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.

Sunday, October 6, 2013

APNA 2013 Poster

I have been on a writing hiatus. Between the new position at work and being 28 weeks pregnant, I am out of the habit of blogging. Though I would have really enjoyed doing a podium presentation again, I had a feeling it might have been more than I could tack on to an already packed schedule. . . as evidenced by the fact I just completed and ordered the hardcopy today and am leaving on Wednesday for the conference. This was really a fun one to research over the past few months, and I am looking forward to another great APNA conference. See you there! 

Friday, May 10, 2013

Will the DSM-5 Define Normal?

Or rather, neuro-typical?

I realize phrases like "I'm not normal" and "Who wants to be normal?" and "I never wanted a normal life" are often a person's way of differentiating themselves from what they believe is mainstream (i.e. boring) living. Yet there are many, many people living quiet little wild lives unbeknownst to their neighbor. What looks like the white-bread nuclear family to the casual observer may be anything but. People get altogether too comfortable in their assumptions of how others live and think. Fact is, most of us are actually normal in that we feel a full range of different emotions, can generally trust our senses, have desires, and respond to the trials and tribulations of life with some balance of primal instinct and societal expectation.

Yeah? Well prove it.

Unfortunately, the one diagnostic reference that tells you all of the ways you are abnormal fails to provide guidelines for what is considered within normal limits.

While physical health is somewhat generically considered absence of disease, there are any number of standardized, objective tests that show clinicians where a patient falls within the range of normal. You know if someone's blood sugar has been in control for a few months by drawing a Hemoglobin A1C. You know if someone has a blockage of their coronary artery by performing a cardiac catheterization. You know if someone has a broken arm by getting an x-ray. With mental health disorders, it is subjective report of symptoms coupled with the observation and interaction skills of the clinician that leads to a diagnosis. There is yet no blood test for depression - though we certainly know that low thyroid or Vitamin D levels can contribute. While we can detect brain injury and atrophy, there is no MRI that can yet detect the difference between hallucinations from schizophrenia, bipolar disorder, depression, or substance use. We know certain lifestyle factors correlate with development of mental health problems, from malnutrition, infection, or drug use while in utero to taking too many blows to the head playing football, however thresholds of these biological factors have not been established.

Perhaps if we had a definition of normal mental health, we could identify high-risk individuals and provide primary mental health prevention with education, screening, and management prior to onset or exacerbation of a disorder. Normal grief, normal sadness, normal anger, normal worry, normal happiness - all emotions are appropriate throughout the lifespan, the issues is helping people get in touch with those emotions and be able to evaluate for themselves individual normal limits.

In the meantime, we have yet another tired update to the Diagnostic and Statistical Manual of Mental Disorders, a book developed by the American Psychiatric Association in collaboration with, well, no one except their own psychiatrists, to let the thousands of non-physician mental health providers (you know, the ones that comprise the bulk of the field - social workers, therapists, psychologists, nurses) know how to consistently label people for the purposes of proper billing and coding. Not treatment. Just billing and coding.

It is unsurprising that the National Institute of Mental Health has come out with harsh criticism and calling for more of a biological base to classifications and thereby increase the validity of diagnosis to guide effective treatment. Though they have not formally entered the competitive ring, it is time the  American Psychiatric Association monopoly on mental health definitions fall into line with what is happening in the treatment room. It’s called collaboration. This includes interdisciplinary input from clinicians as well as the lived-experience of the mental health consumer.

Let’s see if the NIMH can do better: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

The DSM-5 is scheduled for release on May 27th – will you get yours?

Wednesday, April 17, 2013

APNA27 Abstract Accepted

Wow! Three years running I have been honored to have my work accepted at the American Psychiatric Nurses Association Annual Conference. I have put to rest my social networking research and gone back to my roots of practice and interest.  Check out the summery, and get ready for APNA27 this October in San Antonio!

