About One DNP

I earned my "terminal practice" degree in nursing from the University of Tennessee Health Sciences Center in a journey of excitement and challenge. It inspired me to advocate for an all encompassing clinical credential rather than continuing the hodgepodge of nonsensical initials. I hope these entries will provide entertainment and insight into the Doctor of Nursing Practice experience, which will soon be the entry standard for all advanced practice nurses.

Friday, October 15, 2010

Thursday-Night-Fight Highlights

Laaaaaadies and Gentlemen! In this corner, weighing in at 30% of the advanced practice nursing psych professionals wearing APRN badges. In this corner we have 70% of the advanced practice nursing psych professionals wearing CNS badges. And our referee tonight is the general public wearing a hospital gown and bracelet reading "so you are a nurse with a some extra training or something?" This is a mortal combat match. The winner of this round will face off against the biggest opponent to advancement and awareness of nursing practice - no, it is not the AMA, it is a giant mirror.

Now that I got that off my chest . . .

I get it. If I were a CNS with a decade or more of practice I would feel invalidated by the position that the NP will be the basis for advanced practice nursing. I would feel "there are more of us than their are of you, so you should change to OUR title." I would be nervous that, without having the NP designation after my name, that I will loose parts or all of my ability to practice. And I would feel resentful that after thousands of hours of clinical work, I may have to go back to school and take another damn standardized test, not to continue practice, but to have all my bases covered.

Yep, I would have a big fat chip on my shoulder.

Nevertheless, I believe merging the CNS and APRN role into one designation in the future (not retroactively - some folks got stuck on that argument 8-track and couldn't get off no matter how many times the phrase, "not for those currently in practice, this is for those coming in the future" was used) and focusing on lifespan rather than specialty populations makes good sense for several reasons.

  • "So a nurse practitioner you see for colds, but the serious stuff like blood pressure you need a doctor."
  • "You guys are like physicians assistants just without the science background, right?"
  • "Oh yeah, my daughter is an RN - are you going to go for that when you are done?"
We have enough problems trying to explain our "mid-level provider" role to the public without having to explain several of them. Heck, I never heard of a CNS before nursing school and am still not entirely sure what the difference is between NPs and CNSs outside of psych. The argument that we just need to keep all the credentials separate and let the public slowly adjust is illogical - the public has already had a few decades and it has not assimilated. People are busy enough without having to figure out a myriad of differing professional credentials that essentially mean the same thing.

When the provider is lifespan educated, all doors to practice are open even if you want to specialize in a particular population or psych disorder. This way, a patient who started seeing their provider at 14 can keep seeing them into their 30s if both agree it is in the patient's best interest.

Moreover, we need image control. The good-old-boys medical network presents a cool, calm, collected front of intellectuals. We present a hormonal, defensive, fragmented group of providers who maybe were not smart enough to be doctors. Seriously, chiropractors encroach on the MD conscripted "doctor" title and get nearly no political flack for it because even their smarmy ethics get more respect than our uppity-handmaiden persona. The ANA needs a PR firm - it would probably enhance what our lobbyists do 10-fold.

I have argued this from the DNP angle ad nauseam. If the DNP is the single designation for advanced practice by the time all of us have returned to the dust, I feel we have done our job. In the meantime, the NP role in the psych multidisciplinary team has established itself well in the decade it has been in existence. Our peers in other specialties are phasing out the CNS as the NP becomes the dominant degree, and while psych does tend to be slow to adopt change, there is no need to separate ourselves for the sake of preserving a title. Other professions, like the MD and the PsychD and the DPT, may have specialty focus beyond their core training, but their is no role confusion or use of multiple credentials within the same education levels as there is with nursing. Being different is great if you are in the business of fashion or retail or sports, but in healthcare, conformity is a good thing - Iit fosters "brand awareness."

It costs a lot of money to create certifications exams and state licensing. The less there are, the less expensive the fees will be. Or slower the fees will rise, at any rate. I imagine testing may evolve to some sort of module model at some point, but in the meantime streamlining is more cost effective and can result in greater speed and delivery of the application, testing, and certification process.

