The Trouble With Interdisciplinary Studies: Everybody

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

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

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

Abstract

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

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

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

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

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


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

Proposed Guidelines  

The following are proposed key components for foundational interdisciplinary guidelines that each of the professions could expand upon according to their own licensing and regulation requirements.  

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

Serendipity: DNP Admission Essay

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

UTHSC DNP Application Essay 2009

“I’m not taking that disrespect medicine! And get these f*cking rent-a-cops out of here.”

“I respect you. These gentlemen are here for all of our safety. Please take the medicine.”

“Don’t you tell me what to do little girl. I know you just want to control my mind.”

“I just want you to rest and relax so you can speak to the doctor and get you home.”

“Bullsh*t!”

“Please make the good decision. If you take the medicine you can lie in bed and wait for the doctor. If you refuse we will have to put you in seclusion and maybe restraint. Which one do you think is more disrespectful?”

“Fine – give me the medicine.”

“Thank you.”

            When I relate this and similar encounters to my BSN students, they usually respond with a shudder and ask why I would ever want to work in a place like emergency psychiatry or in the psych field at all. They feel nervous around the unpredictability and worry about violence, sexual advances, and suicidal revelations. They are uncomfortable that the diagnosis of psychiatric illness cannot be confirmed with a lab value or imaging study and that there are no tactile tasks as there are in the medical setting. I tell them these are the exact reasons why I love working with this patient population and being a psychiatric and mental health nurse.

            After I came out of my accelerated BSN program in 2005, I took the advice of some nursing professors and began in the emergency department. It was not a good fit. I wanted to spend more time with patients than what was considered suitable for a department whose priorities were to stabilize and ship off. I had family ask if I could be their loved one’s nurse when they were transferred to ICU and I had individuals who had mania remember me as the nurse who took time to get to know them instead of locking them in a seclusion room just because they had “Bipolar” written in their history.

            I made the switch and took a position as a second shift nurse at Ten Broeck, a private psychiatric facility that catered to adults, children ages 3-12, and active duty military personnel. I also worked with the psychiatric assessment team that went to ER’s all over Louisville to determine level of care and initiate disposition to the appropriate facility. After two years I craved a higher acuity environment and more diverse patient population and took a position in emergency psychiatric services at University of Louisville Hospital. I also became certified through the ANCC as a psychiatric and mental health nurse and began teaching psychiatric clinical for Bellarmine University.

            In 2008 I began the Family Nurse Practitioner Program at Bellarmine. I chose the FNP because, while I love working in psych, I also wanted professional diversity. In addition to prevention, management and education of health conditions across the lifespan, a large percentage of primary care involves treatment of depression, anxiety, ADHD and PTSD and screening for substance abuse and domestic violence. Although I wanted more medical experience, I planned on obtaining my Psych NP certification even prior to beginning my FNP, and this resolve was strengthened during my educational clinical experience. While I enjoyed primary care in pediatric and adult settings, when I got to the psych portion of the rotation is was like a sigh of relief. With the new Doctor of Nursing Practice degree becoming a requirement in the next five years, I also feel it is important to continue my education while I am still in the flow of academia rather than waiting or being grandfathered in.

            In addition to nursing, I have also been an acupuncturist and Doctor of Oriental Medicine for the past ten years and have focused my practice in pain management, women’s health, and mental/emotional disorders. I have had the opportunity during my training and professional practice to work with chemical dependency, depression, anxiety, stress management and PTSD using a combination of modalities including acupuncture, herbal therapy, nutrition, Tui Na, exercise, and mediation. I was also involved in development of a research project that compared the effectiveness of CBT with and without acupuncture intervention in patients with PTSD.

            My professional goals include integrating my specialties to develop a holistic approach to education, prevention and treatment of anxiety disorders. While other disease processes such as bipolar, schizophrenia, and personality disorders are also of interest to me, in the higher levels of education I feel it is important to narrow the field of concentration. I have had experience in Internet blackboard courses and working at an accelerated learning environment while maintaining employment throughout my educational career. The ability to obtain the dual certification in mental health with the DNP allows me to have more freedom and a greater variety of choices to peruse my goals. 

I Passed! A Review of the Review and Exam

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

There is a DSM code for that.

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

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

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

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

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

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

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

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

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

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

The Study Plan

After listening through the Barkley review with a mix of triumph and dismay at my knowledge base, it is time to dig into the source material. My test date is looming and it is time to see if I know what I think I know.  Sources are primarily the ANCC review book and a couple of the well-used texts from school, which I hope will result in a super-pass. Here is my life for the next few days:

Saturday: PMHNP role, scope, regulations, and theory

Sunday: Neuroanatomy, neurophysiology, behavior, and assessment of disease

Monday: Pharmacological principles and non-pharmacological treatment

Tuesday: Mood and anxiety disorders (apropos as I am getting a massage)

Wednesday: Psychotic and cognitive disorders

Thursday: Substance and personality disorders

Friday: Child/adolescent disorders and managing the dreaded yet interesting "other"

Weekend: Practice tests and reviewing the "know this cold" sections from Barkley review.

