Lessons Learned from my First Clinical Rotation...

I finished my first clinical rotation several weeks ago and if I had to describe the experience in one word, it would be..."unspectacular."

Let me explain how the clinical experiences work during the first semester. For the first semester we complete twelve weeks of medical-surgical clinical. The twelve weeks are divided into two different six-week clinical assignments. For my first six weeks, I was assigned to a hospital almost 30 minutes away. On Mondays I traveled to the hospital to research the patient that I would be taking care of the next day. On Tuesdays and Wednesdays I spent six hours each day caring for my assigned patient.

I have since moved on to my second rotation but I wanted to share with you a few lessons that I learned from my first clinical experience.

1. Don't expect to learn many acute nursing skills on a night rotation. In fact, there's very little to do because everyone is asleep. Why are they asleep? Hmm...maybe it's because it's nighttime and that's when people sleep. While my classmates were placing catheters, suctioning tracheostomy tubes, and caring for gunshot victims, I was still learning nursing 101.
2. You will get lots of opportunities to wake patients up so that you can do a physical and psychosocial assessment. This was the part of the clinical experience that made me feel like a horrible person. Imagine having to wake up a burn or stroke victim and telling them that you have to subject them to an endless list of psychosocial assessment questions and that you will have to percuss, auscultate, and palpate their belly and other parts of their body as well! I was lucky that my patients exhibited such gracious patience because some of my clinical group members weren't as lucky.
3. Nursing is not just about technical skills. My preceptor taught me the most valuable lesson. She's a nurse with over 30 years of experience and she said one thing to us that I'll never forget: "I know you guys didn't get to do a lot of technical things on this floor. But, that's not what's most important. Anyone can put in a catheter. What's important is to use this time to develop your nursing judgement. " I'm not sure if my other group members saw the wisdom in that statement, but, I couldn't help but apply what she said to my future career as a midwife. I realize that there will be many instances where, in order to protect the birth process, I will have to rely on my judgement rather than on a specific maneuver, position, or machine.

Before I started my second clinical rotation, I worried that our group was underprepared. Yet, after talking with other students, I soon realized that not everyone was having those spectacular medical-surgical nursing experiences that a few students had been so vocal about. It was clear that there was a large degree of variation among clinical experiences.

At the start of our current clinical, my preceptor was surprised that we hadn't yet learned how to hang an IV, give a clinical case presentation, or dress a wound. If she was disappointed by our lack of experience, she didn't show it. Instead, she assigns our patients strategically and proactively finds unique learning experiences for us. In just a few short weeks, I no longer felt like I was playing catch-up.

Anyone else felt like their clinical experiences have been...."unspectacular?" How were you able to make the best of it?

This Is Your Brain on GEPN Year...

You might be wondering why my first post in three weeks (sorry!) begins with a picture of feet and a random stack of papers. Look closely at the picture. There's something that is not quite right.

As one of our professors often says: "Looking is Not Seeing."

If you still don't get it, here is what you're actually seeing:

1. I'm at the gym with my fellow smiddies! (Yes, you have time for the gym in your GEPN year).

2. I have lecture notes in my hand :( . (When you have three exams in ten days you have to study while you're exercising).

3. I'm wearing two different shoes. Yup...two completely different shoes! My fellow smiddies pointed out my error and we had a good laugh about it...

But, the really funny/pitiful thing is that this is not the first time I've made this mistake. Around this time last year, I was juggling a full-time job and taking my last pre-requisite class and I made the same mistake. I had had a crazy day and I remember having to run to class in order to get there on time. Well, right before we began our experiment my lab partner suddenly looked down and asked me loudly, "Are you wearing two different shoes?" LOL.

I figure this post would be an easy way to let you in on the craziness that has unfolded in the past few weeks. I wanted to write about so many things! The good news is that I have three weeks without any exams and Thanksgiving break is just around the corner. Since things have calmed down I will be back later this week to share. Until next time...

Movement In Labor...Not as Straightforward as it Sounds?

When I taught childbirth classes as a Lamaze Certified Childbirth Educator, Healthy Birth Practice # Two: Walk, Move Around, and Change Positions Throughout Labor always held a prominent role in each class. I brought birth balls that moms (and oftentimes, dads) could sway on during class, I used various games that required moms and dads to get off the comfy pillows and onto their feet, and I staged "labor rehearsals" during which they would practice different positions and pain coping techniques.

