Becoming a Real Nurse

By Sylvia Wrobel • Photography by Jack Kearse

Early every Tuesday for 15 weeks, Whitney Winston and Kaitlin Ahienius head to unit 10-E in Emory University Hospital

(EUH). On each of those Tuesdays, the Emory nursing students work alongside 30-year seasoned nurse Corinne Slack throughout a 12-hour shift. They say the long shift—typical for nurses— marked their first acclimation to real-world nursing.

They are there in the morning when the night nurse gives Slack an update at patients’ bedsides. They squeeze in with their instructor in the small medication room, reviewing each patient’s updated laboratory results and medication orders. Although Winston and Ahienius lack the privilege to access the locked medicine cabinets, Slack hands them the drugs, which they check against orders on a computer, then watch their teacher double-check their work. Pushing a cart loaded with medicines and the ubiquitous computer, they next follow Slack to the first patient’s room, where her name as nurse and theirs as students are printed on a white board at the foot of the bed so that the patient and family members can identify them.

Traditionally, groups of nursing students have trailed a nursing professor through different clinical units to get their first interactions with patients, to draw blood or give injections on a person rather than a mannequin, to see how quickly emergencies occur and staff nurses respond. But what Winston and Ahienius are experiencing is total immersion in a dedicated education unit (DEU), where they begin to understand the pace, choreography, and culture of a unit in a complex, tertiary care hospital.

Susan Grant, chief nursing officer for Emory Healthcare, says even the best-prepared new nurses can take months to become comfortable and confident—time health care can ill afford in an era of shortages, both of staff nurses and nursing faculty to train more. That’s one reason Emory Healthcare was eager to be a part of a joint plan with Emory’s Nell Hodgson Woodruff School of Nursing to offer a faster-track, more immersive, staff nurse-centered clinical rotation to junior and senior nursing students.

Emory launched the first two DEUs in 2009— at EUH on 10-E, where patients are recovering from gastrointestinal surgery and at EUH Midtown on a floor for patients with a range of complex medical and postsurgical conditions. A DEU in Midtown’s women’s services soon followed, and others are now in the works.

Although DEU programs vary widely, they usually share a strong partnership between nursing schools and hospitals, experienced staff nurses who serve as the primary clinical instructors, and a commitment of the nurses on these units to help students learn what it means to be one of them.

Teaching students and the teachers

As coordinator of Emory’s DEU program, Kelly Brewer meets with undergraduate students weekly or whenever they need answers or context. She grades their assignments and stays with the students—whom she affectionately calls “my chicks”—during the long days they spend on the DEU clinical rotation.

Brewer also prepares and supports the staff nurses who serve as the students’ primary clinical instructors. Many DEU instructors already have experience as preceptors who have taught the ropes to new nurses. But having primary responsibility for undergraduates requires a different level of responsibility: meeting educational objectives, evaluating work and providing feedback, motivating students to keep performing and progressing, encouraging them when they break down, and correcting them when necessary.

The payoff for students makes the effort worth it. Because DEU students work in pairs and do not have to wait for a professor to do a procedure among a larger group, they say they sometimes do more real nursing in one day than they did in total during three regular rotations.

As a DEU clinical instructor, Slack continually evaluates her students’ strengths and weaknesses, teaching them new skills when they are ready. Today, for example, her students carefully change a surgical dressing. Good job, says the young patient, then asks Slack if she can walk down the hall later that day. Yes, is the answer, and Whitney and Kaitlin will come help you.

Of course, if patients prefer not to have students involved in their care, they can opt out. Few do. Most, like a middle-aged man with a belly swollen from his surgery, seem to enjoy participating in the program. “They were nervous at first,” he jokingly says, “but I started teaching them right away.” Under Slack’s watchful eye, the students ask the man to rate his pain. They take his vital signs, give him a scheduled injection, and log their actions into the computer. Slack rechecks everything and nods almost imperceptibly—both at the skill of the injection and the “confident demeanor” she considers to be a vital part of learning to be a nurse.