July 30th is the big day. Wish me success!

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.

Abstract Accepted!

Acupuncture News: Pushing the Point: Integrating Acupressure and Chi...: Integrative therapies are all the rage, particularly in psychiatric and mental health settings. It is an honor to be accepted for a pre-conference session at the American Psychiatric Nurses Association's 26th annual conference in Pittsburgh this November. Check out the abstract . . .

An Important Announcement

To Graduating MSN, DNP & PhD Students:
Congratulations on your upcoming graduation from the University of Tennessee Health Science Center College of Nursing! In conjunction with the UTHSC Commencement the afternoon of May 25th, the College of Nursing will host a Dean’s Convocation the morning of commencement honoring our graduates and their families. A reception will follow the ceremony. Attendance is required at both the Dean’s Convocation and Commencement unless excused by the Dean.

The convocation will be held at Lindenwood Christian Church, 2400 Union Avenue at 9:00am on Friday, May 25, 2012. Students and faculty will be in full academic regalia during the convocation and, of course, in appropriate dress afterwards. Lindenwood Church is located on Union Avenue immediately east of the intersection of Union Avenue and East Parkway, approximately 3 miles from the College of Nursing. Plan to arrive at the church at 8:30am. We anticipate the ceremony & reception will be completed no later than 11:00am. Invitations are being printed for the convocation ceremony and will be forwarded to you shortly for your use in inviting family and friends.

Congratulations again and we look forward to celebrating with you and your family on May 25th.

! Sent with high priority (no kidding!)

Mental Health Providers & Social Networking

I have not been blogging much about the DNP experience this semester for a couple of reasons. First, life. Second, class is over with all of the focus and attention going toward our capstone projects. With that in mind, I am embedding the survey here for the next month to try and capture as many mental health providers (nurses, psychiatrists, psychologists, social workers, therapists) as possible. You can also access it at www.SurveyMonkey.com/s/OneDNP 

My goal is to gather at least 500 responses and publish the results later this year. Feel free to post any comments or questions. Thanks!

Create your free online surveys with SurveyMonkey, the world's leading questionnaire tool.

Theory for Thursday

When I first heard the words "nursing theory," I snickered.  I thought it was yet another example of the white cap club trying to stake a piece of unnecessary territory when they should be changing a bandage or administering an enema.  Seriously, how much of a theory do you need beyond "take care of the patient?" As with many other moments on my nursing education journey, a little dose of the real world to go along with the literature took care of my ignorance. I hope. The following is a report on one of my favorite theorists, Afaf Meleis, who's work on transitions has provided guidance for those times in practice when there is no map.

Meleis: Transitions Theory Evaluation

Transition is an emerging middle range nursing theory that emphasizes the role of the nurse in facilitating healthy individual role sufficiency. While straightforward in concept, transitions theory contains multiple components that have changed over time and encompass more than assisting a patient adjust to new changes in health status. Fawcett (2005) provides an appropriate framework for analysis and evaluation for the developing transitions theory as conceptualized by Afaf I Meleis.

Analysis

Origins
     Meleis first became interested in nursing theory during her master’s studies when she researched the role of meaningful and informative interactions between caregivers with patients and their families (Meleis, 2007). After attending several types of support groups, she found the transition processes were similar whether the group concerned family planning, grief, or illness. Her doctoral dissertation focused on the importance of role clarity through dialogue and interaction in couples planning to start a family. Through her research, she concluded that the major role of the nurse was to prepare the patient to cope well with developmental, situational, and health transitions (Meleis, 2008). Her research focused on people who made poor transitions and on nursing interventions that could facilitate better outcomes. Meleis began forming her role transition theory and created the first concept map in 1984 (Meleis, 2007) with a revision in 2000 (Meleis, Sawyer, Im, Messias, & Schumacher, 2000).
     Meleis (2010) suggests change is addressed in some manner in every nursing theory citing Peplau and Travelbee as examples of how to find growth and meaning though the change of illness, Roy’s adaptation model, patterning from Rodgers and Newman, and change in self-care ability from Orem. The act of caring for a patient using nursing therapeutics incorporates transition as a vital component. Transition theory was formulated to promote healthy evolutions and well-being in individuals by using nursing and social support. The nurse provides education, skills, and strategies for the patient and family to understand and cope with the experience of transition. This theory explains the transition experience as a change from one role to another with individuals having unique circumstance that may facilitate or inhibit the ability to define and master a new role and integrate it into their identity (Meleis, 2007). By providing an understanding of the nature of transition, conditions that potentially facilitate or inhibit positive change, and patterns of response, the nurse has a framework for preventing role insufficiency and anticipating the patient’s physical and psychosocial needs required for successful transition.
     In the initial conception of role transition theory, Schumacher and Meleis (1994) listed time and nature of change as one of the properties of nature in transitions. Later, Meleis, Swayer, Im, Messias and Schumacher (2000) added awareness, engagement, and critical points. Indicators of healthy transition included subjective well-being, role mastery, and well-being of relationships (Schumacher & Meleis, 1994) which were later altered and incorporated into process and outcome indicators (Meleis & Sawyer et al. 2000). There were also changes in and additions to the use of terms including roles, role stress, multiple role stress, transitional gender roles and coping, especially when the theory was used in disciplines other than nursing.
Unique Focus
     Meleis (2010) transition theory focuses on the period of evolution from what has been to what will be and is best classified as a developmental theory. It concentrates on the transition of the individual, family impact and involvement, the role of the nurse in facilitating the transition, and cultural, societal, and community support. Areas of theory application include change in health status; change in social support and relationships, such as relocating to a new city, becoming a parent, or loosing a friend; when an individual looses familiar reference points as with immigration to a new country or nursing home placement; or when there are new needs or an inability to meet old needs in familiar ways.
Content
     Positive role transition is facilitated or inhibited by nursing intervention and personal, social and community conditions. Transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).