However, being able to move freely during labor is not always as easy as "walk the halls of the hospital with your IV pole." There are times when women have to contend with many more tubes and wires. To illustrate that point, I frequently showed an image of a laboring mother who was "hooked up" to various wires and tubes in the hospital. The image (shown below) was published in Mothering magazine as part of their article "Cesarean Birth in a Culture of Fear" by Wendy Ponte in the September 2007/October 2007 issue of Mothering Magazine.

The image was illustrated by Kim Martens.

This illustration is, of course, an extreme, and I made sure to point that out. However, I really wanted to get across the idea that being able to move in labor depended on whether or not you could actually get out of the hospital bed! I couldn't help but feel like I would be doing a disservice to my clients if I didn't prepare them for the obstacles they might face if they did in fact want to be able to move around freely.

The issue of whether or not you could get out of bed was controlled by various external and internal factors, including:

• Using routine interventions
• Having care providers that do not encourage or support movement in labor
• Choosing a birth setting that does not encourage or support movement in labor
• Giving birth with pain medication

Some of the above factors are modifiable and can be planned for. But, birth planning can only go so far- it's impossible to totally predict the choices you will make and the needs you will have once labor and birth has started.

Ultimately, like all of the other Healthy Birth Practices, being able to "Walk, Move Around, and Change Positions Throughout Labor" does not exist in a vacuum and is dependent on the larger birth culture. It's especially difficult to talk about factors such as birth setting and care provider in a childbirth class because the expecting mothers are seven/eight months pregnant and at that point expecting mothers *usually* find it difficult to consider those factors modifiable.

Thus, what starts off as a discussion about movement during labor can morph into a valuable discussion about making choices before and during labor. It's also a great opportunity to review the concept of informed consent and to discuss how to foster an atmosphere of respect and equality when communicating and negotiating with a caregiver. Because ultimately, these are the tools that couples will need to be able to call upon when they are confronted with obstacles that might prevent them from moving freely in labor.

Interview with Amy Romano from Science and Sensibility (Part 2 of 2)

Today is the second and final blog post in a two-part interview series with Amy Romano from Science and Sensibility. Click here if you missed the first post. Amy Romano is a Certified Nurse-Midwife, a YSN graduate, and the primary blogger at Science and Sensibility.

Nurse-midwifery is often looked at skeptically because of it's ties to hospitals and physicians. Unfortunately, nurse-midwives are often assigned the pejorative role of "medwives" (midwives who are more closely aligned to the obstetric model of care). I wrote about this dilemma when I discussed the compatibility of Holistic Midwifery and the CNM. Do you think nurse-midwifery is compatible with holistic midwifery? Do you consider yourself to be a holistic midwife? If so, how do you incorporate holistic midwifery into your practice?

"I do think that nurse-midwifery is compatible with holistic midwifery, but I think that our system gives all midwives two choices: assimilate or opt out. So every midwife faces a choice of whether she wants to improve care from within the system or accept being marginalized in order to provide a more family-centered style of care. Of course there are exceptions to this rule in both directions, but in general I do think it's assimilation or marginalization. There are some pockets in the U.S. where hospital-based CNMs are providing truly exemplary care with physicians who understand collaborative care and the midwives' independent scope of practice. We need to continue to be vocal about these practices and show how this midwife-led model, regardless of birth setting, contributes to the best outcomes and satisfied consumers. I realized recently that very few midwives are aware that there was a 2009 Cochrane Review that showed quite conclusively that *independent* midwifery, aka midwife-led care, is safer and more effective than physician-led care (where midwives work for doctors) or even shared-care (where midwives work with doctors). And the findings held for women whether or not they were "low risk".

With all of that said, I think that the current way that nurse-midwives are educated does contribute to medicalization of the profession. I think that the reasons I was able to practice "holistic" midwifery were despite my education, rather than because of it. For one, I worked in a birth center in Guatemala during the summer before I started the GEPN program and for the two subsequent summers. The U.S.-trained midwife who ran the birth center was a really important mentor for me and taught me a lot about normal birth. In addition to that, the hospitals we would transfer to in the case of complications provided really inadequate care, and basically everyone who transferred would have a c-section. So we "managed" a lot of things at the birth center that would certainly have led to transfers in the United States. It gave me an understanding of how to handle complications in a humane and mother-friendly way and bring in only the aspects of technology that were needed to correct the problem rather than throwing the baby out with the bathwater (i.e., converting completely to a paternalistic interventive style when complications cropped up and reserving "midwifery model" care only for those lucky enough to have no complications).

