under the blanket. Each time she does so, the old woman pulls her arm away. Guan opens a cupboard door near the bed and finds the patient’s hearing aids. One is black, the other is red. Guan isn’t sure which goes in which ear. She leaves to find Barone. The patient closes her eyes and seems to fall back asleep, then begins to cry softly, “Get away, get away.”
Guan spends the rest of the day rousing her patient from the dream world she keeps slipping into. Even with her hearing aids in place, the old woman appears not to hear. Even when she’s awake, she closes her eyes, which makes it impossible to feed her breakfast and then lunch.
“Open your eyes,” Guan chants, hitting hard on each syllable.
Guan clearly has this Thursday’s most demanding patient. Caroline Andrew’s patient has kidney stones and will be discharged today. Two of the other patients, both middle-aged, have terminal cancer, and there is not much to be done for them except to make them comfortable. Kesler’s patient has liver cancer, but doesn’t seem very ill. “It’s hard to know what to say to someone with that diagnosis,” Kesler says.
Unlike Guan, the other five students have time to eat lunch together at the round table where they do charts in the morning. Cardiello says everything is beginning to click for her. Kesler says that, to her surprise, she likes this clinical better than working with the newborns and mothers in the maternity clinical class. She finds it harder but more interesting, owing to the wider range of patients. Andrew agrees. “I thought I was going to hate this,” she says.
Meanwhile, in a nearby room, Guan leans over to draw a sterile sample from the tubing that runs from her patient’s catheter to a urine bag. The patient is napping again, this time in a chair, but there’s no need to wake her. The problem is, there is not much urine. So Guan and Barone have to wait for the dozing patient to urinate, which takes time, as everything does with this patient. Finally there is enough, and then with care Guan transfers the urine, which she has collected in a cup, into a test tube so the sample can be sent to the lab.
That done, Guan smiles, having added another procedure to her repertoire. It’s a start. None of the students has yet put in a catheter, changed a wound dressing, or flushed a central line. With the bulk of the semester to go, there is still time for that. Thursday by Thursday, they are becoming nurses.
Amy Sutherland is a writer in the Boston area.
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