 Serotonin OTC: The Latest in Mental Health Nutraceuticals 

Abstract:  The U.S. vitamin and supplement industry grosses nearly $30 billion per year with a growing number of products targeted to the prevention and alleviation of mental health related conditions. Although the industry is regulated by the FDA and products must adhere to Good Manufacturing Practices (GMP), broad claims of efficacy for mood, sleep, concentration, and other general psychiatric symptoms are not subject to scientific validation. Popular nutraceuticals including GABA, n-acetylcysteine (NAC), and Ashwagandha are advertised as natural alternatives or augmenters to standard psycho-pharmacy, and while consumers who self-medicate without informing their providers may experience a measurable benefit, they put themselves at risk for deleterious outcomes. Consumer interest, desire to decrease pill burden, and product proliferation in the marketplace have encouraged increased research to substantiate health claims, determine potential interactions with medication, and provide a basis for recommendation. This presentation will provide an overview of the functions of 10 common and novel mental health focused nutraceuticals, evaluate the base of evidence for implementation into practice, and provide strategies for educating patients on appropriate use of OTC supplements.

Presentation Summary:  This presentation provides an overview of the functions of common and novel mental health focused nutraceuticals, evaluates the base of evidence for implementation into practice, and provides strategies for educating patients on appropriate use of OTC supplements.

Objective 1:  Identify the key functions of 10 nutraceuticals supplements frequently used in management of mental health disorders.
Objective 2:  Describe potential interactions between classes of psychiatric medication and OTC mental health nutraceuticals.
Objective 3:  Evaluate the evidence base for use of OTC mental health supplements in PMH practice

Tuesday, April 2, 2013

Rats! Foiled Again.

For yet (what is it, the third year in a row?) legislative session, the Kentucky senate figures our rural population can take their health problems and shove them in the coal mine. Enormous problems with obesity, smoking-related illness, and opiate abuse are prevalent all over the state, but hey, just think how much worse it would be if Nurse Practitioners were allowed to get involved by administering independent care to the full scope of their training and practice? Because after all, Nurse Practitioners are just a bunch of greedy harpies who were too dumb to get into medical school, have totally rigged the statistics showing cost-effective and equivalent outcomes in primary care, and are only in the healthcare business to divert narcotics, defraud the public, and take money out of the hands of the poor, selfless, hardworking medical doctors who work in cities.

This is why I can never run for office.

Here is the official press release from the AANP:

Access to Health Care
The American Association of Nurse Practitioners expresses disappointment
AUSTIN, TX (March 28, 2013)–

Angela Golden, President of the American Association of Nurse Practitioners (AANP), said today that the Kentucky legislature's failure to act on Senate Bill 43 will make it harder for state residents to obtain quality health care by barring access to direct and comprehensive services provided by nurse practitioners (NPs).

"The American Association of Nurse Practitioners is extremely disappointed that Kentucky continues to prevent patients from directly accessing high-quality health care services provided by NPs. Nowhere in the industry is it acceptable to limit patients the best that health care had to offer not two or even three, but four decades ago. However, that is exactly what states are doing when we keep these dated state practice laws in place.

"The health care services we provide – writing prescriptions, evaluating patients, making diagnoses, ordering and interpreting diagnostic tests, and managing acute and chronic health conditions – have been proven safe and effective for more than 40 years. There are more than 60 medically underserved counties across the state and every one would have benefited from the provisions in this bill.
"It is equally disappointing that the community of organized medicine in Kentucky went beyond simply opposing the bill by introducing counter legislation to increase state restrictions on NPs. This move flies in the face of recommendations by a growing number of independent entities (e.g., the National Academy of Sciences' Institute of Medicine) that call for modernizing state practice laws governing NPs. Such organizations understand that these changes are necessary in today's health care environment.

"The legislation that was before the Kentucky legislature did not expand NPs' scope of practice. It simply retired an outdated, bureaucratic piece of paper that prevents patients from having direct and full access to NP care. Removing this dated provision would have opened access points in rural and underserved counties, and streamlined care in all sites around the state.

"AANP and those who supported these measures remain committed to ensuring access and health delivery improvement. These pro-patient bills are planned to be reintroduced in 2014."