Evaluation

Explication
     Afaf I Meleis grew up in Egypt and received her nursing degree from the University of Alexandria in 1961 (Meleis, 2008). After briefly teaching nursing in Egypt, she immigrated to the United States where she received her master’s degrees in both nursing and sociology from the University of California Los Angeles. She completed her dissertation “Self concept and family planning” in 1968 and was awarded her doctoral degree in medical and social psychology. Meleis has authored numerous journal articles and is an international keynote speaker in women’s health, doctoral nursing programs, and health care research. She served as a university professor in the United States, Kuwait, and Australia, and is currently the Margaret Bond Simpson Dean of Nursing at the University of Pennsylvania. Her teaching methods focus on organization of nursing knowledge, health transitions, and international nursing.
Transition theory assumes there are universal properties in transition that include change in identity, roles, relationships, behavior patterns, structure, function, and dynamics (Meleis, 2007). Transitions naturally occur throughout life but are not always predictable or sequential and a variety of multiple changes may occur simultaneously. Nurses facilitate, inhibit, or ignore transitions directly affecting the outcome. Personal, cultural, social environmental factors also influence the outcome of a transition.
Comprehensiveness of Content
     Role transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).
     There are four types of transitions: developmental, situational, health-illness, and organizational (Meleis, Sawyer, Im, Messias, & Schumacher, 2000). Developmental transitions are those that occur in the normal process of growth and maturity and include milestones such as puberty, parenthood, and menopause. Situational transitions may be unexpected or sudden such as widowhood or a car accident. Health-illness involves a medical change such as a spinal cord injury, cancer, or autism. Organizational transitions refer to changes in delivery systems including leadership, policy, and administration. Single patterns transitions occur once or one at time such as a developmental milestone. Multiple patterns can occur more than once as with childbirth, marriage or death of a loved one. Sequential patterns occur one after another while simultaneous patterns may be a mix of transition types occurring at the same time. Patterns may or may not be related to each other (Meleis et al., 2000). Nursing interventions, especially those involving education, have an influence on awareness, engagement, change and difference, and critical points and events (Meleis et al., 2000).
     A number of transition conditions are discussed in the literature. Personal conditions include meanings, cultural beliefs, socioeconomic status, and preparation for the individual. Entry into a psychiatric facility can mean abandonment, powerlessness or failure to a newly admitted patient and manifest itself as anxiety or resentment (Aroian & Prater, 1988). Conversely, admission could represent an opportunity to manage a disorder and accept medical and lifestyle assistance. Cultural beliefs and attitudes toward transition should be acknowledged, addressed, and accommodated by culturally competent nurses. The birth process in American born women is different from Arab American women who are often more modest, subordinate to men, and do not regard planning as an important aspect of childbirth (Meleis & Sorell, 1981). The experience of menopause in middle-class or wealthy American women differs from low income Korean immigrants who tend to report fewer symptoms and discount menopause as an unimportant transition (Im, Meleis, & Lee, 1999). Nursing home entry is often a difficult and varied transition; personal preparation and knowledge may hinder or help both the person in transition and the supporting family (Rossen & Knafl. 2003).
     Communities with productive and safe recreation outlets, educational facilities, and accessible health care facilitate effective transitions. Adolescents moving from a comfortable, supportive, and familiar community to a new area of the country are at risk for ineffective role integration and substance abuse (Puskar, Kathryn, & Martsou, 1994). Societal conditions that impact transition include federal and state programs, laws, and cultural norms. A society that seeks to reduce the amount of the population who smokes tobacco may institute bans and offers cessation programs and incentives, thereby making it easier for the individual to quit. Societies who revere the elderly may have less elder abuse and nursing homes then in those who have more negative attitudes toward aging and home care (Davis, 2005).
Once the nature and conditions of transition have been identified, there are patterns of response an individual will exhibit. Process indicators help evaluate and predict the success of a transition and guide the nurse in developing interventions to help plan and meet goals. These indicators include feeling connected, interacting, location and becoming situated, and developing confidence and coping (Meleis et al., 2000). The nurse assists in facilitating these response patterns by providing individually tailored interventions, education, action plans, and community resources. The nurse takes into consideration the conditions and nature of the transitions before forming an intervention plan. The ongoing evaluation of process indicators and response patterns guide future interventions. Outcome indicators are marked by mastery and fluid integrative identities (Meleis et al., 2000). That one copes with and accepts the diagnosis, treatment, and remission of cancer demonstrates mastery of a role. For an individual to identify themselves as a survivor, a parent, and an accountant exemplifies role integration.
     Although there are several components to transition theory, the theoretical propositions and relational statements are clear and concise. Transition leads to the development of a new role. Understanding the properties of specific transitions guides the nurse in planning effective interventions to assist the patient in adapting to a change in identity. If transition conditions in personal, societal and communal spheres are facilitative, the individual and their family will develop positive patterns of response. Promotive nursing interventions increase the amount of positive process indicators. The more process indicators and individual possesses, the greater the ability to master and integrate the transition into their self-concept (Meleis & Sawyer et al. 2000).
