Trashing the CAPA-NS!

As of today, nurse practitioners in Kentucky can submit a form to dissolve the collaborative agreement with physicians for non-scheduled medications, provided they have been prescribing for 4 years. This is an exciting change on the road to full practice authority. Next stop, the removing the barriers for scheduled prescribing!




Visit the Kentucky Coalition of Nurse Practitioners and Midwives for the most up-to-date legislation on APRN practice in Kentucky!

SB7 Passed! A Small Step with a Huge Compromise

The fight to eliminate the anachronistic farce of a collaborative agreement in Kentucky has been underway since before I became a nurse practitioner. Though gaining more support every year it has come up in the legislative session, the opposition has found ways to keep nurse practitioners beholden to the dispensation of physicians in a manner that reeks of FTC violation and hinders healthcare delivery to a woefully underserved rural population across the commonwealth. This time, there were no stall-tactics, no tacking on of offensive amendments, no removal of mutually beneficial components, or other means of killing the bill.

Senate Bill 7, the first bill to be passed by the General Assembly this year, eliminates the mandated non-controlled substance collaborative agreement for nurse practitioners provided they have been in a prescriptive practice for 4 years. There are also key language amendments in this new section of KRS Chapter 314 that further clarifies that nurses oversee nursing practice - something that has been a huge area of misunderstanding by our physician colleagues. The bill passed on January 14th 2014 with only one "nay" (see voting record), and will go into effect this summer. The official signing ceremony is set for February 28th and I expect with Governor Steve Beshear, there will be bourbon to celebrate. 

The Kentucky Collation of Nurse Practitioners and Nurse Midwives has worked tirelessly to move us another step closer to achieving the ideals of the Institute of Medicine's vision for the future of nursing. While the ideal is to get to full independent practice to the full scope of our education and training, Kentucky is not a state that embraces change without a lot of time to mull it over. To the bone. Even when the preponderance of evidence recommends action. My only question is whether the next step will focus on the controlled-substance collaborative agreement, or the 4-year mandate.

Patience is a nuisance. 

Rats! Foiled Again.

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

This is why I can never run for office.

Here is the official press release from the AANP:

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

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

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

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

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

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

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

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

Kentucky Battle Cry . . . Y'all

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

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

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.

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.

More Than One Way to Change a Bedpan

While writing a story about military nursing careers, my husband expressed his condolences on the lack of branding among nurses.  The following breaks down part of the problem:

"Nurse" = 1 year vocational degree (LVN/LPN, certification)

                  2 year associates degree (RN, ADN)

                  4 year bachelor degree (RN, BSN)

                  5-6+ year undergraduate and masters degree (RN, ADN with bachelors/BSN, MSN)

                  7-8 year undergraduate degee with clinical doctorate (RN, BSN, DNP with/without MSN)

                  9+ year undergraduate with research doctorate (RN, BSN, PhD with or without MSN)

While this variety provides a lot of career path options, it also fuels arguments within and against the nursing profession. From bedside to research lab and from team member to leader, we are omnipresent in every aspect of healthcare delivery and comprise the largest group of licensed providers in this country, yet have only a small voice in the politics of healthcare. 

Among ourselves, we have been fighting over establishing the BSN as minimum entry to RN-level practice for decades, played with practice doctorate titles for more than a generation until finally settling on the still misunderstood DNP, engaged in "class warfare" between educational, licensure, and certification designations, and maintained our continued participation in eating our young.  Some of us in advanced practice forget we share the same theory of care as LPNs and RNs and our responsibility to represent the entire discipline, not just our little part of it.  Though many opportunities exsist, we are not enthusiastically active in national organizations as students and let memberships lapse as 12-hour shifts and general life erode our enthusiasm and participation in professional development. 

Meanwhile, our "most trusted profession" public rating year after year, research supporting expansion of independent practice based on delivery if cost-effectivene care with patient outcomes and satisfaction on-par or better than physicians, and government encouragement for equal collaboration among independent licensed providers continues to be discounted by many provider-peers who continue resisting the change from paternalism to partnership and parity. 

Yes, we need a rebranding.

My First Task Force!: APNA State Chapter Operations

I had the privilege of being invited to a task force to brainstorm methods of enhancing APNA chapter operations. The room was packed with national board members, current and former state chapter presidents, and colleagues and staff members I had previously only known through email or member forums.  This meeting of the minds began with a few key aphorisms:

“Opinions are not facts until proven” 

“Loud and passionate people can be wrong” (can you say “Facebook?!”)

