By Kirsten Ainlay, BSN, RN, CMGT-BC

My nursing practice has developed into the importance of treating the root of the problem, and not the symptoms alone. This nursing practice aligns beautifully with the case management process. The ability to identify gaps in care and various health inequities is the foundation of solving the origin of the symptoms. In my current position as a public health nurse case manager, I medically manage youth within the foster care system. I advocate for their healthcare needs by providing insurance companies with detailed rationales as to why an otherwise uncovered service is needed for the child to thrive. Personally, I view a multidisciplinary approach as the most effective tool when all members of the care team bring their expertise to the table. The amount of collaboration and new ideas that are born from this multidisciplinary approach are extremely beneficial to the child and their healthcare needs and goals.

I began my career in the Neonatal Intensive Care Unit, and to say I was nervous and self-conscious of my abilities as a new grad. Unfortunately, there will always be members of the care team that are focused on the inexperience of the new graduate, and I took it upon myself to attempt and remove the severity of that mindset within our unit. Was everyone on board? No. Was I told I wouldn’t know what to do when a code is called? Yes. My team: the ones that I work alongside to save a life was fixated on the fact that I did not seem to have enough experience. The main oversight was that these nurses could have utilized me for up-to-date evidence-based practice. What I lacked in years of experience, I made up for through my drive, passion, critical thinking skills, and debriefing information regarding every patient.

Here I was, a new nurse who had been chewed up and spit out. I felt like I had failed and that I wasn’t a good nurse. As those very thoughts popped into my head, a code was called. I did know what to do and I was anticipating next actions. I was going to do my best despite the negative input from those team members who doubted me. This patient had gone into labor at 28 weeks after an overdose. The main demographic of patients was wealthy and barriers in social determinants of health were few and far between for a large population. Upon those doors bursting open and the emergent report, I could tell that there was a general sense of judgment against the mother, and I felt my heart sink in my chest. Running alongside the mother to the operating room, I couldn’t help but see the heartbreak in her actions. She wasn’t a bad person, she had no malicious intent, she was experiencing the physical symptoms of labor and regaining consciousness through medication all at one time.

I cannot say for sure what made me feel like there was a looming cloud of judgment. I knew that this mother was utilizing methadone therapy to be successful in her sobriety. She was becoming someone her child would have around and someone they could look up to. The fear in her eyes struck me to my very core. To say the least, it was a very complicated delivery, followed by a very complicated NICU admission. Once the newborn was stable, I advocated for mom to stay with the baby for the remaining days she would have with that child. This act of advocacy was not well received by most individuals on the unit. In the middle of the night, I made sure to speak with her about any concerns, but also give her the chance to explain what had happened. Though the report should be accurate, sometimes personal bias can hinder the overall care of the patient. While the newborn was withdrawing and experiencing some of the most brutal symptoms, mom was there. Mom gave her all to do the very best she could in the short amount of time she was able to do so. Later, she thanked me for being so respectful and non-judgmental toward the situation. I said I was proud of her. The confusion on her face showed me that no one had thanked her for sitting in the room for five days straight to ensure that her baby had the best possible outcome.

This woman was intelligent; like many others, she was held captive by addiction, but she knew that skin-to-skin and breastfeeding would only contribute positively to the baby. I came to learn her entire life story and it boiled down to a lifetime of healthcare professionals focusing primarily on pieces of the story that would naturally lead to judgment. It hurt. It hurt to know that individuals in my field could let barriers be the demise of someone’s life and well-being. This woman had a sibling pass away when her mother started withdrawing from opiates. Drugs were made readily available to her, as her mother was turned away from mental health services to follow up with an otherwise extremely traumatic event. As the new mom and I spoke, I began to understand the choice between what she thought would be the lesser of two evils. This woman was without money, transportation, or proper identification because of an abusive boyfriend and his gang affiliation. It was important that she was completely dependent on him to maintain her attachment and fear regarding his presence. She was left without transportation and could not get to the methadone clinic. After hours of overcoming a transportation barrier, she was able to obtain a ride. She was unable to be seen because of the lack of identification. It had been about six hours and she was beginning to withdraw badly. She told me all she could think about was her brother dying for the very same thing. The only option she felt she had was to obtain drugs on the street to avoid withdrawal. She knew what could happen, but she didn’t want her child to suffer from her mistakes. Unknown to her, the drugs were contaminated with fentanyl. This would ultimately lead to her overdose and possibly the worst week of her life.

This is one of many scenarios in which my soul grew deeper and deeper into sadness. It broke my heart that services were available but weren’t made available to her. It was hard to watch people walk out of those doors with discharge information and not know how things would pan out for them. I began to see the massive impact that preventative care, education, support, and advocacy could have on many demographics. Case management became such a passion to me, and I felt as if all of my efforts and hard work may actually begin to change the way things operate. I have her to thank for that, and I hope that she knows how much impact she had on me.

I began working with pediatric patients in the foster care system and their foster families. I started questioning processes and policies to ensure that they were in the best interest of the children backed by best practices. When I saw an injustice or medical decisions rooted in judgment, I would advocate at all costs. This process was not and is still not easy. I frequently think of that specific NICU experience and how I can ensure that preventative services and support are easily accessible. Accessibility is only half of the battle. As case managers, it is our position to ensure that these services are free of barriers. I work tirelessly to establish concrete foundational plans to fix the root cause and not the symptoms.

CMSA’s public policy initiative serves to represent member interests on issues affecting care management professionals and their patients' wellbeing. To learn how you can get involved click here:

Bio:  Kirsten Ainlay BSN, RN, CMGT-BC is Executive Director of RN Ruth Advocacy and Founder of Barton Nightingale Apothecary Health & Wellness Gathering.