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.

Tuesday, August 28, 2012

Serendipity: DNP Admission Essay

As Robert A. Heinlein put it in Time for The Stars: “Serendipity is when you dig for worms and strike gold.” This is what happened this morning as I was cleaning out my laptop files looking for a concept paper, but found my DNP admission application essay instead.  My nursing network has grown significantly in the past year and a number of folks are planning or in the process of applying to programs. While mine is psych/mental health focused, it might help provide inspiration for potential applicants. 

UTHSC DNP Application Essay 2009

“I’m not taking that disrespect medicine! And get these f*cking rent-a-cops out of here.”
“I respect you. These gentlemen are here for all of our safety. Please take the medicine.”
“Don’t you tell me what to do little girl. I know you just want to control my mind.”
“I just want you to rest and relax so you can speak to the doctor and get you home.”
“Please make the good decision. If you take the medicine you can lie in bed and wait for the doctor. If you refuse we will have to put you in seclusion and maybe restraint. Which one do you think is more disrespectful?”
“Fine – give me the medicine.”
“Thank you.”

            When I relate this and similar encounters to my BSN students, they usually respond with a shudder and ask why I would ever want to work in a place like emergency psychiatry or in the psych field at all. They feel nervous around the unpredictability and worry about violence, sexual advances, and suicidal revelations. They are uncomfortable that the diagnosis of psychiatric illness cannot be confirmed with a lab value or imaging study and that there are no tactile tasks as there are in the medical setting. I tell them these are the exact reasons why I love working with this patient population and being a psychiatric and mental health nurse.
            After I came out of my accelerated BSN program in 2005, I took the advice of some nursing professors and began in the emergency department. It was not a good fit. I wanted to spend more time with patients than what was considered suitable for a department whose priorities were to stabilize and ship off. I had family ask if I could be their loved one’s nurse when they were transferred to ICU and I had individuals who had mania remember me as the nurse who took time to get to know them instead of locking them in a seclusion room just because they had “Bipolar” written in their history.
            I made the switch and took a position as a second shift nurse at Ten Broeck, a private psychiatric facility that catered to adults, children ages 3-12, and active duty military personnel. I also worked with the psychiatric assessment team that went to ER’s all over Louisville to determine level of care and initiate disposition to the appropriate facility. After two years I craved a higher acuity environment and more diverse patient population and took a position in emergency psychiatric services at University of Louisville Hospital. I also became certified through the ANCC as a psychiatric and mental health nurse and began teaching psychiatric clinical for Bellarmine University.
            In 2008 I began the Family Nurse Practitioner Program at Bellarmine. I chose the FNP because, while I love working in psych, I also wanted professional diversity. In addition to prevention, management and education of health conditions across the lifespan, a large percentage of primary care involves treatment of depression, anxiety, ADHD and PTSD and screening for substance abuse and domestic violence. Although I wanted more medical experience, I planned on obtaining my Psych NP certification even prior to beginning my FNP, and this resolve was strengthened during my educational clinical experience. While I enjoyed primary care in pediatric and adult settings, when I got to the psych portion of the rotation is was like a sigh of relief. With the new Doctor of Nursing Practice degree becoming a requirement in the next five years, I also feel it is important to continue my education while I am still in the flow of academia rather than waiting or being grandfathered in.
            In addition to nursing, I have also been an acupuncturist and Doctor of Oriental Medicine for the past ten years and have focused my practice in pain management, women’s health, and mental/emotional disorders. I have had the opportunity during my training and professional practice to work with chemical dependency, depression, anxiety, stress management and PTSD using a combination of modalities including acupuncture, herbal therapy, nutrition, Tui Na, exercise, and mediation. I was also involved in development of a research project that compared the effectiveness of CBT with and without acupuncture intervention in patients with PTSD.
            My professional goals include integrating my specialties to develop a holistic approach to education, prevention and treatment of anxiety disorders. While other disease processes such as bipolar, schizophrenia, and personality disorders are also of interest to me, in the higher levels of education I feel it is important to narrow the field of concentration. I have had experience in Internet blackboard courses and working at an accelerated learning environment while maintaining employment throughout my educational career. The ability to obtain the dual certification in mental health with the DNP allows me to have more freedom and a greater variety of choices to peruse my goals. 