“A camel is a horse designed by a committee” 

Following brief introductions was a legal discussion on incorporation status, state and local laws, chapter duties, tax exemptions, 501(c) classifications, lobbying activities, and income categorization. If this sounds dull, guess again. This presentation confirmed my suspicion some of the activities of one of my other professional organizations has been performing “substantial lobbying activities” and clarified the core purpose of APNA:

To be the unified voice of psychiatric-mental health nursing

Well that’s nice, but how does that happen? Through value propositions.  APNA has identified 3 key branding features:

• ·      Community (make me feel good as part of the crew)

• ·      Commitment (don’t screw me over and keep your promises)

• ·      Content (give me something meaningful that I can use)

In order to make the individual state needs merge with the overall mission of the “mother ship.” Given that membership numbers have doubled over the past 6 years and retention rates have risen by 15%, we are doing quite well on the national level. State chapter involvement and operations are more variable, and I am ashamed to admit I have not been as active in Kentucky as I should be. The relationship with state chapters is bidirectional – the national mission trickles down and tailored to apply to local issues, while the individual state matters diffuse upward and are encompassed by the whole. So how do we improve operations and encourage coalescence? Our breakout group came up with 3 areas to focus our efforts and match our core values.

Technology (Advancing Community)

            In addition to our active member bridge, the APNA website offers a number of fantastic tools and social media platforms to aid in chapter operations, however, the technology is not utilized to it’s full potential and there are knowledge gaps among members. Webinars, one-on-one tutorials during national and state conferences, and use of virtual conferencing can bridge these knowledge gaps, further connect the community, and disseminate information faster, more comprehensive manner than previous platforms including mailers and email. There is value in face-to-face networking and interpersonal communication (my tutorial on bourbon with Bud Crouch would not have happened or been nearly as entertaining in Go-to-Meeting) and technology should be used as an enhancement and expansion, not absolute substitution.

ADVANTAGES: The efficient use of communication technologies to disseminate information among members and increase communication among individules, board members, chapters, and APNA national are significant advantages. Platforms are continually developed to be more intuitive for ease of use, which can help decrease generational gaps in knowledge.  APNA has been diligent about keeping costs low and maintaining an in-house staff of tech savvy individuals.

HURDLES:  Maintaining situational awareness of emerging technologies, providing education, and performing outreach to members requires significant time investment. Resistance due to reasons of privacy, lack of proficiency, and lifestyle are barriers for engagement by members.

Standardization (Preserving Commitment)

There are toolkits and staff available to aid in chapter operations, yet there remains significant variability in many processes such as meeting agendas, elections, and communication with APNA national. Clear, concise, consistent guidelines for major chapter operations and functions should be developed, but allow flexibility for local variation to expand on the roles and goals of specific state issues.

ADVANTAGES:  A common ground for operations provides security for board members when they assume a position and for all members to experience a consistent, organized environment that will be familiar when visiting or transferring chapters.  It prevents “reinventing the wheel” every time a new board is elected so that time can be better spent on education, advocacy, and networking.

HURDLES: With standardization change and a real or perceived loss of control, particularly in chapters already active and well organized. Coming to agreement on optimal balance of protocol and individuality is time consuming with potential to be too vague or too rigid.

Recruitment/Retention (Enhancing Content)

The big question for joining any membership with dues is “what’s in it for me?”  This can be anything from personal recognition, CEU and professional development opportunities, networking, discounts, collaboration, or professional updates. APNA is supposed to represent all members, not just advanced practice members or the most active chapters. While not an organization with a primary purpose of political activism, more members input from mental health nurses in every area of practice and all manner of nursing license is essential to provide the most accurate representation of our interests as a whole.

ADVANTAGE: Participants active at the local and national level become more competent, invested providers, which translate to better care and advocacy for our patients.  More members result in increased ideas, greater reach of applicability for national agendas, public awareness, and professional strength.

HURDLE: As an organization, membership and involvement have been on an upward trend and this may not be the most urgent area to focus chapter efforts.  In a down economy, membership dues may not bee viewed as a value-added expense.

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.

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

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.

