Presentation submitted and accepted for CEUs for the American Association of Nurse Practitioner's annual conference in New Orleans June 2015. I have to admit, I do think my working title "When Liquid Gold Goes Bust" was a smidge catchier. Here is a sneak-peak for those of you coming to AANP15 and for those of you who will be there in spirit.
Showing posts with label Fun with Thinking. Show all posts
Showing posts with label Fun with Thinking. Show all posts
Sunday, April 19, 2015
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
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?
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.
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.
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!
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 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.
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.
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.
Saturday, December 15, 2012
Roles in Healthcare: A Who's Who Guide to the Gray Area
With all of the posturing over who has more training hours, patient-satisfaction scores, positive outcome measures, and cost-effective care, something has been lost in the Dr. Nurse/Dr. Physician debate: Role of the Discipline.
First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter. Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.
What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.
When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job. While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care. There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.
Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes. Medicine is interventional at the disease level, thus the training is focused at that level of care. Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.
What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention. Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person. To be successful in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.
The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.
Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians. This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting. Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.
There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care. Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention. Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.
A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care? An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.
But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.
Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority. This is where medicine is the best choice.
So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.
First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter. Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.
What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.
When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job. While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care. There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.
Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes. Medicine is interventional at the disease level, thus the training is focused at that level of care. Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.
What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention. Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person. To be successful in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.
The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.
Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians. This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting. Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.
There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care. Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention. Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.
A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care? An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.
But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.
Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority. This is where medicine is the best choice.
So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.
Sunday, May 13, 2012
Capstone Update (with life thrown in)
Topping out at nearly 7236 words, 53 pages, and more tables and figures than I want to reflect on, the culmination of nearly two years of work, Social Networking and Mental Health Providers: Practice Trends and Perspectives to Shape Interdisciplinary Guidelines has been submitted for subjugation to the red pen. Hallelujah!
Now, who wants to publish it?
For that matter, who want to come along for some travel and networking? In the past two weeks I had the opportunity to hob-knob with writers from the ASJA and entertain guests for Derby Week. Monday I am taking off for Las Vegas to attend the Contemporary Forums #Psych12 conference. The psychopharmacology units will be especially useful as I prepare for my ANCC psych-nurse practitioner boards. Graduation in Memphis comes the following week, then in June I will be attending the Army Medical Experience in San Antonio as he APNAs representative. For some reason I agreed to do a tandem jump with the Golden Knights which is perhaps a sign I need my dosage checked.
In the midst of all this fun come the job hunt and quandary over how best to use my new found genius. One one hand, I can continue to do what I have been doing - adjunct teaching and running a private practice 3-4 days per week. The freedom is phenomenal and I love the variety of practice with teaching. Option two is to take up teaching on a full time basis with practice taking on more of a part time role. Benefits include . . . well, benefits, loan repayment, and the collaborative opportunities for research and speaking which do not come as a solo-provider. Option three is to focus on intensive clinical experience working with the VA (application submitted) while maintaining my practice on a part time basis. The advantage here is to hone my clinical skills with a population I enjoy working with in an area that is finally getting the funding it requires, and possibly the opportunity to ingrate acupuncture with PTSD treatment.
Any decision is a good decision and I will be able to apply the leadership skill I have learned throughout he DNP program. Note that every scenario includes an element of private practice. I realized long ago I do not thrive in a 9-to-5-one-job environment.
My routine is variety. Except for sleep.
Now, who wants to publish it?
For that matter, who want to come along for some travel and networking? In the past two weeks I had the opportunity to hob-knob with writers from the ASJA and entertain guests for Derby Week. Monday I am taking off for Las Vegas to attend the Contemporary Forums #Psych12 conference. The psychopharmacology units will be especially useful as I prepare for my ANCC psych-nurse practitioner boards. Graduation in Memphis comes the following week, then in June I will be attending the Army Medical Experience in San Antonio as he APNAs representative. For some reason I agreed to do a tandem jump with the Golden Knights which is perhaps a sign I need my dosage checked.