Logical Congruence
     Transition theory aligns well with the partnership model of health care and holistic practice of nursing. A patient should be informed about every procedure they undergo, every medication they take, and every viable treatment option available. It is the professional responsibility of health care providers to increase the patient’s knowledgeable about the current process and feel empowered in the management of their condition. Encouraging patients to enlist as many tools as possible to manage their conditions including family support, community group therapy, online resources, and mind-body techniques provides autonomy and aids the practice of cultural competence. This theory puts responsibility on the nurse to educate, use critical thinking to develop effective treatment strategies that involve patient and family, and assess effectiveness of strategies. Social values are covered in relation to how an individual perceives and is assisted by society. Americans expect knowledgeable, courteous, ethical health care providers and this theory implies that nurse will exhibit these behaviors. This theory was born using a variety of cross-cultural observations and research on transitions. Provided the nurse refrains from assumptions regarding meaning to the patient and his or her own personal bias, transition theory is applicable among many diverse worldviews and nursing areas.
Generation
Meleis intended the transition theory to be used in practice, education and research specific to nursing and healthcare. Transition is moderate in scope and defines a facet of nursing practice. It is classified as a middle range theory because it is not precise and restricted enough for situational or practice theory, but too limited in scope and abstraction to be considered a grand theory (McEwen & Wills, 2002). It is also used as a framework for developing situation specific theories (A. I. Meleis, personal communication November 2008; Nelson, 2006). While conceived for the field of nursing, role transition is a theme in sociology and psychology that is applied in works concerning women and cultural issues (Meleis & Rogers, 1987; Im et al. 1999). In these applications, different inconsistent terminology and meaning made comprehension and identifying major concepts difficult. Due to Meleis’ (2008) profusion of published journal articles, it was cumbersome and confusing to differentiate between those articles that discussed transition as a theory rather than a cultural or developmental process. As this theory evolves and more elements are added, parsimony decreases.
Credibility
Social Utility. Transition theory is used in areas such as psychiatry (Aroian & Prater, 1988), long-term care (Davis, 2005), cardiac rehabilitation (Dracup, Meleis, Baker, & Edlefsen, 1985), and motherhood (Sawyer, 1999) to either prepare an individual for change, or evaluate the effectiveness of intervention prior to or following a particular transition. It has been used to guide research and develop situation-specific interventions in the sibling experience of childhood cancer (Wilkins & Woodgate, 2006) and transition to adulthood in adolescents with developmental disorders (Pearson, 2002). Transition theory is currently used as a framework in undergraduate and graduate nursing programs at institutions including University of Connecticut and University of Pennsylvania (A. I. Meleis, personal communication, November 2008). Transition may be adapted from nursing and used for changes in social and political spheres such as the recent health care reform act.
Social Congruence.  Transition theory is a cross-cultural, adaptable theory that can be used by nurses and other health care professionals to elicit positive role integration in an individual, family, organization, or community. While the origins are based in nursing, the social and psychological aspect of application makes this a useful framework for multiple disciplines. Using this model to prepare for, understand, and anticipate change, increases the probability of successful transition.
Social Significance.  Those who are prepared for change are more apt to accept a new role to the benefit of their family and community. When people are knowledgeable, adapt easily to changes, and are able to integrate a new role into their self-concept with a sense of well-being, society benefits. The world is moving toward globalization in several arenas including healthcare and the environment. This theory provides strategies for society and individuals to have healthy transitions through knowledge and use of available resources. An understanding of universal properties of these transitions assists in devising successful strategies in international social, political, and health policies.
Contribution to Nursing
     Role transition clarifies and specifies the major role of the nurse. It assists the nurse in assessing areas of vulnerability, readiness, environment, and support. It demonstrates that education prior to, during and following transition increases the likelihood of successful role integration. It also provides a framework for planning nursing interventions with the goal of healthy stability. In a study involving the sibling experience with childhood cancer, nurses used transition theory to develop educational interventions that allowed the sibling to understand the disease process and provide support to enhance the therapeutic outcome for the affected sibling (Wilkins & Woodgate, 2006). When transition theory was applied to the recovery process in major depression, Skarsater and Willman (2006) concluded transition planning facilitated health, recovery and quality of life. The role of the nurse in preparing parents for the discharge of their children from hospital care to homecare validated that education and preparation for transition led to healthy and adaptive outcomes ( Weiss, Johnson, Malin, Jerofke, Lang, & Sherburns, 2008).