KMA Launches Offensive Counter-Attack Against APRNs

Direct from an email. First tornados, now this! Help Kentucky out!

IF YOU THOUGHT HB 4 WAS BAD, TAKE A LOOK AT SB 190!

KMA LAUNCHES OFFENSIVE COUNTER-ATTACK AGAINST APRNs

KMA has launched its counter-attack by having Sen. Carroll Gibson (R-Leitchfield) file SB 190 on Thursday. SB 190 The bill is very cleverly drafted, as it never uses the word "supervision”, but puts the description and execution of both Collaborative Agreements and the relationship between physician and NP in their (physician) licensing statute – KRS 311.

Perhaps even more alarming and damaging are the sections dealing with the Collaborative Agreements. The legislation not only puts the physician in the position of defining the NP’s scope of prescriptive authority, but also defining the NP’s scope of practice. The latter is specifically referenced in the bill with regard to diagnosis, test ordering, analysis, and recommending referrals. In other words, if SB 190 becomes law, the collaborating physician could use the CAPA to put limits on your practice!!

In the sections describing the CAPA-NS and for the CAPA-CS, the bill spells out requirements that have never before been included in the CAPA’s: notifications by the physician to their licensing board (KBML) of any change in the CAPA or in the NP’s scope of practice. Also referenced are mechanisms for communication, meetings between the physician and the NP and the minimum number of charts to be reviewed and cosigned by the physician.

The bill goes on to state that the collaborative agreements are "required in the interest of patient health and safety”. Another section of the bill tells the KY Board of Nursing (KBN) how they are to handle complaints about the physician conduct with the CAPAs!

TAKE ACTION NOW: IT’S A ONE-TWO PUNCH: Call the Legislative Message Line – 1-800-372-7181 – and leave a message for all Senators: "Please oppose SB 190. It would put Nurse Practitioners out of business. And please support SB 187, Sen. Hornback’s Nurse Practitioner bill to increase access to quality health care.”

And please try to get more letters of support from physicians. Click here for new sample letters.

---

Kentucky Coalition of Nurse Practitioners & Nurse Midwives

1017 Ash Street - Louisville, KY  40217

PHONE:  502.333.0076
EMAIL:  kcnpnm@kynp.org
WEB:  www.kcnpnm.org 

Interprofessional Education and Practice

The Association of American Medical Colleges (2012) put out this press release last week that falls in line with our discussion topic, especially for those interested in using your DNP role as an educator:  


Six Leading Health Education Associations Unite to Form a New Organization Focused on Interprofessional Education and Practice (click to read more)


Washington, D.C., February 15, 2012—Six national health professions associations have formally joined to create the Interprofessional Education Collaborative (IPEC), a new national organization that will focus on better integrating and coordinating the education of nurses, physicians, dentists, pharmacists, public health professionals, and other members of the patient health care team to provide more collaborative and patient-centered care. The founding members include the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health. 

The new IPEC organization will formalize the collaborative work that began three years ago and led to the release of a May 2011 report, “ Core Competencies for Interprofessional Collaborative Practice” (click to read the report).  This seminal document identified individual-level core competencies needed by all health professionals to provide integrated, high-quality care. Disseminated broadly to health professions schools, the report has sparked a wave of implementation efforts by educators looking to prepare clinicians to meet contemporary practice standards.

As a stand-alone entity, the new IPEC will provide leadership around national initiatives to advance interprofessional education (IPE) and share information on IPE best practices and collaborative practice innovations. A growing body of work demonstrates that shared learning experiences among health professions students across disciplines can improve health outcomes. Leading authorities including the World Health Organization, the Institute of Medicine, the Robert Wood Johnson Foundation, and the Josiah Macy Jr. Foundation, among others, have all identified IPE as an effective way to enhance the preparation of the health care workforce and improve care delivery. 

In May, IPEC will sponsor its first faculty development institute, “ Building Your Foundation for Interprofessional Education.”  The program will enable faculty from across the health professions to meet with peers in plenary and interactive learning sessions focused on building strong programs for team-based learning. Registration will open on February 22.    

The six IPEC organizations also are founding members of the Institute of Medicine’s Global Forum on Innovation in Health Professional Education, which is set to launch later this month.  Inspired in large part by the 2010 Lancet Commission report, “Health Professionals for a New Century,” this forum will convene stakeholders to illuminate issues in health professions education and support an ongoing, innovative mechanism to incubate and evaluate new ideas.