In the midst of all this fun come the job hunt and quandary over how best to use my new found genius. One one hand, I can continue to do what I have been doing - adjunct teaching and running a private practice 3-4 days per week. The freedom is phenomenal and I love the variety of practice with teaching. Option two is to take up teaching on a full time basis with practice taking on more of a part time role. Benefits include . . . well, benefits, loan repayment, and the collaborative opportunities for research and speaking which do not come as a solo-provider. Option three is to focus on intensive clinical experience working with the VA (application submitted) while maintaining my practice on a part time basis. The advantage here is to hone my clinical skills with a population I enjoy working with in an area that is finally getting the funding it requires, and possibly the opportunity to ingrate acupuncture with PTSD treatment.
Any decision is a good decision and I will be able to apply the leadership skill I have learned throughout he DNP program. Note that every scenario includes an element of private practice. I realized long ago I do not thrive in a 9-to-5-one-job environment.
My routine is variety. Except for sleep.
Friday, April 20, 2012
New Grad Self-Care
As I prepare for my own graduation, another year of BSN students are heading toward their own commencement. The first year a practice can be an enormous reality shock, so much so that we have attrition rates in the double-digets. Several of my students who graduated last year have already changed jobs, and a few from two years ago have already left nursing entirely. I have a vested interest, both as a peer and as a patient, to make sure each graduating class produces intelligent, competent, committed nurses who enjoy their work and represent the profession well. This is a brief presentation I created a few years ago to help navigate the role transition and promote life-long job satisfaction. Congratulations class of 2012!
Self Care for Nurses
Self Care for Nurses
Sunday, June 19, 2011
Fat Nurses
I have been one. And felt like an absolute hypocrite when preaching excellent nutrition, exercise, and rest education that I struggled practicing.
It is not just nurses, but healthcare workers in general often make horrible role models of wellness. We eat out of vending machines, grab the greasiest thing in the cafeteria or drive thru, work long shifts without taking breaks thinking it is good for the waistline to skip meals, bring in baked goods for any reason that presents itself, crash diet, OD on artificial sweeteners, consider walking during their shift/playing with their kids the big exercise of the day, and on and on. Although I have never been a smoker, it falls in the same category. Many hospitals have banned smoking on-site leading workers to retreat to their cars or form a line-up across the street of scrubs and smoke. If there is anything to the detrimental effects of 3rd-hand smoking, I think hospital staff has to be the worst of the offenders. Yuck.
Since last year I have lost roughly 30 pounds. The first year of the DNP program has left VERY little time for food tracking on Sparkpeople which was a big contributor to helping get realistic about how much I was eating previously. I was in a total exercise rut for a good part of the winter. I had a feeling it was going to happen so I lifted heavy in January/February before slacking in March/April. I think that was a big help since I have been fluctuating between the same 5 pounds since the beginning of the year. I used to be a huge snacker, especially with stress, but I forget to when I am caught up studying and writing papers on things I find interesting.
I am currently on a 30-days to Vegas personal challenge to get back on the fitness wagon and have been doing a ton of new circuit training videos. Despite being a total narcissist, I love Jackie Warner's Xtreme training DVDs - she is very encouraging, tough, and motivating. Your Body Breakthru Circuit with Michelle Dozios is also solid. I picked up Kelly Coffey-Meyer's 30 minutes to fitness and while I like the workout and variety of pre-mixes, I cannot get over her background exercisers are wearing tank tops with her name on them. Naturally, I am also continuing with Beach Body workouts and supplements - sure it's a big fat pyramid scheme (excuse me, multi-level marketing) but both Shakeology and their fitness programs are awesome. If you want to help me pay for next semester, order something from my site: http://jingbody.com and make sure to select me, Jing Body, as your coach ;)
I plan to finish up with the required clinical hours before my vacation and, in theory, I could take a month off before classes start back in August. However, my awesome and savvy teachers gave everyone an incomplete in clinical so we could front load hours over the summer for the next semester. I am taking full advantage of this and should have an extra 40 hours to my credit. I am probably going to take a break from teaching in this Fall as well so I can grab an extra clinical day and front load for the Spring. And so I can avoid the fat-rut for the winter!