If nurses run the healthcare system, nobody seems to know it. Stratified as we are, unity through every educational level of the profession is a challenge, but it is attainable and it has to come from the "top" down. We must make our scope and standards clear in order to lobby for uniform advance practice rights in EVERY state. We cannot accomplish this with 31-flavors of advanced practice nursing.

I do not endorse the medical practice model, however I do endorse the medical designation model of one, all encompassing practice credential. I also believe the generalist-to-specialist education model provides a solid foundation to which all of us can relate to. I would not go so far (yet) as to say all of us need to be FNP certified first before becoming CNMs or CRNAs, but we should have a good chunk of our didactic education the same as well as some form of uniform clinical component.

Ultimately, we need to do whatever is necessary to result in full autonomy and the elimination of physician oversight of our profession. This strength will allow us to advocate for RNs and LPNs who we must still consider our professional responsibility to promote and protect. Our stratification is unique compared to other health care disciplines - we decide if it works to our advantage or our demise.

Thursday, October 14, 2010

APNA Wednesday Pre-Conference Highlights

The last national conference I went to was for Acupuncture and Oriental Medicine, so the organization, offerings, and generally off-beat personalities of psych nurses made this a much different experience and a winner from the get-go. I tend to feel more in-sync with my nursing colleagues since they seem much more tolerant of CAM practitioners than CAM practitioners seem of western healthcare. Plus, no political booths!

Online Course for Optimum Student Learning
The current institution in which I work is not, shall we say, one that is full of early adopters. Even with the economy falling apart, older nurses not retiring at an expected rate, and more people considering nursing as a steady career, there is and will continue to be a national nursing shortage for many years. If the healthcare bill goes on as planned, ARNPs are also going to be in demand and already are in certain areas. As an X-er, I am comfortable with the boomer lecture style and the millenial tech-enhanced delivery of education, but the world is moving to more hybrid and fully web-based systems and we have to adapt what works in the class to work on the web.

This course left me saturated in ideas about constructing online courses and enriching the in-class experience beyond providing information. We also discussed VARK and constructed an MSE module to target a variety of learning styles. This was an excellent opportunity to get into groups, share challenges, and pick-each other's brains. Almost no one at the session was from Louisville, so the groups were laden with fresh ideas from all over the country. I have been using blogs for clinical, but this went into the details of what constitutes a good design where the student gets equal or more content then lecture style.

I was able to get some one-on-one time after lunch with Dr. Merrie Kass, who walked me through some of her courses at University of Minnesota. It brought home the overwhelming reality of the work involved in constructing a quality course, online or otherwise. I received excellent guidance on designing on-line and on-line hybrid courses and tossed around ideas on how to make assignments feel relevant rather than feeling like "busy work."

The collaboration is one of the best things about being in Psych as a nurse. There is always some degree of posturing, but the "I'm better than you" feeling is not nearly as pervasive as it is in other specialties. And from LPN to PhD, nursing can get pretty catty!

Key-Note CD
For $50 you can get every lecture from the conference in voice over power-point with the ablity to earn an extra 32 hours of CEU credit. You can upload it to a smart phone from your computer too. Yaoza! There are a few on here I will likely adapt for my classes.

Tuesday, October 12, 2010

To Infinity!

And so it came to pass, that Epidemiology was over, and the weary, yet resilient DNP student, conquered the grueling and rigorous demands required to study the distribution and detriments of health related states in specific populations and to apply this knowledge to control health problems.

100.55% - how sweet it is!

And to give nod to my new appreciation for the usefulness of epidemiological research methods, I provide the following relevant stories:

And next up, Biostatistics!

Sunday, October 10, 2010

Life in the Midst of Midterms

And finals.

I posted most of the following on another blog, but feel it is important to include since this led to asking for extensions on all of my tests and assignments this past week. I have never done this before, but I realized there are some things you can't just suck up and perform. At least if you want to stay sane. Since I am specializing in mental health, I decided to practice what I preach and ask for help. Thankfully, all of my professors gave me an extension without asking for an explanation. And here it is.


We found out we were pregnant in August after 8 positive home pregnancy tests.
Since I had a miscarriage in June, I wanted to get serial HCGs and breathed a sigh of relief when it doubled in 48 hours and my progesterone was where it needed to be. Went for the ultrasound on Sept 22nd with hubs laden with camera gear. We should have been about 9 weeks along but the fetal pole measured 6 weeks 4 days. I can read ultrasounds and I saw there was no heartbeat. Doc told me to come back in a week to make sure because I could have been off on the due date.