Interprofessional Education Collaborative (2011). Core competencies for interprofessional collaborative practice. Retrieved from http://www.aacn.nche.edu/education-resources/IPECReport.pdf 

Association of American Medical Colleges (2012). Six leading health education associations unite to form a new organization on interprofessional education and practice. Retrieved from https://www.aamc.org/newsroom/newsreleases/273754/120214.html

Occupy With Grace

From the Engage with Grace rally to revolutionize end-of-life planning . . . 


Occupy With Grace

Once again, this Thanksgiving we are grateful to all the people who keep this mission alive day after day: to ensure that each and every one of us understands, communicates, and has honored their end of life wishes.

Seems almost more fitting than usual this year, the year of making change happen. 2011 gave us the Arab Spring, people on the ground using social media to organize a real political revolution. And now, love it or hate it - it's the Occupy Wall Street movement that's got people talking.

Smart people (like our good friend Susannah Fox) have made the point that unlike those political and economic movements, our mission isn't an issue we need to raise our fists about - it's an issue we have the luxury of being able to hold hands about.



It's a mission that's driven by all the personal stories we've heard of people who've seen their loved ones suffer unnecessarily at the end of their lives.


It's driven by that ripping-off-the-band-aid feeling of relief you get when you've finally broached the subject of end of life wishes with your family, free from the burden of just not knowing what they'd want for themselves, and knowing you could advocate for these wishes if your loved one weren't able to speak up for themselves.

And it's driven by knowing that this is a conversation that needs to happen early, and often. One of the greatest gifts you can give the ones you love is making sure you're all on the same page. In the words of the amazing Atul Gawande, you only die once! Die the way you want. Make sure your loved ones get that same gift. And there is a way to engage in this topic with grace!

Here are the five questions, read them, consider them, answer them (you can securely save your answers at the Engage with Grace site), share your answers with your loved ones. It doesn't matter what your answers are, it just matters that you know them for yourself, and for your loved ones. And they for you.



We all know the power of a group that decides to assemble. In fact, we recently spent an amazing couple days with the members of the Coalition to Transform Advanced Care, or C-TAC, working together to channel so much of the extraordinary work that organizations are already doing to improve the quality of care for our country's sickest and most vulnerable.

Noted journalist Eleanor Clift gave an amazing talk, finding a way to weave humor and joy into her telling of the story she shared in this Health Affairs article. She elegantly sums up (as only she can) the reason that we have this blog rally every year:

For too many physicians, that conversation is hard to have, and families, too, are reluctant to initiate a discussion about what Mom or Dad might want until they're in a crisis, which isn't the best time to make these kinds of decisions. Ideally, that conversation should begin at the kitchen table with family members, rather than in a doctor's office.

It's a conversation you need to have wherever and whenever you can, and the more people you can rope into it, the better! Make this conversation a part of your Thanksgiving weekend, there will be a right moment, you just might not realize how right it was until you begin the conversation.

This is a time to be inspired, informed - to tackle our challenges in real, substantive, and scalable ways. Participating in this blog rally is just one small, yet huge, way that we can each keep that fire burning in our bellies, long after the turkey dinner is gone.

Wishing you and yours a happy and healthy holiday season. Let's Engage with Grace together.




To learn more please go to www.engagewithgrace.org.This post was developed by Alexandra Drane and the Engage With Grace team.

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.

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!

The New & Improved ANA Social Networking Principles!

While I am not narcissistic enough to believe my contributions during the "open to public comment" period had anything to do with the excellent edits, I like to think the synergy of many like-minded nurses worked to improve the specificity and decrease the Ratched. The ANA was also nice enough to provide a Tweet and Learn #anachat for 0.5 CEU credits. Now we own it!

Benefits

• Networking and nurturing relationships 
• Exchange of knowledge and forum for collegial interchange 
• Dissemination and discussion of nursing and health related education, research, best practices 
• Educating the public on nursing and health related matters 

Risks 

• Information can take on a life of its own where inaccuracies become “fact” 
• Patient privacy can be breached 
• The public’s trust of nurses can be compromised 
• Individual nursing careers can be undermined

 ANA’s Principles for Social Networking 

• Nurses must not transmit or place online individually identifiable patient information.
• Nurses must observe ethically prescribed professional patient — nurse boundaries.
• Nurses should understand that patients, colleagues, institutions, and employers may view postings.
• Nurses should take advantage of privacy settings and seek to separate personal and professional information online.
• Nurses should bring content that could harm a patient’s privacy, rights, or welfare to the attention of appropriate authorities.
• Nurses should participate in developing institutional policies governing online conduct.