It is not just nurses, but healthcare workers in general often make horrible role models of wellness. We eat out of vending machines, grab the greasiest thing in the cafeteria or drive thru, work long shifts without taking breaks thinking it is good for the waistline to skip meals, bring in baked goods for any reason that presents itself, crash diet, OD on artificial sweeteners, consider walking during their shift/playing with their kids the big exercise of the day, and on and on. Although I have never been a smoker, it falls in the same category. Many hospitals have banned smoking on-site leading workers to retreat to their cars or form a line-up across the street of scrubs and smoke. If there is anything to the detrimental effects of 3rd-hand smoking, I think hospital staff has to be the worst of the offenders. Yuck.
Since last year I have lost roughly 30 pounds. The first year of the DNP program has left VERY little time for food tracking on Sparkpeople which was a big contributor to helping get realistic about how much I was eating previously. I was in a total exercise rut for a good part of the winter. I had a feeling it was going to happen so I lifted heavy in January/February before slacking in March/April. I think that was a big help since I have been fluctuating between the same 5 pounds since the beginning of the year. I used to be a huge snacker, especially with stress, but I forget to when I am caught up studying and writing papers on things I find interesting.
I am currently on a 30-days to Vegas personal challenge to get back on the fitness wagon and have been doing a ton of new circuit training videos. Despite being a total narcissist, I love Jackie Warner's Xtreme training DVDs - she is very encouraging, tough, and motivating. Your Body Breakthru Circuit with Michelle Dozios is also solid. I picked up Kelly Coffey-Meyer's 30 minutes to fitness and while I like the workout and variety of pre-mixes, I cannot get over her background exercisers are wearing tank tops with her name on them. Naturally, I am also continuing with Beach Body workouts and supplements - sure it's a big fat pyramid scheme (excuse me, multi-level marketing) but both Shakeology and their fitness programs are awesome. If you want to help me pay for next semester, order something from my site: http://jingbody.com and make sure to select me, Jing Body, as your coach ;)
I plan to finish up with the required clinical hours before my vacation and, in theory, I could take a month off before classes start back in August. However, my awesome and savvy teachers gave everyone an incomplete in clinical so we could front load hours over the summer for the next semester. I am taking full advantage of this and should have an extra 40 hours to my credit. I am probably going to take a break from teaching in this Fall as well so I can grab an extra clinical day and front load for the Spring. And so I can avoid the fat-rut for the winter!
Tuesday, April 26, 2011
Kiss My A!
Thankfully, my dissident spin on the assignment won back the points I should have lost by not following directions . . . I put it in a pdf instead of a word document. Hey, the syllabus said a policy brief should stand out!
Tuesday, March 29, 2011
Direct from the Policy & Leadership Blackboard: Social Media Ethics
From couponing and microblogs to wikis and networking, social media is all the rage. MD personalities like Oz, Mercola, and Phil, not to mention high-profile facilities like Mayo and Cleveland are all over Facebook and Twitter dispensing health and wellness advice to the masses. Yet some physicians have had some difficulty adapting to the personal privacy and boundary issues of the new medium, which is surprising for a discipline trained to put beepers and unlisted phone numbers between patient and provider. A study on Twitter use among physicians reveled violations in patient privacy, use of derogatory, profane, and sexually explicit content, unsupported medical claims, and advice in contrast to standards of care (Chretien, Azar, & Kind, 2011). The AMA (2010) has created a policy statement on professionalism in the use of social media highlighting some on the unique personal and professional considerations as well as potential benefits of social media use.
But what about the nursing organizations and the individual (and decidedly non-phenomenon) nurse practitioner? Despite it's own engagement in multiple mediums, all the ANA has advised is a generic call to follow the code of ethics (American Nurses Association, 2010), specifically the sections on conflict of interest, accountability for judgement and action, professional growth and maintenance of competency, and preservation of integrity and (American Nurses Association, 2001)." Behavior online is not necessarily analogous to behavior in person or even over the phone. Should you "friend" patients, coworkers, or students, and if you do, are you responsible for knowing and responding to their posts? Imagine one of your patients posts suicidal statements on a social media site and you see it. Students may post negative comments on your class or violate the school honor code. Coworkers who begged you to cover when their child is sick may post pictures from Fiji the same day. While some scenarios seem like cut-and-dry common sense, others require professional guidance in terms of best practice. Moreover, no precedent has been set in regard to liability, and there are plenty of legal considerations in terms of confidentiality, nonmaleficence, veracity, solicitation, and malpractice.