Lets get this fixed! For some real-world social networking, meet me in Las Vegas for the AANP national conference. For all of the details and registration, visit the AANP National Conference Page  

And for more information on how to do Vegas your own fabulous way, check out my Pinterest Conference Board

Wednesday, March 13, 2013

Kentucky Battle Cry . . . Y'all

Seriously, if you live in Kentucky or know someone who does, please take a moment to voice your support for SB 43 which will end the collaborative agreement for non-scheduled drugs for nurse practitioners and decrease direct supervisory time for new-graduate physician assistants. Just click the link to email your senator - it takes less than 3 minutes: Vote "YES!" to SB43

The postcards below are from the previous SB52. The facts are still the facts.

Monday, March 4, 2013

Laugh and Discuss

A few years ago I ran across this video that humorously illustrates the dangers of narrow focus.  I was reminded of it the other day when discussing frustrations related to provider communication issues and stigmatization. There are a number of similar scenarios between different specialties that pop up after the video, including some amusing psychiatry vs. physical medicine interactions, but this remains my favorite.

I needed a laugh today  - have one with me:

Tuesday, February 26, 2013

Countdown to Vegas!

RIP 2006
Those of you who know me in the real world are pretty clear that I love Las Vegas. I first visited in 2001 when a friend announced "my nephew is eloping at Mandalay Bay in Las Vegas and I really want to go support him, but there's no way I can afford it." Being young, spontaneous, and flush with student loan money, I replied "if you want me to plan it, I will and we're going. What's you budget?" Of course, he did not believe I was serious until I was about to click the purchase button on the SWA package for 2 nights at the Stratosphere (IP and Sahara were the close runner ups) with car and flight from Albuquerque for something like $400.

We had our first beer on the flight up and I am pretty sure I stayed pleasantly inebriated for the entire trip. I remember his family felt guilty for the drama that made them want to run away and wound up coming anyway. The mentionable events that stick out:
  • Walking the strip, thinking "I hope I can afford to stay at a fancy place like Treasure Island . . . how do families afford to stay here at $200/night?" 
  • Aerialists hanging from the ceiling at Ra in Luxor (now LAX) and finding myself in the center of the dance floor with a handsome partner and an attentive audience
  • Going to the Stardust showroom to see if it was dark. Yep. To this day I often pack for my trips with Nomi Malone! 
  • The yellow brick road at MGM, a wizard sticking out of Excalibur, and general theming on the south side of the strip 
  • Carrying a cup of change with my whole $20 in gambling/drink tip money (I left with $16). 
  • Wait, the drinks are free?!? 
  • Seeing "Bottoms Up", the topless afternoon show at Flamingo where admission was only a $7 Heineken with coupon. 
  • Taking a ride on the Big Shot at Stratosphere
  • Learning that marriage in Vegas is not the place for sentimentality. These people have a schedule to keep and your 30 minutes start the second you hit the dressing room (yet I still teared up!) 
  • Taking off at twilight and while we were taxiing down the runway, I gazed longingly at the strip as the lights came on, sad to be leaving but thinking, "I will see you later, Las Vegas strip. I will see you later."
And I have.  A lot.

While the strip has changed dramatically since that first visit, the vibe of Las Vegas holds the same promise of excitement, the same respite from everyday reality, and the same unpredictable wonder that keeps me coming back.

You woke up. Celebrate.
When the American Academy of Nurse Practitioners announced they were having the 28th national conference in my favorite destination city, there was no question I would be attending. However when I started talking up the conference to colleagues, I received a lot of negative feedback on our host city. Much like tequila, folks have a visceral reaction when you mention sin city: "It's smoky," "Nothing to do there but gamble,""It's so manufactured," "Way too stimulating" "So crowded," "Everyone's drunk," "Such a hassle to get around," and my personal favorite, "Ugg, Vegas."

So for those attending the conference who have never been to Vegas and for those reluctant to revisit, I have started board on Pinterest to help make the most of the free time you have have. And maybe even entice you to spend a couple of extra days exploring the Entertainment Capital of the World!

