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.

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...