Summary and Recommendations

Meleis provides a detailed framework to execute successful role transition by illustrating and describing the role nurses have been playing for decades. As an evolving theory, there remain issues of consistency and clarity when researching the origins and evolution of concepts. There is also a lack of relevant data in relation to men and a need for expanded theory testing. Despite these shortcomings, role transition is an adaptable theory that has applications beyond the scope of nursing practice.

The IRB (Exempt) Stamp of Approval

As any of you following along may have guessed, my DNP project involves an investigation into the current practices of social networking among mental health providers and suggestions for appropriate use. I hope to get a diverse response base and would appreciate help with dissemination to nurses, psychiatrists, psycologists, therapists, and social workers. I spoke on this topic at the APNA conference, but have made some significant revisions to the questionnaire since then. I would appreciate any mental health professional willing to take the time to fill out the survey and pass it along to colleagues:

https://www.surveymonkey.com/s/OneDNP


Thanks!

Worth the Price of Tuition

Every week in clinical I learn something new, but this week was full of particularly intriguing one-liners. Learning is not always quantifiable, but for those that question the value of obtaining yet another advanced practice degree to do what you already do, I raise the possibility that the educational process may at minimum make you think differently than you have been thinking. And thinking changes practice. 


I just don't feel the way I do. 
     - LPN (just chew on that one for a moment!) 


The trouble is not that people change, but that they don't
      - Patient insight


Anywhere else it would be called assault instead of rock'n'roll
     - Paient insight


The truth of everything is known when you achieve it
     - PTSD fear awareness group


It's not hypocritical if you want to believe it
     - Spontaneous response from patient session (something I need to work on)

Anyone can pay for knowledge, but belief has no price tag 

     - Reflective practice insight after patient session

My First Sponsored Term Paper

I probably should have put a disclosure statement on the bottom of my Health Economics final since Kronos did pay the $1500 conference fee and $200/night hotel room for me to research the topic. All perks aside, you can't argue with cost savings, if they are indeed cost savings since they are very secretive on how much they charge for timekeeping solutions and automation. I am sure there is some kind of business story in there, but that is not my area.

What was surprising was how few nurses were present during the healthcare sessions. Pardon my prejudice, but HR and payroll representatives reporting on the success of a system is not as convincing as hearing it from the people who use it daily to run the hospital, especially when we are talking about a group of people who are generally hesitant to accept change (but are also a lot more fun). Interestingly, I have had about five or six conversations on workforce development technology in the past few weeks that makes me think I should ask for a kickback from the Kronos. . . but I will settle for an invite to the 2012 conference in Las Vegas!

Here is the analysis in all of it's glory . . . note the comments in red at the bottom :)

Cost-Benefit Analysis of Workforce Management Technology

Jaclyn Engelsher

University of Tennessee Health Science Center

          Since the 1960’s, increased productivity and decreased labor costs have contributed to the adoption of employee self-scheduling in hospital and healthcare systems (Hung, 2002). While the majority of nurse managers continue to use paper sign-ups and e-mailed spreadsheets as the scheduling platform, an increasing number of facilities are implementing workforce management technology programs that deliver web-based and mobile solutions to optimize labor cost, manage absenteeism, and minimize compliance risk (Mercer, 2010). Development companies claim the savings generated from cost-effective staffing pay for the total cost of ownership, generate additional revenue, and improve patient and provider satisfaction. With the current unstable economic environment and implementation deadlines for healthcare initiatives approaching, hospital financial offers are searching for cost containment tools to help manage labor costs, the largest component of net operating hospital revenue (Williams, 2008). A cost-benefit economic analysis of workforce management technology will determine impact on cost, productivity, and compliance in the healthcare setting.