Surprisingly, this was not the longest week of my life because by the time we walked out of the office, I came to grips with the fact he (I always felt the baby was a boy) was dead.

Sure, there was a chance, but somehow I knew we would not be in the lucky percent. I had a dream a couple of weeks ago that I gave birth to a belly full of water. I also had stabbing pains in He-Gu, an acupuncture point that is contraindicated in pregnancy because it can dilate the cervix. Around week 7 I also developed a total aversion to all the prenatal books and videos I had been so gung-ho about and had stopped browsing Amazon day and night. None of this was meaningful at the time, but as I sit here and think, they all kind of work together.

I am a little irritated that the first pregnancy symptom to go away was the great complexion I had developed.

I spotted very lightly through the week, so I had prepared myself for the inevitable. On the return trip to the OB, the fetal pole measured 6 weeks and 1 day but the gestational sac had grown. Great. Before he could finish the "D&C" talk, I asked how he felt about 800mg of Cytotec i-vag instead. He was somewhat surprised (hell, if you told me a few years ago I would rather pass a dead baby then get it all over with at once with a D&C I would have called you crazy) but he did a quick consult with one of his partners and fixed me up with 2 prescriptions and his cell phone number.

A part of me was hoping I would not need it, but by Friday night I was still spotting only slightly heavier so I decided to take the plunge around 8:30. I also popped 5 mg of valium hoping to sleep through the cramps. I didn't, but I also don't remember them that well. Even knowing there is no life to be had, it was still difficult to do this. Had I though there was even a slight chance I would have waited another week, but unfortunately clinical reality squashed optimistic hope.

Within a few hours, I had mild but escalating cramping. I spend a good part of the wee hours of the morning writhing around and deep breathing. I guess the "Bellydance for Labor" video paid off since the more I moved my hips, the less it hurt. And it hurt.

24-hours later I am not gushing as some others have described, and while I have clots I have not passed the sac. I don't think this is going to be real for me until I do.

I had a deeper attachment to the baby this time than I did the first time, yet somehow this miscarriage is easier. I guess it is a combination of saying good-bye, not having told as many people, and navigating (unfortunately) familiar territory. The good news is, we are fertile and, with hope, will remain so and actually conceive and carry next time.

I have to admit I harbor some bitterness over the situation since, as a nurse practitioner and psych nurse, I have seen so many women do everything wrong and have one baby after another without a problem. On the other hand, I have several clients who have due dates close to when I should have been due for both my first and current miscarriage and I feel so happy for them and proud of the role I played in helping them conceive.

As for trying again, I do not think I am going to be ready for quite some time. I am not sure I can ever have a positive pregnancy test again and feel excited about it. It sounds morbid, but I feel as though "hey, we made it over halfway through the first trimester this time, maybe we will get all the way to the second trimester before we kill the next one." Maybe I need to take up smoking or a crack habit - it seems to work well for a lot of my former patient population.

Hmmmm, that was not a subtle defense mechanism, was it?

As the guilt wheels start turning, I wonder if I did too much baby acknowledgement and prenatal madness. Too much reading, too much talking to the baby, too many prenatal workouts. But then again, I do not want to second guess my actions since all of the research left me armed with a plan for the future - doulas, hospital, postpartum care, etc - so it was worthwhile for next time. Or maybe someone else's next time.

There is plenty of info on the feelings and emotions related to miscarriage, and I have been through all of them. Since I had a difficult time finding personal stories, I wanted to speak to the physical aspects of what happened to me on the end of my Cytotec journey.

At one day past the Cytotec dosage, I was toeing the line between heavy spotting and light period with discomfort, but not pain exactly. I planned on giving myself until Monday evening to start the second dose if things had not progressed.

Monday morning I want into the office around 9 for my first patient and the cramps, well, I think I should call them contractions since it felt like a vampire squeezing my uterus, began. I popped some IBU and arnica which did little to help anything. By 10:30 I had passed 3 baseball-sized blood clots that were, thankfully, bright red. Not really knowing what the sac was supposed to look like, I collected one of the clots thinking there might be tissue in there.