Veteran nurse Corinne Slack (top left) reviews medication instructions with nursing students on 10E in Emory University Hospital—where they experience the real world of a busy, clinical unit at a tertiary care center.

Students also must learn to prioritize, says Slack. When a crisis occurs on the unit—a bleedout or a cardiopulmonary arrest—the students see prioritization in action, staying out of the way but later getting explanations from Slack, Brewer, and other nurses. They review the events of the day over a meal with Brewer in the hospital cafeteria and share entries from their clinical journals.

Between patients, Slack talks informally to her young charges in the conference room about how to deal with problems she and her colleagues have faced. She also tells her young charges that patients know their bodies best and will be their biggest allies and partners in care.

Where quality and teaching meet

As health care becomes more complex, staff nurses increasingly are called on to fill expanding roles, master more technology and information management systems, and collaborate and coordinate care across growing teams of health professionals. That’s a lot of responsibility. When Grant first proposed the DEU initiative to nursing managers and staff nurses in Emory Healthcare, she half expected a veiled protest: “Oh goody, something new again.” Instead, she got enthusiasm for more teaching—as long as it didn’t diminish safety and quality of care for patients.

That was three years ago. Far from diminishing patient care, these units get extra staffing to assure teaching time doesn’t take away from patient time. Quality is foremost in the DEU, where students are taught that the daily qualityimprovement plan is as important as the care plan.

“I know there will be new things when we start practice,” says Winston, “but I don’t think they will be such a shock.” “And now that I’ve been part of this team,” adds Ahienius, “I feel more confident, knowing there will always be nurses to help me like the ones on 10-E help us and each other.”

Health Access In

By Dana Goldman

The goal was to improve the everyday lives of Ethiopians by giving them access to better health services. That ambitious dream not only came true but also is spreading in new directions throughout the country and beyond.

It all started in Addis Ababa, roughly 20 years ago, during a meeting between U.S. President Jimmy Carter and Ethiopian President Meles Zenawi. The two leaders and friends had just toured an agricultural demonstration project in rural Ethiopia, in which the Carter Center of Emory University was assisting. (The project later contributed to grain exports from Ethiopia for the first time in modern history.)

Both men were energized by the opportunities in Ethiopia after the end of a brutal civil war. Still Zenawi knew that to stabilize his country, he needed to address a severe lack of access to health services—especially in rural areas.

At the time, Ethiopia had several government-run universities that were training physicians, but most of these professionals soon left Ethiopia for better economic opportunity. Limited infrastructure, poor access to safe water, and high fertility all contributed to an already challenging situation there.

During their discussions, Carter and Zenawi agreed that any plan to train health workers and improve health conditions should be implemented by Ethiopians for Ethiopians. Their brainstorming led to the Ethiopia Public Health Training Initiative (EPHTI), launched in 1997, which set out to build a sustainable health care workforce and strengthen capacity to better tackle health needs.

“Our ultimate goal was to improve the lives of everyday Ethiopians by giving them access to better health through better trained health workers,” says Shelly Terrazas, who served as EPHTI assistant director.

Nothing like the EPHTI had previously been attempted on a national scale in a developing country. To complicate matters, the plan called for collaboration between two Ethiopian ministries—Education and Health—one which trained health workers and the other which deployed them, but these ministries had had little communication with each other.

However, the effort had several things going for it: a strong political commitment, the Carter Center’s grassroots experience in agricultural development and Guinea worm eradication, and access to Emory faculty expertise.

Over the next 13 years, the partners—including seven governmentfunded Ethiopian universities—focused on creating culturally appropriate and accurate health materials as well as training teachers. Colleagues from the Carter Center and Emory (led by Emory nursing professor and thenEPHTI director Joyce Murray) frequently flew to Ethiopia to train faculty counterparts there to become more effective teachers. Throughout the year, small groups of Ethiopian faculty members from around the country met to discuss health concerns and create new learning materials, a process of collaboration and open dialogue that was new for them.

Another key component of the work was providing $1 million worth of new reference materials. Many of the materials in Ethiopia’s classrooms and university libraries were decades out of date.