6 Tips to Avoid Problems

• Remember that standards of professionalism are the same online as in any other circumstance.
• Do not share or post information or photos gained through the nurse-patient relationship.
• Maintain professional boundaries in the use of electronic media. Online contact with patients blurs this boundary. 
• Do not make disparaging remarks about patients, employers or co-workers, even if they are not identified.
• Do not take photos or videos of patients on personal devices, including cell phones.
• Promptly report a breach of confidentiality or privacy.

What's in a Set of Initials?

During on-campus time this week (more on that later) some of us were looking through the UTHSC yearbook and realized every other health discipline with the exception of nursing only listed their highest academic/licensed achievement. For those that were strictly degreed and certified in one discipline (i.e. only a medical doctor or a pharmacist rather than a physical therapist with a philosophy doctorate), their formal listings looked something like this:

John Doe, MD
Neurology

Jane Doe, DDS

Will Brown, PhD

Sara Brown, DPT

Steve Norris, AuD

Nancy Norris, Pharm.D

 . . . and then there was the nursing department:

Ann Smith, PhD, DNSc, MSN, APRN, FNP/GNP-BC, BSN, RN-BC

(Really? Yes, really.)


On a few of my professional LinkedIn groups, a number of threads have been started questioning the need for alphabet soup credentials and in what order to put them in. One of the participants posted an informative article from ANCC called Playing the Credentials Game (and quite appropriately, the author had an absurd number of credentials listed after her name) which reccommends listing degrees highest to lowest, state license, ANCC certifications, fellowships, and other awards. So I guess my high school GED comes before my RN-BC which comes before the Walden Theatre Unicorn Award I won for being a team player, but after my Golden Key Honor Society membership.

What it comes down to is that without a national scope of practice represented by one designation, as most of our healthcare colleagues have, we are likely doomed to feel listing degree, licensure, state designation, and national certification essential. I suppose either bravado or compensation makes us feel it necessary to list awards and certifications. As for myself, I will stick with my original response to the question of how to present one's name:

I am passionate about the over-listing of credentials that nurses have adopted in comparison to other healthcare professionals that pick their highest degree/license. I list my highest licensing credential (APRN) and that is it because it encompasses my RN and graduate level education (which you cannot have without some level of undergraduate, and for that matter high school education). After reading the article Francis posted (thank you), I am more compelled with my plan to list my DNP only, since it is the terminal degree for advanced practice, just like the MDs, PsychDs, DPTs, and PharmDs do:

Jaclyn Engelsher, DNP
Family, Psychiatry

Sweet News!!!

Nursing Leaders call on Director General of WHO to change policy about nursing leadership | Global Health Delivery Online: Improving health care delivery through global collaboration

Geneva, Switzerland; Valletta Malta, 7 May 2011 - Expressing extreme
concern at the lack of nursing policy presence within the World Health
Organization (WHO) structures, an emergency resolution* was passed by the
governing body of the International Council of Nurses (ICN) at its biennial
meeting held in Valetta, Malta. The official representatives of ICN’s member
national nurses associations voted unanimously to demand that the WHO
Director General empower and finance nursing leadership positions throughout
the organization.
“At this time of health system redesign aiming to enable access and costefficiency,
it doesn’t make sense for WHO to advocate for nurses to fully
participate in the health care team at the clinical level, yet exclude them from
playing their full role at the policy table,” declared ICN President Rosemary
Bryant.
“As we move to discussion of the Resolution on Nursing and Midwifery at the
upcoming World Health Assembly, we urge member states to add their weight to
the call on Dr Chan to remedy the appalling lack of nursing leadership positions
throughout WHO structures, including at headquarters and in the regional
offices, beginning with reestablishment of the post of WHO Chief Nurse
Scientist.”