Monday, February 18, 2013

The Most Restrictive Environment

The psych ward. The nut house. The loony bin.  The asylum.  Whatever you call it, it is not the place most of us want to be, yet it often becomes the dump site for the stigmatized. Although we are trending toward more blended medical-psychiatric and gero-psychiatric inpatient units that allow more medical management to take place concurrently, the ideal environment for mental health management is in the outpatient setting.

I believe in the principle of least restrictive environment for mental health care.  Some providers are confused and feel psychiatric floors should be the depository for issues they do not want to deal with or are not interesting enough for medicine. Certainly, chronic mental illness is an issue of management rather than cure, and acute-care physical health providers are often intimidated by conditions that cannot be eliminated by pharmacological or surgical interventions. Many would prefer to pass people off rather than deal with complex matters of mind-body interaction. Perhaps if some of them visited a psych unit, they might get a fresh perspective. Let's review what happens when a person is admitted to a psychiatric ward versus a medical ward:

We take your clothes
We search your belongings and lock them up
We lock the doors and windows to the unit so you cannot get out
We take your phone, e-reader, laptop, music player, and electronics
We restrict when and who can visit you
We tell you when you can and cannot talk on a common, public phone
We tell you when you get up and when to go to bed
We put you in a room with 1-3 other people in beds that do not adjust
We tell you what you can and cannot watch and when on a common TV
We take away your right to smoke
We take away  your food choices and deny outside delivery
We take away your right to breath fresh air
We label you as a "psych patient" for life with all the privileges of stigma therein

In short, we take away your constitutional liberties.  So why do we do that?

Sometimes, it is because it is the only way to keep a person safe. Psychosis, suicidality, homicidality, mania - these are viable reasons to put someone in this most restrictive environment with the intent and hope of finding the right treatment plan as quickly as possible to get this person stable and back in the community. Sometimes we do it when the person really feels it is in their best interest because they feel unsafe or unstable and want to prevent escalation of symptoms.  These are the two scenarios where admission is the right thing to do.

However, not everyone who has delusions, suicidality, or mania needs to be admitted.  Just because it is in the brain, does not mean it needs to be managed by psych. For example, seizures are seizures - whether from epilepsy, alcohol withdrawal, or psychosomatic origins, they need to be monitored by the medical team.  Keeping the old Maslow's Hierarchy of Needs care theory becomes particularly useful in holistic, individualized treatment planning for patients with complex and co-morbid disorders.

These days, to be in a hospital for more than an outpatient procedure, you better be sick. This goes for physical and mental illness. Unfortunately, many providers take a cavalier attitude when it comes to dispositioning someone on a locked psychiatric ward and use a DSM diagnosis as a basis to gloss over a through medical assessment and justify an inappropriate admission to a psychiatric unit. Two areas that seem to be ripe for controversy are dementia and substance abuse.

Being confused is not justification for taking you freedom. If it were, half the hospital staff would qualify by Thursday afternoon. This confusion about the confused occurs frequently with the elderly, who will often manifest altered mental symptoms as a result of multiple drug interactions, any number of physical condition, or just plain physical neurodegenerative changes related to a specific disorder or the normal aging process.  When medicine tries to label all hallucinations as psych in origin, I harken back to a high school biology class where we discussed the how visual and tactile hallucinations were linked with everything from UTIs to syphilis.  This was repeated and detailed multiple times through the course of my nursing education in the family practice and mental health specialties. Plus, I have seen Trainspotting at least 5 times. See it if you haven't.

Needing to dry out from a bender is also inappropriate not only from the aspect of liberty, but competent care for withdrawal symptoms. Most psychiatric facilities and wards have restrictions on medical interventions or devices. IVs, catheters, ports or lines, telemetry monitoring, uncontrolled seizures, and unstable vital signs are just some common limitations that warrant the patient seeking a medical rather than psychiatric management, no matter what their state of mind. When medical teams refuse to medically detox a patient "because they are psych," I get miffed.