In addition, when I was in midwifery school I briefly decided I was going to do a dual degree program and get my Masters in Public Health. Well, I got about 2 weeks into the public health stuff before I realized that I had taken on way more than I could chew. So I withdrew from EPH and ended up having a year off in the middle of my two midwifery years. I was expected to keep up with my clinicals, though. So I did a regular GYN rotation and also designed two independent study rotations. One was following an entire CenteringPregnancy group from their first visit through their postpartum care. The other was a home birth rotation with Birth & Beyond. I learned more in those two rotations than I did in any of my previous clinical experiences. Centering allowed me to learn a facilitative style, really dig in and talk about nutrition or domestic violence or you name it, and include women in their own care. I got the same lessons from the home birth rotation but was also able to attend the births and learn comfort measures, how to correct problems with labor progress, how to give good breastfeeding support, and when and why to transfer or refer women. I would be a very different midwife were it not for these experiences, but it was truly a random thing that I got to experience them.

I think midwifery programs in the United States need to think about placing more students in these types of settings, and students should be demanding these types of experiences. When I was practicing with Birth & Beyond we constantly had students asking if they could come shadow us or set up a clinical assignment, but no one ever followed through. In the meantime, though, we had a high school student, an undergraduate nursing student, and a medical student intern with us. And they all had wonderful, eye-opening experiences!"

I'd like to thank Amy again for taking the time to answer these questions. It's always great to hear from more experienced midwives!

If you are interested in exploring more about using research to improve maternity care, visit Amy's blog Science and Sensibility: A Research Blog about Healthy Pregnancy, Birth & Beyond.

My Email Should Be Working Now...

As some of you know I have been having problems with my email address! I apologize if you tried to email me and received an error message. My email address should be working now.

If you need to contact me, please email me at: nursemidwifeintraining [@] gmail [dot] com. If you are still having problems emailing me, then leave a comment on this post.

Thanks!

Resources for Care Planning

If you're a nursing student then you know that care planning is a necessary evil in nursing school. Besides taking up at least four hours of your time, it helps you to think about the most important nursing considerations when it comes to contributing to the care and health management of your patient.

I'm not an expert on care planning but I wanted to give current and future nursing students (especially accelerated students) some quality sources for nursing care plans.

General Tips:

• Think of nursing care plans as a way to organize your time during clinical and a way to start developing clinical judgement
• Find the mix of electronic and print sources that work for you
• Use your school's electronic books system! Your nursing school most likely has several electronic nursing diagnoses books and resources of which you should take advantage

Electronic Drug Resources: All three of these resources include the basic information for drugs such as indications, adverse effects, contraindications, and drug interactions. I've mentioned three sources below that I like for different reasons.

• Electronic version of 2009 Lippincott's Nursing Drug Guide: This resource includes nursing assessments, interventions, and client teaching points. It's great for in-depth care plans and for helping you create a cheat-sheet for your clinical.
• Electronic version of Davis's Drug Guide for Nurses (2009): Love this guide for the same reasons as the Lippincott's Nursing Guide and because it also includes nursing diagnoses to accompany the nursing assessment section for each drug.
• Micromedex: A great quick reference that is often available in hospital computers as a bookmarked link when you are on the floor and need to do some quick research on new drug orders. Be aware, however, that it is not nursing specific and so you won't find nursing considerations such as assessments, interventions, and client teaching points.

Preparing for Clinical: On one sheet of paper have the following things:

• A chart of all of the drugs that your client is taking, including why THAT INDIVIDUAL is taking it. Include the other indications for that drug only if you think your preceptor is going to ask you about them. Besides the clinical justification also include: the dose, any notable interactions, and the relevant nursing considerations. For example, with a diuretic, one of your nursing considerations will be to make sure you check the electrolyte balance, specifically the potassium level, before you give the drug because if the potassium level is too low and you give the diuretic anyway, your patient could end up hypokalemic.
• A schedule so that you can organize your time. For the 6 hours that you are in clinical, map out when you will give a bed bath, give meds, do your physical assessment, interview your patient, have your post-conference with your preceptor and fellow students, change wound dressings, and so on and so forth. It's important to be organized because time will get away from you!

Finally, if you need help identifying nursing diagnoses, try the Ackley and Ladwig Care Plan Website. I love this website because it allows you to identify nursing diagnoses based off of specific symptoms or disorders.

Hope this helps anyone struggling with care plans and preparing for clinical. Are there any quality resources that I've missed?