I personally use social media extensively as a way to promote my business and the profession and plan to continue to do so. Carefully. I think it is important that the ANA address this specific topic in the next edition of the code of ethics to provide a basis of guidance and support for nurses. I would much rather see our governing body set the precedent than the winning attorney of the first lawsuit.
American Medical Association. (2010). AMA Policy: Professionalism in the Use of Social Media.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: ANA.American Nurses Association (2010). House of Delegates resolution: Social networking and the nurse. Kansas Nurse, 85(6), 21-21.
Chretien, K. C., Azar, J., & Kind, T. (2011). Physicians on Twitter. JAMA: Journal of the American Medical Association, 305(6), 566-568.
Thursday, March 10, 2011
I Would Have Rather Been a Waitress
A Facebook pal and classmate posted this and I had to share. At just shy of 60 years from the writing of this passage, APRNs have almost managed to get the phrase "physician extender" out of the vocabulary, and RNs are continually ranked the highest in professionalism and respectability in the healthcare field. Enjoy how far we have come!
The Handmaiden
Nursing is an extension or component part of medicine;
--Nurses are physical extensions of the doctors
--Nursing work is solely delegated medical work done under the close control of a doctor
--Nursing is a part of medicine’s business, and doctors can speak for nurses.
Because the nurse is no more than a participant in medical care, the nurse is expected to obey the doctor.
Nurses are not expected to challenge doctors even if they believe the doctor to be making mistakes which are endangering the patient’s life.
If the nurse carries out the orders of the doctor without question the nurse will not be at fault even if s(he) believes on reasonable grounds that the doctor’s orders are incorrect or immoral and may endanger the patient.
--Even if the nurse performs activities which s(he) knows to be morally wrong, the nurse can be exonerated if s(he) were ordered to do so by the doctor.
The nursing profession is the handmaiden of medicine and the final success of the treatment of disease is often bound up with the efficiency of both. Hon. Dr. Parr, Hansard, 9 September 1953.
Saturday, March 5, 2011
ANA on Social Media and Networking
Social networking and the nurse.
There is very little research regarding the new phenomena of social networking and its role in nursing practice. The ANA HOD, in an effort to begin the dialogue, brought forth an informational resolution. An informational resolution does not require the ANA HOD to take action, however, it does indicate action will be considered in the future as nursing research evolves and demands attention.
The nature of social networking is new to most everyone. Nurses need to understand the potential reach of social networking sites such as Facebook®, MySpace®, and Twitter®. Although social networking sites have positive benefits in the realm of mutual support and knowledge sharing, there are negative effects as well. Some negative aspects include: loss of privacy, legal liability, and loss of professionalism (Frohna, McGregor, & Spector, 2009).
The ANA Code of Ethics outlines ethical responsibilities of nurses in practice relating to social networking (ANA 2005). Crossing over through personal and professional boundaries can represent a conflict of interest for the nurse. Nurses have accountability for individual actions, professionally and personally. Nurses have the responsibility to behave consistent with personal and professional values to protect the integrity of self and profession.
The HOD supported this informational resolution. Social networking remains unfamiliar territory for the ANA. Research is needed to guide and inform policies and practices in the utilization of social networking on the national stage as well as at the local level.
Referring to the ANA Code of Ethics is like saying "wear your cap and keep your mouth shut"- I venture to guess less than 5% of all nurses have read the thing (ohh, good idea for a survey!). I do not think we need to go through the whole finger-shaking nursing diagnosis way of creating a position on this. The time is over-ripe for the profession to play a dominant rather than handmaiden role in the healthcare marketplace and stop relying on the old "most respected profession (so why change?)" pat-on-the-head. Responsible use of social media can make that happen. Let's put it in writing!