They may have psych issues. They are not themselves psych.  They are people who need placement in the least restrictive environment possible to provide positive outcomes for long-term management.

Monday, February 11, 2013

How the DNP Improves Nursing (Not Medicine)

Anyone who has met me in person has heard (and tuned-out) my impassioned soliloquies advocating  nurses embrace role and practice purpose during one of our most critical periods in professional identity. Though I am a DNP and support the transition of making it the minimum entry to advanced practice, I do not automatically endorse current NP practitioners to pursue it. For those starting NP education in 2015, they will not have a choice, but for those with an MSN, there is likely no foreseeable benefit to pay thousands of dollars in tuition and to take time out of their current clinical role to return to school. For a brief history on this changeover and the controversy, read Dr. Nurse: Development and Implications for the Clinical Nursing Doctorate

Afaf Meleis, one of my favorite nursing theorists, has long been an opponent of this transition (ironic, since her theory IS transitions!). I respectfully disagree with her contention "if it ain't broke, don't fix it." I do not believe the MSN is broken, but it is getting worn around the edges, particularly for those in leadership and clinical roles. I am on board with residency or supervisory models toward full licensure in NP practice provided they are guided by peer-NPs, but why would we beef up the MSN rather than incorporate these improvements into a degree when the MSN is one step below parity with every other mainstream and complementary health care provider?

This is the same for nursing leadership. There is so much more to running a hospital than staffing, mediating personnel conflicts, and generating patient loyalty. Expertise in emerging technology for care delivery and communication, initiating clinical research, implementing evidenced-based practice, and meeting the ever-growing core measurements for reimbursement are no longer realistic as an RN "with a little extra training" at the MSN level. When you see more and more MDs going back to school for MBAs so they can meet leadership demands, you know times have changed. We have to change with them, and take responsibility for our educational choices.

Though many argue the DNP is not a pure practice or clinical doctorate because it is not for APRNs only, remember that a significant portion of clinical nursing involves education and mentoring of other nurse clinicians rather than direct patient care and management. Running the hospital is clinical practice. In the leadership role the focus is on providers who treat all populations rather than on the individual patient.  While the DNP leadership clinician may not directly deliver interventions to the individual, they must be just as versed in clinical practice guidelines and standards of care among all nursing levels and specialties as those that work at the bedside and clinics.

For those that believe there is no added benefit for making doctoral study the minimum entry to practice for FNPs because it will not help us catch up to physician training, you are right. It should be obvious but it bears repeating: it is not a medical degree, it is not supposed to become a medical degree, it is not a replacement for a medical degree, it is not a short-cut to becoming a physician equivalent, and it does not now nor ever will train you to be a medical doctor. Again and again, role crossover does not equate to role redundancy.  There are many NPs who incorrectly believe they practice medicine, or worse, actually do. This is partially because we have allowed medicine to oversee our advanced practice and have accepted the inappropriate role of physician extender.  I am an advocate for our discipline practicing independently to the full scope of our training, but not beyond it.  Know what a nurse is and what the role is supposed to entail. See the Guide to the Gray Area

Just as the BSN improves on the ADN in overall knowledge and delivery of RN-level care, the DNP improves upon the MSN with the increased focus on role, systems, theory, and clinical-based research.

When you become a better "thinker," you become a better provider.

Tuesday, February 5, 2013

Associations That Care About You, Not Your Lawn

Yep, I live in a traditional town neighborhood. I love the throwback architecture and planning, that I can walk to my clinic, do not need to worry about driving if I have a few cocktails at one of the restaurants, and can get all kinds of unique gifts from small business owners without having to fight traffic at the mall. And yep, I pay a higher dollar per square foot for my house and business properties and owe yearly and monthly association dues for the privilege of living in a southeast replica of The Truman Show.  Every once in a while, someone gets complaining about dog messes, unapproved plants, fences painted the wrong color, or some other inane issue that makes the front office puff up their chest and point fingers with threats of "or else." When this happens, my husband starts pulling up the real estate section and yearning for a couple acres of property away from people and their meddling rules. Make that Federation Rules, if we happen to be on a Star Trek kick.