Thoughts on the ANA Social Media Policy Draft

Three cheers for the ANA who developed a task force late last year to help write some rules and regulations for nurses to refer to in the uncertain environment of social networking. We are on par with other health care disciplines in the scramble to determine the implications of potential boundary violation of both patient and provider before the lawyers carve out a new specialty branch of practice. I think this is an overall great start (even though it is a direct crib from the AMA's policy) but I would like to see some more specific and supportive language.  Naturally, this nurse has plenty of public comment which is lovingly provided alongside each of the following provisions in glorious technicolor!

APRIL 25, 2011
FOR PUBLIC COMMENT (click to add your 2 cents)
PRINCIPLES: SOCIAL NETWORKING AND THE NURSE (click for the full document)

Background

Relying on an Action of the 2010 ANA House of Delegates, “Social Networking and the Nurse,” ANA staff, in consultation with the CNPE Practice and Regulation Workgroup and the ANA  Ethics Advisory Board, developed an outline of professional principles to guide nurses in their use of social media. The House of Delegates Action resolved that ANA “support the application of ANA’s foundational documents – the Code of Ethics for Nurses, Nursing’s Social Policy Statement, and Nursing: Scope and Standards of Practice –to the use of social media.” The following provisions from these foundational documents helped to inform the draft principles for Social Networking and the Nurse.  Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) – The Code of Ethics for Nurses is a seminal ANA document establishing ethical standards for the nursing profession. It provides a framework for nurses to use in ethical analysis and decision-making. Each of the nine provisions of the Code, along with select Interpretive Statements, provides guidance on the application of professional values and personal judgment in nurses’ use of social networking and media.


In addition to reliance on ANA’s three foundational documents, the draft principles for Social Networking and the Nurse also consider pertinent statutes and legal documents,  the experience of health professionals with social networking as reported in the media,  as well as the social media policies of other health care organizations.

Preface

Nurses who are currently practicing or preparing to enter the workforce have a professional obligation to understand the nature and consequences of participating in social networking of all types. The social network and the Internet provide an opportunity for unmatched knowledge exchange shared quickly among many people. There are many positive implications for nurses and nursing practice: it provides an opportunity for broad dissemination and discussion of nursing and health –related education and communication; it can nurture relationships and mentoring among developing professionals; and it provides a forum for collegial interchange and the development of an online professional presence. It also offers the profession a vehicle for educating the public on many nursing and public health matters. At the same time, information contained on a social network has the capacity to propagate itself, taking on a life of its own in cyberspace. Nurses must be aware that the social media venue is shared by their patients, and that unintended consequences of poor decision-making can breach a patient’s privacy, damage a patient’s trust in the individual nurse and the profession, and further damage a nurse’s professional and personal future. Inaccuracies become “fact” by mere repetition, which is a particular danger when discussing public health needs. Despite the feeling that comments, videos, photos, or other online materials may seem transient or “gated,” the nature of the Internet is that such materials are permanent and just about anyone can and will see these postings. Thus, it becomes essential for nurses to consider a number of guidelines when functioning within the “virtual” world of social media:

Principles

1. Patient privacy is a fundamental ethical and legal obligation of nurses. Nurses must observe standards of patient privacy and confidentiality at all times and in all environments, including online. Nurses must not transmit or place online individually identifiable patient information. The nurse’s primary commitment is to the patient and nurses are ethically required to practice with compassion and respect for the inherent dignity and worth of every individual. The key here is "identifiable" and I would like the ANA to include a statement addressing acceptable or exemplar generic comments. Reporting a bad day at work or mentioning difficulties with performing a particular procedure should not be grounds to call "breech!" Likewise, mentioning the good feelings that come from providing benefit that day should not be labeled inappropriate if are patients not "identifiable." 

2. Nurses who interact with patients on social media must observe ethically prescribed patient –nurse professional boundaries. The precepts guiding nurses in these matters are no different online than they are in person. Does this refer to professional social networks such as those run by the CDC or Mayo Clinic or those which have private encryption such as the telemed/psych services at the VA? This provision needs to differentiate between personal and professional persona. Public social media outlets provide no guarantee of privacy, therefore engaging with a provider on a social network implies that the client understands confidentiality cannot be guaranteed. Just as a consumer cannot ask a provider a medical question on a talk-show or radio program and expect it to constitute a through and private assessment, the same is true for social media outlets. The client cannot ask the nurse a healthcare related question then accuse the provider of a violation if the provider answers the question or cry "patient abandonment" if they do not acknowledge the interaction - label it the "call-in clause." If a nurse chooses to maintain a professional site, a statement regarding privacy, who is allowed in the network, and reminder that members can see other members participation should be clearly noted so everyone knows what they are getting into if they choose to join, for example, a Facebook page or twitter feed. The ANA might consider creating example statements that nurses could post as an FYI to fellow networkers. For example, these are from my professional and personal facebook page (suggestions for improvement are welcome!): 