Background

          In few other industries are outcomes more linked to staffing than in 24-hour healthcare operations. The fluctuating nature of patient acuity and needs dictate the skills sets and ratios necessary to deliver high quality of care. The nation faces a new nurse attrition rate of up to 25%, a workforce where the median age is 48.9 years, and an anticipated need for over three million nurses within this decade (Bernard Hodes Group, 2011). Absence contributes to 35% of annual payroll costs, 9% of which is attributed to incidental and extended absences (Mercer, 2010). Whereas the cost of planned absences can be budgeted, unplanned absences from casual sick-days to FMLA leave result in lost time with the average employee missing 5.4 days per year. For a staff of 500, this results in a loss of 783 workdays per calendar year and up to a 29% decrease in productivity. The Fair Labor Standards Act places burden of proof on the employer for alleged violation. Just to go to court for an alleged FMLA violation costs employers an average on $150,000 per case (Kronos Incorporated, 2011).
          When staffing levels fall below patient requirement by as little as eight work hours under optimum ratio, risk to patient safety and mortality increases up to 6% (Needleman et al., 2011). Units delivering increased care hours by staff with the most applicable skill set to the patient population results in lower rates of infection, failure to rescue, length of stay, and decubitus ulcers (Blegen, Goode, Spetz, Vaughn, & Park, 2011). When considering the expense of recruitment, training, productivity loss, sentinel events, and coverage labor, turnover can costs employers up to $64,000 per nurse (Jones & Gates, 2007). Staffing and communication are the top two areas for improvement reported by nurses with shift and work-life balance ranking in the top five reasons for recruitment and retention (Bernard Hodes Group, 2011).
          Employee self-scheduling increases job satisfaction by providing choice and control over work-life balance and has a beneficial impact on primary and secondary health outcomes in staff (Joyce, Pabayo, Critchley, & Bambra, 2010). While most hospitals offer some variation for employee input into scheduling, the manual process of can be cumbersome, inequitable, and result in hours of management time lost trying to fill open shifts with the best staff member at the lowest cost (Mercer, 2010). Workforce development technology companies have integrated automation into self-scheduling systems to reduce labor costs and compliance risk while increasing productivity and patient care. Unlike the unit binders or email requests, the technology can be expensive and require hors of training to master. A cost-benefit analysis is the first step to determine if implementing an automated self-scheduling solution is an appropriate intervention for an individual healthcare system or facility.
Cost-Benefit Economic Theory
          Santerre and Neun (2010) explain cost-benefit analysis (CBA) as a decision-making tool that estimates the total cost and expected benefits of a proposed health policy, intervention, or technology. When the net benefit is greater than the estimated sum of direct and indirect costs, implementation would be recommended. Implementation may also be recommended if the costs and benefits are equivalent, depending on if emphasis of value is placed more on the cost or the benefit. Implementation is unlikely in the event the cost significantly outweighs the benefit. While the CBA can help direct an organization toward solutions that maximize benefit and minimize cost, inaccurate calculations, unaccounted for expenses, and unfulfilled outcomes may occur.
          Direct costs are narrowly calculated, predictable expenses directly attributed to the proposed product or service. In workforce development technology, these include purchase or rental of hardware, training time, service agreements, licensing fees, updates, and installation. Training on workforce development software takes an average of 2 hours for users up to one-two days for managers (Kronos Incorporated, 2011). Training can be delivered remotely, as part of new employee orientation, or by company representative site-visits. Most companies do not publish pricing data due to the tailoring required for each individual organization, variable incentives, and negotiating flexibility. Conservative cost estimates range from $50 per month for limited functionality in small hospital systems, to $100,000 per licensed user for sophisticated solutions. Indirect costs are associated with the proposed product or service, but are not clearly traceable or quantified. Obsolescence, system malfunctions, hardware replacement, software updates, re-training, and sub-optimal utilization, are indirect costs that are difficult to predict and calculate. Examining how various solutions have functioned in like-organizations and reviewing consumer reports of products can help with estimation.
          Outcome benefits are commonly measured in time, money, or satisfaction. A substantial benefit of workforce management technology implementation is reduction in the cost of absence. The benefits paid as a result of absence, such as sick or vacation time, may not significantly vary, however productivity loss from using a less efficient replacement can improve by as much as 5% of payroll by reducing use of overtime employees, agency staff, redistribution among coworkers, or reallocation of work to the supervisor (Mercer, 2010). In a hospital employing 500 nurses with an average salary of $43,000, this results in a savings of nearly $370,000 per year. When Norton Healthcare implemented the Kronos workforce productivity and analytics tool, they saved $5.5 million in labor costs among their 9,700 employees in their first year (Kronos Incorporated, 2008).
          Timekeeping tools decrease labor expense by analyzing patterns of absenteeism and tardiness, labor laws, time-off accrual, and use of agency staff. When using the Kronos mobile scheduler, 70% of open shifts are filled within five minutes of sending a text alerts (Kronos Incorporated, 2011). University of Utah Healthcare saw an 80% drop in agency labor cost the first year of use and the community-based Arch of Baltimore saved $900,00 in total labor costs. Ford Healthcare Systems replaced the office “white-board” with Shiftboard’s online nurse scheduling software which decreased time spent in recruitment, applicant review, and payroll, which aided their expansion into three neighboring states (Shiftboard, 2009). After implementing API Healthcare’s solutions, Coffee Regional reduced overtime cost by $625,000, eliminated $3000 in payroll error, and increased staffing efficiency to a level where for every two retiring nurses, only one replacement was required (API Healthcare, 2010). Data analytics in these solutions allow managers to ensure consistent application of scheduling policies by providing equal opportunity for employees to request time-off, fill open shifts, swap shifts, and be considered for first-cut.
Recommendations
          Workforce development technology should be implemented for organizations that need to maximize operating efficiency of healthcare delivery and decrease compliance risk. To determine potential, an organization must first calculate the cost of absence, compliance violations, sentinel events, and turnover that can be attributable in part to inefficient staffing. Staff input regarding current scheduling procedure and preferred solution platforms must be elicited to determine level of interest and resistance. Review of patient surveys should focus on complaints that effect loyalty such as time spent with providers, staff attitudes, and quality of care. Once the benefits have been quantified, a budget can be created in which to research available workforce management technology. Pricing data varies from between companies and it is important to keep in mind that all direct costs are negotiable and competitive. Once the CBA has been completed, a cost effectiveness analysis can be performed to compare relevant competing solutions.
References
API Healthcare (2010).  Case study: Coffee regional medical center. Reterieved from http://www.apihealthcare.com/_asset/r80vgj/API_CSCR-0310-Coffee_Regional.pdf