So the point of this mini rant is the question, "what do nursing associations really do for me?" 

As an RN student, I did not see the point of membership in professional nurse associations, largely because it was never emphasized in my leadership class. With loans coming due and taking on a new mortgage payment, spending money on membership was not a priority. Shortly after getting my license, however, I did become a member of the American Holistic Nurses Association as it fit with both my new nursing role and practice as an acupuncture and Oriental medicine provider. I also joined Sigma Theta Tau when I was nominated both from my undergraduate and doctoral programs. Other than a free journal and random emails, I was too busy getting my nurse legs to really look at the whats and whys of these organizations or to get involved in any way.

When I started my FNP training, one of the first things we discussed was the importance of joining state and national associations and what they do for us. Advocacy for NPs to practice autonomously to their full scope of training is one of the main activities. Live and distance continuing education applicable to practice is another important aspect, and membership typically provides substantial discounts. On-line member forums to collaborate on practice and legislative issues, find mentors, and cultivate relationships that often start from live networking at conferences is one of my favorite benefits. There are also some discounts or freebies on re/certification, related memberships, journal subscriptions, and other tangible goodies.

Despite these incentives, if I were to join every association that represented my professional interests, I would have to give up a lot of my discretionary time and funds.  Here is a sampling of just some of the key ones in nursing:

American Nurses Association ($291 /yr with mandatory state membership in KY)
Kentucky Coalition of Nurse Practitioners and Midwives ($95/year)
National League for Nursing ($115/yr),
American Holistic Nurses Association ($125/year)
International Society of Psychiatric-Mental Health Nurses ($125/yr)
Nurse Organization of Veterans Affairs ($105/yr)
Sigma Theta Tau International Honor Society of Nursing ($104.50 and $109.50/yr for both chapters)

While I have been or would like to be a current member of these organizations, like all good nurses, I have to prioritize. My basis for choosing an association is related to my current role and what I feel I can contribute the most time toward as an active member. I am continually a member of the American Psychiatric Nurses Association  ($125/yr) because they represent all psych/mental health nurses, not just NPs. The conferences are well organized and clinically relevant, the member bridge is functional and informative, they really try to involve all members in task forces and outreach representations, and they fund the state organizations to promote involvement at the local level without additional dues.  The mission of APNA is educational, rather than political,  so the dues are 100% tax deductible. They use social media effectively to promote the profession and increase care quality while reducing stigma of the population we work with. Plus, its an evidenced-based fact that psych nurses have more fun, which is why I have not missed a conference since joining!

I recently decided it was time to join the newly merged and powerful American Association of Nurse Practitioners ($125/yr). Now that the two main NP organizations have agreed to speak with one voice, there will be a stronger, more cohesive representation our collective interests. The AANP is another organization active on social media, they have direct legislative involvement so some of the membership dues fund the push for independent practice, they run a daily RSS feed to keep members current on activities applying to all practice aspects, and they represent all APRNs so those of us who may be loosing a skill here and there can catch-up or acquire new competencies at the annual conference.

Did I mention the AANP decided to have their annual conference for 2013 in Las Vegas? That's right. Vegas, baby.  The Venetian better be ready for OUR action!

For those of you going, make sure you live-Tweet using #AANP13 - lets get it trending!

Nurses are the most populous of health providers, yet we have one of the weakest voices and are underrepresented throughout the LPN, RN, and APRN practice levels. Most of us want higher pay or reimbursement, more respect, and the ability to practice to the full scope of our training. Increasing the number of active member nurses from all educational levels is essential for strengthening our position at the legislative table and owning our profession to accomplish these goals.

Join and be active!

Saturday, January 26, 2013

The Trouble With Interdisciplinary Studies: Everybody

For those of you contemplating your capstone projects, take heed of the following.