“When we started, the majority of faculty members were newly graduated students themselves with no experience in the classroom, and they were using notes they took as students as lesson plans because they had nothing else to work with,” says Terrazas. “We worked to strengthen their teaching skills and help them develop a comprehensive curriculum that each of the universities in the network could use.”

Fast forward to today: more than 2,500 experts have been trained through Ethiopian universities, nearly 230 health learning modules have been developed, and more than 26,000 health care professionals have been trained to serve the rural population, the majority of the population.

The EPHTI has made good on Carter’s and Zenawi’s commitments to each other. Ethiopia is now a model for a new wave of development that focuses on empowering local communities to build long-term, sustainable capacity for health services and infrastructure.

The project also has paved the way for more collaborations between Emory and Ethiopia. For instance, Emory nursing professor Lynn Sibley, who has served as an EPHTI consultant, currently is conducting a multi-year project in two rural areas of Ethiopia that helps new parents recognize signs of health problems in their newborns and connect with local health workers (see photo top left).

Perhaps most satisfying to the EPHTI team, however, is what’s happening outside of Ethiopia: the EPHTI model is spreading to other African countries. Elements of the program are being replicated in Liberia to train local health workers on mental health issues, and several African countries are working with the Carter Center on plans to create their own public health training initiatives.

WEB CONNECTION Through support from the Ethiopian government, all EPTHI learning materials are available for free download at: cartercenter.org/health/ephti/learning_materials/index.html.

See also Educating Health Professionals in Low-Resource Countries, by Joyce Murray, Anna Frances Wenger, Elizabeth Downes, and Shelly Terrazas, on conducting teacher workshops in Ethiopia.

Protecting Parkinson’s brains

With the help of experimental gene therapy, Emory doctors are hoping to encourage brain cells under stress from Parkinson’s disease to do more nurturing.

The goal is to prod the brains of Parkinson’s disease patients to produce more of the growth factor neurturin. Neurturin is a naturally occurring protein that has been shown to protect and improve the function of damaged brain cells in animal models of Parkinson’s. Doctors think neurturin could help prevent loss of the dopamine-producing brain cells that help regulate movement and slow progression of the disease’s motor symptoms, including tremor and stiffness.

The study is aimed at Parkinson’s patients who continue to experience motor complications despite adequate drug therapy. Emory is one of 11 institutions nationwide participating in the research, which is partially funded by the Michael J. Fox Foundation for Parkinson’s Research. The clinical trial will follow 50 patients for 15 weeks up to three years after treatment to test safety and efficacy of the treatment.

A new Emory study that uses an experimental gene therapy approach seeks to help Parkinson’s patients who continue to experience motor complications despite adequate drug therapy.

In the trial, surgeons will inject a gene that encodes neurturin (clothed in a modified virus that doesn’t cause disease) directly into the substantia nigra and putamen, two key brain areas damaged in Parkinson’s. Half

Using breath to detect lung cancer

of the participants will undergo a placebo procedure, where nothing will be injected. If the study demonstrates the therapy to be safe and beneficial, those who receive placebo operations can receive the therapy later at no cost.

“Most available therapies for Parkinson’s disease treat symptoms and do not address the degeneration of the brain cells,” says Emory neurosurgeon and principal investigator Nicholas Boulis. “This trial takes a new approach that emphasizes the protection of brain cells and is aimed at restoring function and ultimately delaying the progression of the disease.”

Another Emory study takes a similar approach for Alzheimer’s patients, but it uses a different gene (nerve growth factor) and targets a different part of the brain.

In previous clinical trials, surgeons have inserted growth factor directly into the brains of Parkinson’s patients with disappointing results. However, in the aftermath of those trials, they believe that the growth factors didn’t spread enough to benefit the targeted areas.