Thursday, February 10, 2011
Plagiarizing Blackboard Discussions
I am plagiarizing myself from my leadership and health policy class, so no honor code violations have been broken! I am most excited to see that the battle is back on for eliminating the anachronistic and undermining collaborative agreement between physicians (who are educated and practice in medicine, thus have no more basis to supervise nurses than they do any other health profession they themselves are not masters of) and advanced practice nurses, many of whom have been charged thousands of dollars a year by opportunistic physicians for the privilege of prescribing within their already given scope of practice. I guess when you make the kind of money primary care physicians don't make, you have to plunder every potential revenue source you can. Nicky the Stick would be jealous.
I will have much more to say later, meanwhile, check out the LEO article MAD Money for the spicy pre-fight analysis.
Last year in KY, a number of state and national nursing organizations put up a unified fight to get rid of the need for physician oversight of NPs in regard to prescribing. House Bill 556 (sponsored by May Lou Marzian, an RN) and Senate Bill 75 bill were written with the intention of compromising to exclude scheduled medications. The MDs on the board put up the usual objections to "giving a bunch of nurses the same privileges as an MD," but it managed to pass in the house committee. Documentation showing APRNs received less complaints, made greater use of KASPER to decrease narcotic "doctor shopping," and equal outcomes as compared to primary care MDs were presented. A few handshakes and some bourbon on the rocks in the back office made the smear campaign that began shortly afterward sure to get the bills stalled - nursing may have had the greater head-count, but the MDs had more bucks.
I will have much more to say later, meanwhile, check out the LEO article MAD Money for the spicy pre-fight analysis.
Last year in KY, a number of state and national nursing organizations put up a unified fight to get rid of the need for physician oversight of NPs in regard to prescribing. House Bill 556 (sponsored by May Lou Marzian, an RN) and Senate Bill 75 bill were written with the intention of compromising to exclude scheduled medications. The MDs on the board put up the usual objections to "giving a bunch of nurses the same privileges as an MD," but it managed to pass in the house committee. Documentation showing APRNs received less complaints, made greater use of KASPER to decrease narcotic "doctor shopping," and equal outcomes as compared to primary care MDs were presented. A few handshakes and some bourbon on the rocks in the back office made the smear campaign that began shortly afterward sure to get the bills stalled - nursing may have had the greater head-count, but the MDs had more bucks.
The good news is, the fight is back on for 2011 and the passage of health care reform (whether you like it or hate it, use what you can of it to your advantage) has put APRNs in a much better bargaining position. The shortage of primary care physicians is not going to get filled because the pool of medical students willing to spend their youth and money on education with a payoff of less than $200K/year is getting smaller and smaller. MDs should use that education to specialize and focus on disease care and pass the baton to ARNPs for the wellness care. This is going to be a nasty fight!
Drake, S. (2010). Courier Journal. Bill to expand nurse practitioner duties advances in Kentucky. Retrieved from http://www.spapn.org/blog/?p=171
Shaw, S. (2011). LEO Weekly. Mad medicine. Retrieved from http://leoweekly.com/news/mad-medicine
Thomson Reuters. (2010). 2010 Kentucky senate bill no. 75, Kentucky 2010 regular session. Retrieved from http://www.midwife.org/siteFiles/legislative/Kentucky_bill_S_75_2010.pdf
Wednesday, November 24, 2010
Philosophy vs. Practice
Last week I had a discussion with one of my students that made me realize there are a lot of new BSNs anxious to start their advanced practice education before 2015 and be grandfathered in rather than have to get a doctorate. After launching a discussion concerning the potential issues with competition in the job market, reimbursement, and practice scope down the road, I finally got to the real reason this and several other students have been saying "no" to the DNP - "I don't like all that research and dissertation stuff."
Translated - "Homework? Yuck!"
I explained the DNP was a practice doctorate, much as the MD is, that incorporates philosophy of science, but with the emphasis on the area of clinical specialty in the field rather than academic research in the library. And for those students for whom autonomy is a priority (aka "I don't like to be told"), it provides true professional parity with the other advanced level health care practitioners. On paper.