Although social networking is all the rage in health care, I knew when my provider-focused capstone involved a range of mental health disciplines I would have trouble finding a home for it.  The vast majority of responders were nurses, which makes it unsuitable to publish in psychiatry, psychology or social work journals. Not all of the responders were nurses so the nursing journals passed as well.  Many of the social networking journals have gone under, and most of the interdisciplinary ones either make you pay to get published or require you have an MD, PsyD, or LCSW as the primary author. One reviewer mentioned this would be more appropriate for inpatient psych nursing journals, despite the fact most of the responders wee coming from community-based clinics.  In retrospect, I can think of a number of SN topics that would have "sold" better that were patient, disorder, or single-issue focused. I took a risk, it didn't pan out.

While my ego is nursing the bruise of rejection, I have to remind myself that time not only money, it is time. Rather than continue to edit and rework the article to meet the broad ranges of journal editors' criteria for zero-cents-per-word, I am going to do the unthinkable: Share the results on the Internet. This is probably scholarly publication suicide, but suck-it-dry, it is more important to share the findings than wait for the research to go obsolete. This is the PDF proof from one of my submissions:
Social Networking and Mental Health Providers: Practice Trends and Perspectives to Shape Interdisciplinary Guidelines 

Background: Social networking activity and media development in health care are advancing rapidly and without a firm understanding of implication for use among mental health providers. Social networking is used to provide education, foster advocacy, promote the profession, and influence policy, but with potential to violate therapeutic boundaries, infringe upon privacy, create liability, and damage professional credibility.  

Objective: This survey was designed to examine current social networking practice trends and perspectives from psychiatric nurses, psychiatrists, psychologists, and therapists. Determining how mental health providers engage in social networking activity and their viewpoints on best practice offers a basis for recommending interdisciplinary guidelines.  

Design: A 20-question online survey was used to gather data from mental health providers recruited through professional member forums, e-mail distribution lists, and social media.  

Results: Key findings demonstrate an extensive use of social networking sites on personal devices for research, continuing education, and peer collaboration; a need to restrict patient communication and access to a provider’s social network; and a desire for specific guidelines to promote prudent, resourceful use of social media that complies with ethical codes, promotes professionalism, and maintains work-life boundaries.  

Conclusions: Results demonstrate the increasing use and evolving nature of social networking requires that clinicians maintain situational awareness of media platforms and technology and a need for further analysis, education, and collaboration to develop a comprehensive consensus model for social networking behavior.

The article is 60 pages with much of it taken up with figures and graphs. If you want to cut to the chase, these are the the proposed guidelines beginning on page 21:

Proposed Guidelines  
The following are proposed key components for foundational interdisciplinary guidelines that each of the professions could expand upon according to their own licensing and regulation requirements.  
  • To protect the therapeutic alliance, maintain confidentiality, and prevent dual relationships, providers should refrain from connecting with current patients on their personal social networks.
  • To comply with federal regulations, providers should not initiate communication or interact with patients on social networks to discuss health-protected information. 
  • Professional profile pages should include a purpose and disclaimer statement with parameters for use on each site (Appendix B). 
  • Office or organizational social networking policies should be included as part of informed consent, and discussed with patients as they are updated (Appendix C). 
  • To demonstrate respect and trust for the patient, providers should refrain from searching for patient information online unless expressly requested by the patient during formal treatment time.

Saturday, January 19, 2013

Beyond Nouns: The Role of Language on the Role Itself

As I have been educating people on "doctor-nurse" education and role, a confused laugh has become the expected reaction. Even I admit, I have referred to myself as doctor-nurse as a jocular shorthand to explain my credentials to colleagues. But why is it more amusing than a doctor-optometrist or doctor-physical therapist or doctor-pharmacist? I do not think it is the novelty alone as nurses have been getting educational and research doctorates for many years. Perhaps because in the clinical area, the two terms conjure up distinctly different images that do not easily meld. In yet another demonstration of how language is the way we view the world, I thought this deserved a little contemplation.