By contrast, “gene therapy would be an improvement over infusion therapy as it involves one procedure and leads to long-lasting expression,” says Emory neurologist and co-investigator Stewart Factor. —Quinn Eastman

Seed grants—or pilot projects—offer one way for an adventurous research idea to get a start. At Emory, one such pilot project is allowing researchers to explore the use of breath for early detection of lung cancer. The project is made possible through part of a $4.7 million gift from Sarah and James Kennedy that set aside support for seed grants, and it was one of five $50,000 awards from the Kennedy Seed Grant program in 2010.

Collaborating with Emory breast cancer surgeon Sheryl Gabram and colleagues from Georgia Tech, Emory thoracic oncologist Suresh Ramalingam and postdoctoral fellow Geetha Vallabhaneni are collecting samples from patients with and without lung cancer. During testing, a patient breathes into a device that separates and detects volatile organic compounds. The presence of cancer cells, which often have altered metabolism, may be detectable in the pattern of organic compounds in the breath.

“Right now, we use CT scanning to decide whether a patient with suspected lung cancer should undergo a biopsy,” Ramalingam says. “Having additional information to bring to that decision would be a significant improvement, and the lung is an ideal place to start.” —QE

Healthy Summer Reading

Recent and soon-to-be-released titles from Emory Health authors

All in the Timing

By Charles Hatcher Jr.

This biography recounts the journey of a small-town boy from rural Attalpulgus, Ga., to the top ranks of the medical ladder, with an insider’s stories on leading Emory’s Woodruff Health Sciences Center.

Before You Take that Pill

By Douglas Bremner

The Emory psychiatrist provides an inside look at the pharmaceutical industry and offers a safety assessment of more than 300 commonly prescribed medications, vitamins, and supplements.

Beyond the White House

By Jimmy Carter

The President’s years after the White House have been among the most productive of U.S. Presidents, a time in which the Nobel Laureate and Emory distinguished professor has waged peace, fought disease, and built hope through the Carter Center of Emory University.

Cheating Death

By Sanjay Gupta

The Emory neurosurgeon and CNN chief medical correspondent known as America’s Doctor explores the medical miracles that are saving lives against all odds.

The Dalai Lama’s Little Book of Inner Peace

By the Dalai Lama

The Emory distinguished professor packages his essential life lessons and teachings under one cover.

A Doctor in Little Lhasa

By Timothy Holtz

The Emory infectious disease professor spent a year providing medical care to Tibetan refugees in Dharamsala. His account is required reading for those searching for a connection between medical training and social justice.

Health Information for International Travel 2011

eds. Phyllis Kozarsky, Alan Magill, David Shlim, and Gary Brunette Learn from the director of Emory’s TravelWell Clinic what to expect before you go abroad and what to take before you pack.

House on Fire

By William Foege

The Emory distinguished professor and born storyteller recounts the adventures and stories of what it was like to work on the ground in some of the world’s most impoverished countries to eradicate smallpox.

Leaves Falling Gently

By Susan Bauer-Wu

An Emory nursing professor ponders how to live fully with serious illness through mindfulness, compassion, and connectedness.

The Real Truth About Aging

By Neil Shulman, Michael Silverman, and Adam Golden

Learn which vitamins may make a difference in your health, safe new approaches to getting a good night’s sleep, and health tips that can save you money in this guide from Emory doctor Neil Shulman and colleagues. See also his Your Body’s Red Light Warning Signals, with co-authors Jack Birge and Joon Ahn, a new edition of an essential reference that puts an ER doctor in your home.

Fragile X revisited

Emory human genetics chair Stephen Warren has led research on fragile X syndrome since it was first identified nearly three decades ago as the most common inherited cause of intellectual disability. In 1991, he led a team that discovered the mutated gene on the X chromosome. Along with other Emory scientists, he helped develop a screening test for fragile X and has been studying it ever since.

Until recently, there has been no treatment, but in 2010, Emory joined four other medical centers in a phase 2 clinical trial that is testing a targeted drug therapy for the syndrome.

In the most recent findings from Emory, scientists collaborating with Warren show how the protein missing in fragile X syndrome acts as a molecular toggle switch in brain cells. To learn more about this research, published in the June issue of Molecular Cell, see bit.ly/ fragileXtoggleswitch.