I admit I am bothered that there are a lot of young nurses who would rather sneak in under the wire than see their advanced education through to the end. It reminds me several competent LPNs I know who are convinced they cannot be an RN because of the statistics requirement. Moreover, I am disappointed that there are many bright, driven individuals capable of representing the nursing profession well who are intimidated by the work involved with a PhD. Advanced practice is not for every nurse, but why put in the effort to reach the middle when the top is just a few tests and papers away?
In a down economy, I understand folks want to get out and start earning revenue and that this is only a transitional hiccup. As universities scramble to change their 2-year MSN to a 3-year DNP, I feel it is part of my role as an educator to foster awareness to the different advance practice options available to BSN students so they do not find themselves at 30 years old pushed out of the marketplace unless they go back to school. I have a number of students interested in becoming educators, and I strongly advocate the PhD or EdD routes as the most appropriate for that track.
I can envision folks opting to do the DNP as an "easy out" to becoming a "doctor" without having to do the deep research of a PhD that is essential to certain aspects of advanced practice, however the PhD across all disciplines opens doors that practice doctorates do not. Many MDs who want to engage in research and education move forward with the PhD and I believe universities will continue to prefer or require the PhD credential for didactic-focused tenure.
I found this comparison chart from the Duke University School of Nursing that really clarifies the matter (it is somewhat program specific):
Doctor of Nursing Practice
|
PhD in Nursing
| |
Focus
|
Nursing Practice
|
Nursing Research
|
Degree Objectives
|
To create nursing leaders in interdisciplinary health care teams by providing students with the tools and skills necessary to translate evidence gained through nursing research into practice, improve systems of care, and measure outcomes of patient groups, populations and communities.
|
To prepare nurse scientists to develop new knowledge for the science and practice of nursing. Graduates will lead interdisciplinary research teams, design, and conduct research studies, and disseminate knowledge for nursing and related disciplines, particularly addressing trajectories of chronic illness and care systems.
|
Curriculum Focus
|
Translation of evidence to practice, Transformation of health care, Health care leadership, and Advanced Specialty Practice
|
Trajectories of Chronic Illness and Care Systems
|
Core Courses
|
Evidence Based Practice and Applied Statistics Data Driven Health Care Improvement Financial Management and Budget Planning Effective Leadership
Health Systems Transformation |
Philosophy of Science & Theory Development Advanced Research Methods Statistics & Data Analysis Longitudinal & Qualitative Research Methods Chronic Illness & Care Systems
|
| Mentored Teaching Experience |
optional
|
Minimum of 140 hours
|
Clinical Hours
|
400 minimum within capstone project
| None |
Capstone Project
|
Yes
| No |
Dissertation
|
No
| Yes |
Distance Learning/Online Option
|
Yes
| No |
Part-time study
|
Yes. Program designed for working nurses
| No |
Point of entry
|
BSN or master's in advanced nursing practice
|
BSN or MSN (or related master's degree)
|
Program Length
|
5 semesters for MSN entry, varies for BSN entry*
|
four to five years
|
Credits Required
|
34 to 94*
| 57 |
Employment Opportunities Post Graduation
|
Health care administration, clinical nurse faculty
|
Nurse scientist, nursing faculty
|
GRE Required
|
Not for students who have an earned master's
|
Not for students who have an earned PhD
|
Tuition Waiver **
|
N/A
|
Full tuition, fees, and health insurance paid by School of Nursing
|
Stipend
| N/A |
Stipend for five years with expectation that students participate in gaining external sponsored support
|
* Program length and required credits depend on advanced practice specialty selected, 73-94 credits for BSN entry. For MSN entry, 34-41
| ||
**All applicants are encouraged to discuss financial aid options with the School of Nursing Financial Aid Office.
| ||
I also liked this editorial about the concern over the role of the PhD. I do not agree the terminal role for all advanced practice nursing should be the PhD, but there are several point for contemplation as we look to define the future of our profession.
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