Interview with Amy Romano from Science and Sensibility (Part 1 of 2)

Today I'd like to share Part One of an online interview with Amy Romano. Amy Romano is a Certified Nurse Midwife, a YSN graduate, and the primary blogger at Science and Sensibility. I "met" Amy online through this blog and have been corresponding with her for the past couple months. Her story is incredibly dynamic and she agreed to share it with all of you. Amy provided such comprehensive and thorough responses to my questions that I decided to divide up the interview into two blog posts.

I have to say that as a student it has been immensely helpful for me to connect with Amy because her journey as a young midwife proves that there is a great deal of clinical and professional potential within the midwifery profession. Be inspired!

In my experience, the path to midwifery is rarely straight and frankly, it is often roundabout. Yet, it's clear that every midwife at some point in her life receives a calling. What led you to midwifery and why did you choose the Yale School of Nursing?

"I didn't know there was any such thing as a contemporary midwife until I was a sophomore in college and was taking a Women's Health course at the University of Michigan. A midwife who worked at a freestanding birth center gave us a guest lecture, and her message just completely resonated. I left that class thinking to myself, "I want to be a midwife." By then, though, the thought of transferring to the nursing school seemed overwhelming to me and I didn't really know enough about direct entry midwifery to realize that it was a viable option, so I kept on in my liberal arts education. I graduated with a B.A. in Women's Health and Economics and thought I was going to end up going back to school for public health.

My first job was a communications internship at the National Cancer Institute, then I got a job at Population Services International, an international NGO working in reproductive health social marketing. (I got to travel to Uganda and Burma!) I started to reach my two year shelf life at that job and got itchy to make my next move. I had a friend from school who *had* gone on to be a nurse-midwife and by then she was practicing. I called her and asked what she thought about me going to midwifery school.

In retrospect, it was a pretty random decision. I could have seen myself making any of a dozen other arbitrary career moves at that time. I don't think it was well into my midwifery education that I realized how much I was meant to work in the field of midwifery. A series of really important mentors helped me clarify my philosophy and politics about birth, and entrusted me with way more responsibility than I probably deserved. I ended up at Yale because it was one of the few schools that didn't require a B.S.N. and (more importantly) because the word on the street was that it was one of the best nurse-midwifery programs."

You graduated from Yale in 2004. What have you been doing since you graduated?

"I gave birth to my first child right after graduating. I expected not to look for midwifery work for 6 months or longer, but I wanted to do *something* midwifery related. Mary Ellen Rousseau (one of my YSN professors) passed along a job announcement to the student list. The job was an editor for the Lamaze Institute for Normal Birth, the advocacy arm of Lamaze International. I applied and, to my sincere disbelief, got the job. As it turned out, I ended up seeing my dream job pop up on MidwifeJobs.com just a few weeks later. It was a midwife-owned birth center on the East Coast, three of the characteristics on my first-job wish list. I knew jobs like that were few and far between so I applied and got the job. So for the first two or so years after school, I worked at The Birth Center: Holistic Women's Health Care in Wilmington, which I just adored. It is one of the oldest birth centers in continuous operation in the United States and the community there really treasures it. I felt really connected with my clients because I had a new family of my own so our ample office visits (30-60 minutes) provided time to connect on the woman-to-woman level, not just the provider-patient level.

In 2006, I gave birth to my second child and decided to take some time off from practicing. We moved back to Connecticut to be closer to family. When my son was about nine months old I began working very part time for Birth & Beyond, the home and hospital birth practice in Madison, CT, and a few months later I became a full midwife in the practice. Unfortunately, that practice closed down this summer as a result of multiple factors - we lost our physician back-up which in turn meant we lost our hospital privileges and we had a very difficult time recruiting a third midwife after one of the midwives in the practice left. The practice was too busy to continue with only two midwives, so we are officially on hiatus until we can sort out a practice model that is sustainable and does not result in midwives who are completely burned out.

In addition to practicing, I've worked for Lamaze International since 2004 and also have worked with the Coalition for Improving Maternity Services as part of the Expert Work Group that evaluated the evidence basis for the Ten Steps of the Mother-Friendly Childbirth Initiative and in their work promoting The Birth Survey, a tool for women to find and provide feedback about providers and birth facilities. I also am co-authoring the next edition of Obstetric Myths versus Research Realities with Henci Goer, due out in late 2010. Basically, everything I do has to do with using research to improve maternity care."

I'll post part two of the interview with Amy Romano next week. If you are interested in exploring more about using research to improve maternity care, visit Amy's blog Science and Sensibility: A Research Blog about Healthy Pregnancy, Birth & Beyond.