When people use the term "nursing" in the colloquial sense, they are usually referring to a nurturing role or healing process. Breast feeding, otherwise known as nursing, is a natural process of providing life-sustaining nourishment and immunity factors for growth and development from mother to child.  We also use it to refer to consumption of adult nourishment, such as "nursing" a whisky all evening. "Nursing" may also refer to the need to nourish and nurture pragmatic matters like retirement accounts or mild illness and injury.  Nursing, as in "back to health," brings to mind images of dressing wounds, holding hands,  providing words of support and encouragement, or enduring the process by handling with care (such as nursing a hangover brought on by the aforementioned whisky!).  People generally "nurse" others.

The colloquial use of "doctoring" often refers to fixing something.  This is particularly the case with under-spiced or pre-prepared foods that one needs to alter or, "doctor up" in order to be palatable. In the realm of home improvements, "doctoring"  refers to a quick fix, temporary patch-job, or a makeshift repair.  It can also refer to tampering with or altering something, such as "doctoring" the evidence. People generally "doctor" themselves.

We have doctored the nursing title of advanced practice, and are nursing an understanding of the doctor title in advanced nursing!

Perhaps this is why being a doctor-nurse is usually met with a giggle. I have doctored plenty of canned pasta sauces in my day, and certainly nursed my share of spirits, but I cannot say vice versa.  While I am not personally much for titles, I feel as one of the first crop of DNPs to hit the clinical setting, using the title is an important step to establishing an understanding of where advanced practice nursing is going on the (long) road to parity.

Tuesday, January 8, 2013

A Better Command Hallucination

The other night a colleague and I were reflecting on some of the people we have worked with who have the bizarre, fun variety of psychosis and started brainstorming "wouldn't it be nice if" treatments. File the following under "why not?" Or delusional optimism.

An inspiring advocate for people living with schizophrenia, Dr. Fred Frese, who has lived with the disorder for several decades,  provides one of my favorite descriptions of different types of psychosis by comparing  them to different types of drunk. There are angry violent drunks, sad crying drunks, quiet withdrawn drunks, functional productive drunks, and (best?) of all, fun dancing drunks.  Unlike intoxication, schizophrenia does not wear off, and the goal of most providers is to eliminate the symptoms.  This is not always the primary goal of the patient. It is important to keep that in mind before labeling a patient as non-compliant.

Hearing a running commentary of behavior, judgements, and commands to act out anything from mundane to harmful behaviors is hard to fathom if you do not experience it for yourself.  While schizophrenia is often referred to as the cancer of mental illness, the good news about the paranoid type is that it is the most treatable. The bad news is that it is paranoid schizophrenia and debatable the most difficult one to live with. While treatment options are improving, the older medication therapies either give you parkinsonian-like side effects including drooling, involuntary movement, and shuffling gait, while the newer ones  make you fat, tired, stupid, and impotent. In addition to these expected side effects, other cumbersome factors may include cost, drug-drug interactions, regular blood monitoring, altering multiple lifestyle factors to prevent toxicity or ineffectiveness, or life-threatening adverse reactions. Oh, and more often than not, patients experience residual symptoms, or "breakthrough" psychosis. It is a high cost of doing business and I get why many folks would rather suffer the disease than the treatment.

So I got to thinking, maybe we are on the wrong track. Instead of elimination of voices through dopamine blockades in the prefrontal cortex, maybe what we need are to change the content of the delusions to something more health promoting.  What if we could trigger the positive self talk areas of the brain, particularly the Broca or Wernicke regions, to create a better hallucination? Instead of hearing "your worthless" or "they are all against you" or "jump off the bridge,"  they could be replaced with "do 30 minutes on the treadmill," or "check that nutrition label for trans fats," or "get home by 10 so you can get your beauty rest!" Who would need Weight Watchers and a personal trainer with voices like that?!

Though I am sure if we did had that ability through medication, advertisers would find a way to have the voices promote their products.

So on second thought, maybe not.

Monday, January 7, 2013

20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers

Great guidance from a fellow Dr. Nurse and patient advocate:

20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers:
Thou shalt respect your client and not judge
Thou shalt increase the well-being, opportunities and happiness of your client
Thou shalt...