Thursday, August 2, 2012

I Passed! A Review of the Review and Exam

In that which we are most confident often results in failure. At least, that was my fear going into the ANCC PMHNP certification exam. Despite hearing this exam was allegedly the easiest test I would take in the long series of nursing hoop jump-training, I did not want to get cavalier. Of all the boards I have taken, this was the most important and with hope, the last. As with my FNP, RN-BC, NCLEX, DOM, DilpAC, and DilpH preparation, I had a study plan, created a "cheat sheet" to write out on scratch paper before starting the test, and worried myself sick that I was a knowledge fraud who managed to graduate by luck or accident.

There is a DSM code for that.

After grabbing my usual eggs and lucky Indivisible Blend from Starbucks, I rolled into the parking lot of the testing center at 8:30am just in time to flip through every page of my review notes and psych myself up. After being ID'ed, wanded over, and searched for concealed textbooks, I was escorted to station 15 to live out the next 3.5 hours slugging through 175 questions, 25 of which were secret, experimental items that didn't count. 

Just 2 questions in and I was feeling nervous. By question 50, I doubted I was going to pass. By question 100, I had a boost of confidence. By question 125 I was trying to figure out if the 30-day test window would allow me to re-take the exam before Labor Day. By question 150 I just went numb and fuzzy. With a little over an hour on the timer to go, I ran back through the 45 questions I had marked, change a few answers, said a prayer, and hit submit. Five minutes later, I received the results and was officially certified! 

So, what was so hard?  This test had content that threw me for a bit of a loop. Unlike the Family NP exam that followed the "common diseases occur commonly" model of testing, the Psych Mental Health NP approach assumed you knew all the commonly occurring assessment and management of mood, personality, anxiety, and psychotic disorders and tested around it, with only a couple of bones thrown to topics like Lithium, psychosocial development, and dealing with a borderline in the milieu. 

There was a lot of neurobiology, pharmacokinetics and pharmacodynamics.  The time I put into neurotransmitter pathways, CYP450, and specific drug effects certainly paid off.  I did not spend as much time focusing in on the details of rating scales like the HAM-D, MMPI, and MMSE as I should have, though I was able to activate my hippocampus well enough to pull it out of my memory. There were a number of questions regarding collaboration and consultation, health policy, legal scenarios, and research. Knowing your role and scope was also included in several ways and folks who are FNPs need to be mindful - do not fall into the trap of treating or teaching beyond the scope of the PsychNP role.  There were a few obscure questions on nursing theorists and how to bill for certain procedures (had to be an experimental question). I felt my exam had an overabundance of child and adolescent content, yet not one questions on ADHD!

I used a number of references to prep for the test. 

The Barkley Review home study was an excellent content overview and helped my prioritize my study plan. Too often I go over what I already know to gain confidence and this helped me know what I really did not know. Copy for sale!

Kaplan & Sadock's Study Guide and Self-Examination Review in Psychiatry (STUDY GUIDE/SELF EXAM REV/ SYNOPSIS OF PSYCHIATRY (KAPLANS)
The MDs really like their background and history. Skip those chapters. NPs are more about the here and now of clinical management and interpersonal communication, which are well covered. Some of the questions reflect the essential differences coming from a disease versus a holistic-focus perspective, particularly when it comes to prioritization and adherence. The MDs go into greater depth than NPs when it comes to the "why," and this is particularly useful for psychopharmacology, etiology, and pathology. This book gives you a box of topics to review, several questions on content, and answers with rational.

Psychiatric Nursing Certification Review Guide for the Generalist and Advanced Practice Psychiatric and Mental Health Nurse, Third Edition (Mosack, ... Review Guide for the Generalist and Advance)
Content review is presented at the beginning of the chapter followed by questions. This does a great job going over the basics, which is invaluable for many PMHNPs who never worked in psych at the RN level or did not have experience during their clinical in group dynamics, milieu management, and staffing issues. Even if you are an old-pro, this one is still useful for the way the content blocks are organized, particularly policy and theory. These questions were most like what I encountered on the exam.

Psychopharmacology Demystified
If Stahl made a primer or Cliff's Notes version of Essential Psychopharmacology, this book would be it. The neuro content is well outlined with good visuals, no redundancy, and a clear picture how drugs work in the brain for the most common DSM disorders.

The Psychiatric Interview (Practical Guides in Psychiatry)
I referred to this a number of times while studying assessment. Great mnemonics for those that learn well that way.