Bailyn, L., Collins, R., & Song, Y. (2007). Self-scheduling for hospital nurses: an attempt and its difficulties. Journal of Nursing Management, 15(1), 72-77.

Blegen, M., Goode, C., Spetz, J., Vaughn, T., & Park, S. (2011). Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical Care, 49(4), 406-414.

Bernard Hodes Group, (2011). RNs at risk: Understanding key tenure points. Retrieved from http://www.hodes.com/rns-at-risk

Hung, R. (2002). $uccess $tories. A note on nurse self-scheduling. Nursing Economic$, 20(1), 37-39.

Jones, C. & Gates, M., (2007).  The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal of Issues in Nursing, 12(3)

Joyce, K., Pabayo, R., Critchley, J., & Bambra, C. (2010). Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Of Systematic Reviews, (2)

Kronos Incorporated. (2008).  Norton Healthcare leads change for consumer transparency with help from Kronos. [Press Release] Retrieved from http://www.businesswire.com/news/home/20080623005101/en/Norton-Healthcare-Leads-Charge-Consumer-Transparency-Kronos

Kronos Incorporated. (2011). Does my staffing level matter? Using analytics to correlate staffing with risk and quality events. Unpublished paper presented at Kronosworks 2011: The World’s Leading Workforce Information Exchange, Orlando, FL.

Mercer, (2010). Survey on the Total Financial Impact of Employee Absences. Portland, OR: Mercer Health and Benefits LLC

Needleman, J., Buerhaus, P., Pankratz, V., Leibson, C., Stevens, S., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal Of Medicine, 364(11), 1037-1045.

Santerre, R.E. & Neun, S.P. (2007). Health economics: Theories, insights, and industry studies (5th ed.). Mason: Thomson South-Western. 6

Shiftboard, Inc. (2009). Case study: Nurse scheduling Ford Healthcare Systems. Retrieved from http://www.shiftboard.com/casestudies/Shiftboard-Online-Nurse-Scheduling-Ford-Healthcare.pdf

Williams, J. (2008). A team approach to cost containment. Healthcare Financial Management Association Magazine. Westchester, IL

You have a good idea but clearly the actual data are very short. Most of what you could find to report is information from the company.  This is always suspicious – they are selling a product.  As you saw, finding all the costs are a problem and limit your ability to do a cost-benefit analysis although you tried.

Background = 10  Application of theory = 8 Conclusions/Recommendations = 9 Grammar = 10 Total = 37 (out of 40)

The Sandusky Teaching Moment: Unfortunate Silence

It started with a many suspicions and a random post of the Penn State fan forum.

Perhaps more accurately, it started with molestation and loyalty to the institution over the community.