***Social Media Policy Statement: While Jing Acupuncture/OneDNP is a health care provider, this page is for entertainment, advocacy, and education by a private citizen - not diagnosis, treatment, and advice from a professional. All interactions on this social networking site are open to anyone who has the good fortune to visit this page. Visiting or "liking" this page does not constitute or imply a therapeutic relationship and is not bound by confidentiality, practice acts, or codes.


***The ANA's new social media policy recommends providers uphold our code of ethics by maintaining professional boundaries online. I am currently not accepting friend requests from current patients who have visited Jing in the past 3 years. To stay in touch professionally, "Like" my page at http://www.facebook.com/JingAcupuncture or follow me at http://www.twitter.com/JingAcupuncture 
My Social Media Policy Statement: While I am health care provider, I use Facebook as a private citizen for entertainment, advocacy, and education - I do not diagnosis, treat, or provide medical advice in any professional capacity whatsoever. All interactions on this social networking site are open to anyone with access to this page including "friends," random hackers, and administrators. "Friending" me does not constitute or imply a therapeutic relationship and is not bound by confidentiality, practice acts, or codes. (And yes, this necessity is ridiculous!)

3. Nurses should take advantage of privacy settings available on many social networking sites in their personal online activities, and seek to separate their personal and professional sites and information online.  I would also like to see the sanctity of provider privacy addressed in relation to self-care.  Curiosity about the personal lives of providers is natural, yet a patient may be able to gain access to a nurse's social network in spite of him/her taking reasonable privacy precautions. In such instances, the nurse should not be held to standards over-and-above those of maintaining privacy and confidentiality in good faith and be free to express personal opinions without fear of professional consequence. Many nursing associations recommend avoiding personal relationships of any kind with a patient after discharged from care for 6 months to 5 years to never -  virtual, "friending" patients does constitute a personal relationship that can have consequences in the 3-D world.  Having a general guideline for the nurse to fall back on would help lessen the potential feelings of personal rejection for clients who want to keep in touch. I feel the ANA should not condone any hiring practice that requires an applicant to allow the potential employer access to their social networking sites, and there should be words to that effect. Support from state boards, organizations, associations, and accrediting bodies would help protect the personal/professional buffer while preventing multiple guidelines that may conflict with each other. 

4. Use of privacy setting and separation of personal and professional information online does not guarantee, however, that information will not bleed through or be repeated in less protected forums. Therefore, it is prudent for the nurse to evaluate all his or her postings with the potential for patient, colleague, or employer viewing in mind. Online content and behavior has the potential to either enhance or undermine not only the individual nurse’s career, but also the nursing profession. This provision may be necessary because, as Voltaire said, "common sense is not so common," however it creates a culture of second guessing one's actions, lays the field wide open for unnecessary scrutiny into the life of a private citizen who works in public service, and implies that a nurse can never be "off-duty." Any implication that the ANA would support employers, accreditation bodies, or state boards taking punitive measures against employees for posting political, religious, social or other opinions as a private citizen demonstrates a distressing lack of advocacy. Ditto for supporting employer social media policies that allow a company to govern any aspect of personal online activity of employees and use it as part of an evaluation process. It is one thing to ask yourself if your post passes the "mother" or "headline" test, it is another to fear the thought police and think your license or job is in jeopardy when off the clock.

5. Nurses who view content posted by a colleague that is unprofessional or that potentially violates ethical or legal obligations should first bring the questionable content to the attention of the individual, so that the individual can take appropriate action. If the posting is egregious enough or if the individual does not remove the posting, the nurse has the obligation to report the matter to supervisors or other authorities. This is in keeping with what occurs in the real world, however, the lateral violence potential here is unlimited. I can envision managers or coworkers stalking social networking sites in search of dirt they can use against an unpopular peer. I do think there is a better likelihood of a peer confronting a peer online than in person because it seems less like a scolding and more like an FYI.