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, 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!