The ongoing reports out of Penn State for the past two weeks have brought forth discussions and elicited strong emotions from those in every sphere of my life.  At first, I started quoting the standard mandatory reporting regulations for sexual assault and how Child Protective Services, at least in Kentucky, do not accept third-party reporting - it has to come from the victim, the witness, or the individual the victim or abuser discloses to. I thought Joe Paterno's retirement at the end of the season announcement was bold and bordering on arrogant, and was exceedingly irritated that many news reports focused on his firing and the unfortunate silence that led to the end of a great coach's career. I did not graduate from a university with a BCS championship-claiber football program, so I have a hard time relating to the initial student protests of his ousting in light of the allegations.

More details concerning the access Jerry Sandusky had to the facilities after his employment immediately brought forth the thought "this is beyond cover up - there are probably others paying in kind to have access to these boys or to keep quiet." With records missing from Sandusky's charity Second Mile, non-communication with the university lawyer following McQueary's report to Paterno, District Judge and Second Mile contributor Leslie Dutchot letting Sandusky go home without bail, Sandusky's interview with Bob Costas where he admitted to showering with the boys appropriately, and police reports on victims going back to 1998, the rabbit hole gets deeper and deeper.

Teaching Moments
In the real world, these kinds of stories are opportunities for all of us to open the dialogue on healthy relationships. Since this story broke, I have asked many of my patients with young children if they have had these conversation and if this story has affected the family in any way. Most report a heightened sense of awareness and want to introduce or re-empasise body rights and choice. This article provides several useful tips: How to Talk to Your Child About Molestation For the teen or tween: Talking to Teens about Paterno, Penn State, and the High Price of Bystanding.

Every state is different, however mandatory reporting for teachers, healthcare professionals, and law enforcement are generally standard. Some states extend the duty to report to all residents, but this is not typically well known. To look up the statues that apply to you, visit State Laws on Reporting and Responding to Child Abuse and Neglect.

The "coach" position is a gray area, as evidenced by Penn States's policy that you report to your superior before reporting to the police or emergency teams. While it is in the rhelm of possibility that a federal mandatory reporting act could pass as a result of this tragedy, the Center for Ethical Youth Coaching posted an excellent guide for action when a coach, or anyone, witnesses child abuse: Procedures for Handling Abuse

May communities have domestic violence and sexual assault shelters that provide community outreach.  The Center for Women and Families is one of our city's greatest gifts and they provide information on spotting, preventing, and healing from these traumas: Educational Brochure Library

Of course, no OneDNP post would be complete without a nursing mention. When stories of abuse break like this, many victims relive their own traumas and can experience setbacks, especially when in the midst of therapy. It is important when providing care that nurses are aware of the effects of vicarious trauma and transference issues. To learn more about preventative healing and self-care, visit Reveal, Release, Reconnect

Remember that silence kills mind and body. The arguments many nurses make to avoid reporting peers for issues such as substance abuse  - ruining a peer's career, not wanting one's name connected with the report, fear of retaliation or disbelief, looking bad on the profession, practice, or organization - are the same reasons the powers at Penn State rationalized their silence. And no, it's not different.

APNA Presentation & Resource List

Uploaded to slide share and ready to view! Well, except my cool social-media sun did not transfer over well.Please remember to take the survey: Social Networking and Mental Health Providers

Social Networking for Psychiatric-Mental Health Nurses

View more presentations from Jaclyn Engelsher

Resources
ANA's Social Media Toolkit - What every nurse should know

Health Vault - The possibilities for collaboration and consultation are encouraging

VA Directive 6515 (Social Media Policy)

Healthcare Communications & Social Media #hcsm Sunday's at 9pm EST

People Say I'm Crazy John Cadigan, schizophrenia patient, movie maker, twitter junkie

Google Privacy Center  An excellent primer

Facebook Privacy The place to update your settings

Working the System to Make the System Work for Me!

One of our big projects this semester is an economic analysis of a healthcare issue or technology.  Between my APNA presentation and Capstone project, I am a little spent (ha, I made a pun) on social media and wanted to tackle something a bit more juicy: Collaborative practice agreements.

After about 10 hours reading a lot of stuff I already knew:

• The Institute of Medicine's position that APRNs should be full partners and allowed to practice their full scope of practice
• In states without collaborative practice agreements APRNs rank as high or better than MDs when it comes to outcomes 
• State medical boards have banned together to push the idea that nursing is actually medicine and must be regulated by state medical boards
• MDs are still bitching to each other on Sermo and publishing their opinions that so-called mid-level providers are only competent so long as they hand 5-15% of their revenue over in exchange for an on-paper collaborative agreement

I learned some interesting things I did not know regarding the Federal Trade Comission citing that the collaborative practive agreement could be considered monopolistic and a restraint of trade.

Then I decided, I like my blood pressure where it is, and scrapped it. I decided to analyze workforce management solutions for healthcare systems, specifically when it comes to mobile technology. Why? Because there is a Kronos conference in Orlando this November that I have been invited to that will allow me to get first, the latest data, second, the ability to network as part of the research, and third, to write off the entire trip.

Now thats some health economics!