I clinically detached first because, aside from the entire thing being tragic, it is an amazing process. The sensations are unique because they are cramps, but they are much different than your basic menstrual variety, and the passage of the endometrium is morbidly fascinating in an "did that just seriously come out of me" way. Second, I needed to dissociate for my own emotional stability.

About halfway through my next patient I was doubled over in pain in the office bathroom and begging for 5 minutes of peace so I could finish up and cancel out for the rest of the day. I have never had malaria, but I must of looked like I did with the cold sweat that kept dripping off my forehead. The "Bellydance for Labor" video was worth it's weight in gold because it really did help move through the contractions and decrease the pain.

At noon (about 5 minutes after my patient left), the pain reached epic proportions and shortly after, baby and all came out. There is no mistaking the difference. The sac looks like a little wrinkled balloon attached to the dark tissue of the placenta. After delivering (I guess you call it that), there were no clots and the pain backed off considerably, but did not totally abate. I have worked-out nearly every muscle in my body before, but this was defiantly new territory for DOMS.

Fred has been a rock, but when I handed him the bag to put in the fridge before going to the OB, he broke a little. After the pain settle down a little, we went over to the OB and he told us it looked like I had passed everything. I wanted to open the sac and see the baby, but I knew they wanted to run tests on it so I left well enough alone. I did take a couple of pictures though. He expects I will continue to have a light period for a week or so, and then have a normal cycle in 6-8 weeks. After that, he is going to run a bunch of tests to make sure all of this is not the result of a clotting disorder.

I cannot say Cytotec was the reason for this occurring Monday or at all, but what I do know is I do not require a D&C, which was my goal. I did not have the massive bleeding others have described, but there was still quite a bit. I hope I never have to go through this again, but if there is a next time, I am going to be sure to ask for some hydrocodone and take a few days off.

Today the clinical observation persona has given way to wistful-mommy-not-to-be grief. I am grateful I have a support system to rely on and that I now have an idea of what labor will be like (to a very small extent) when I finally do have a term pregnancy. There has been a lot of outside drama the past couple of days which I feel is a great distractor, but I am going to have to process this soon if I want to move on.

I made an over-ambitious workout plan for this week, that I quickly realized needed adjustment. I gained back 7 pounds of what I had lost so I am ready to get back on the weight-loss plan next week. In the meantime, I am trying not to "feed the soul hole" with comfort foods, and getting 30 minutes of cardio or weights in every day.


Okay, the grief-bravado lasted a day and the mourning hit hard and fast. All of the pregnancy symptoms disappeared and I was left with continual cramping and aches until last night. Thursday night I realized I was going to fail the Epidemiology final and Stats midterm if I did not ask for an extension, and there was no way I was going to have an effective empathy recording for Interviewing and Counseling because I had none. I am granted an extension until Wednesday and decide to take the weekend to really process and take all of the support my husband had to give.

We had a wedding to go to this weekend and mingled with a lot of folks we had not seen in over a year. I was hoping I could be bride-centric, but naturally we were asked about our plans for children. Fred and I are terrible social liars, especially with friends, so we wound up telling a few people what happened. We received an amazing amount of support and hope. I have found even unhelpful comments usually are a result of wanting to say something and are meant to show concern, so I appreciate them.

I am thinking about re-labeling my prenatal vitamins "pre-conception" so it does not feel so depressing. I am taking a postnatal herbal formula that has also helped with the emotional ebb and flow as well as the dizziness and aches. I packed up all of the books, DVDs, and other accouterments I acquired to celebrate the pregnancy. Fred finally looked at the pictures I took and it made me feel so much better emotionally and physically to share that. He has been amazing through this entire experience and has postponed his own processing to be strong for me. I hope to be as strong for him when he finally lets himself grieve.

Right now the nights are the worst. It is when I feel the intensity of the loss. That was my baby meditation time and when I felt the most excited and pregnant.

There was discussion in class about the benefits of therapy as a healthcare provider and I thought at the time a mental health check-up was a great idea for everyone. we are looking into a few options to help get through this time, but I imagine I will need some sort of support for the next pregnancy as well.