Fight, Flight, Freeze, or Caregive . . . . or Have a Cocktail: Kicking Back with Bowen's Family Systems

Got into Memphis at 8am courtesy of Delta (still the only direct flight to Memphis and a steal at $500 a ticket) and whisked off to the ever reliable Springhill Suites via Last Minute Transportation (superior service, as always).

Afternoon Funk

Nothing gets a trip started like a some sailors jammin' to "Ride Sally Ride" and a hot dog from a cart!

Individual Group and Family Therapy 2-6pm

Sylvia Landau gave an amazing presentation on Bowen's family systems theory. My new mantra: "I'm not being selfish, I'm fostering self-actualization." Seriously, I now have an explanation for why neither mom's Catholic or dad's Jewish guilt trips work on me and new rational for my relative lack of concern for doing what is expected. Of course, there is a fine line between ass and actualized, but it seems those who adopt a Machiavelli attitudes suffer fewer health issues and far more joy than those who take on the world's woes and feel compelled to do either everything for everybody or nothing for themselves. I must have had a self-care premonition since I already booked myself for a facial and reflexology at Rachel's for tomorrow afternoon! Some great points from the lecture:

• Who we are is defined by the family gossip
• You are just one bean in the soup
• Active listening gives the patient permission to do their own work and trust themselves
• Health is to become whole
• Saying nice words does not negate the impact of scary thoughts
• Get neutral, not guilty
• Psychosis can be an adaptive coping response
• Like matter, anxiety can neither be created or destroyed, rather it is projected and absorbed.
• Be a friend, not a blood sucker
• We run from reality as long as we can get away from it
• The system will try and change you back
• Cancers are cells in other systems' business 
• Present mindfulness helps extinguish automatic role patterns and tolerate the familiar
• Feel your emotions, but don't get too sentimental

To top it off, we received a copy of Caterpillars Chrysalis to Butterflies: Humans Change Through the Family Process which Dr. Landau was kind enough to sign for me. Interestingly, we share "All the Way" in common, although Fred and I prefer the James Darren version to Sinatra's.

Dinner at Grill 83

I am working my way through nearby fancy-town dining and had a lovely chat with the bartender about cocktails, sake, and bourbon. May I suggest the Memphis Passion Martini, Shrimp Spring Rolls, Beet Salad, Creme Brulee, and the Memphis French Martini should you care to visit?! 

On the Road Again

For once, it is me this time and not the husband. Being alone all of the time kind of sucks mental health wise - social media tools just don't have that interpersonal touch that makes you believe no man is an island. The good part is that I get to realistically try out some self-CBT before recommending a particular exercise to a client. I even managed for the first time in my post-secondary, oh hell, post-first grade education turn a paper in a whole 30ish hours before it was due.  I am still debating if taking on a an teaching gig was helpful or harmful to my overall development.  On one hand, it was a psych class and the 20 hours a week I spent on prep provided forced study time I may have otherwise neglected. On the other hand, I would not have flaked out on a few Blackboard discussions, could have delved deeper into the material, and, at least theoretically,  concluded my clinical hours without having to take an incomplete.

I love hindsight.

In these last few hours before I leave for Memphis, I have a final in assessment strategies, 2 SOAP notes, 1 Reflective Journal, and 1 process recording to do. When I get back, I also have roughly 90 hours of clinical time I need to log before August. Thankfully, my second clinical site came through so I should just get done before I have to start over again.

If I am not mistaken, the new deadline for the end of the world comes while I am in school. At least I get to go out listening to Elvis with a belly full of barbecue and a blueberry sidecar.

Until the road gets rolling  . . .

Kiss My A!

Thankfully, my dissident spin on the assignment won back the points I should have lost by not following directions . . . I put it in a pdf instead of a word document. Hey, the syllabus said a policy brief should stand out!

Sweet! Presentation Uploaded and APNA Proposal Accepted!

I received awesome news today. Well, awesome in that I am going to get loaded with self-inflicted work! Here it is, straight from the APNA:

Thank you for submitting an abstract proposal for the APNA 25th Annual Conference, October 19-22, 2011 in Anaheim, CA . We are happy to inform you that your abstract has been accepted as a 45-minute concurrent session presentation. Congratulations!

The following is what we have listed for your session:

Title: Social Networking for Psychiatric and Mental Health NursesPresenter(s): Jaclyn Engelsher RN-BC, APRN, FNP-BC, DOM  Tanitha Moncier FNP              

Please email us by Wednesday, April 20th to confirm whether the above information is correct and if you will be participating as a concurrent session presenter. Please email any changes to your title or presenter(s) as soon as possible. This information will be printed in the registration brochure as written above, along with the Presentation Summary you entered during submission.

We will contact you in June with detailed instructions regarding conference registration (you will register online with a discount code which will be sent to only one presenter per session), presenter tips, presentation materials (slide presentations will be due September 1st), etc.

Thank you,

APNA Scholarly Review Committee

Woohoo, I'm going to Disneyland!

Direct from the Policy & Leadership Blackboard: Social Media Ethics

From couponing and microblogs to wikis and networking, social media is all the rage. MD personalities like Oz, Mercola, and Phil, not to mention high-profile facilities like Mayo and Cleveland are all over Facebook and Twitter dispensing health and wellness advice to the masses. Yet some physicians have had some difficulty adapting to the personal privacy and boundary issues of the new medium, which is surprising for a discipline trained to put beepers and unlisted phone numbers between patient and provider. A study on Twitter use among physicians reveled violations in patient privacy, use of derogatory, profane, and sexually explicit content, unsupported medical claims, and advice in contrast to standards of care (Chretien, Azar, & Kind, 2011). The AMA (2010) has created a policy statement on professionalism in the use of social media highlighting some on the unique personal and professional considerations as well as potential benefits of social media use.

But what about the nursing organizations and the individual (and decidedly non-phenomenon) nurse practitioner?  Despite it's own engagement in multiple mediums, all the ANA has advised is a generic call to follow the code of ethics (American Nurses Association, 2010),  specifically the sections on conflict of interest, accountability for judgement and action, professional growth and maintenance of competency, and preservation of integrity and  (American Nurses Association, 2001)."  Behavior online is not necessarily analogous to behavior in person or even over the phone. Should you "friend" patients, coworkers, or students, and if you do, are you responsible for knowing and responding to their posts? Imagine one of your patients posts suicidal statements on a social media site and you see it. Students may post negative comments on your class or violate the school honor code. Coworkers who begged you to cover when their child is sick may post pictures from Fiji the same day. While some scenarios seem like cut-and-dry common sense, others require professional guidance in terms of best practice.  Moreover, no precedent has been set in regard to liability, and there are plenty of legal considerations in terms of confidentiality, nonmaleficence, veracity, solicitation, and malpractice. 

I personally use social media extensively as a way to promote my business and the profession and plan to continue to do so. Carefully. I think it is important that the ANA address this specific topic in the next edition of the code of ethics to provide a basis of guidance and support for nurses. I would much rather see our governing body set the precedent than the winning attorney of the first lawsuit.

American Medical Association. (2010). AMA Policy: Professionalism in the Use of Social Media.

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: ANA.

American Nurses Association (2010). House of Delegates resolution: Social networking and the nurse. Kansas Nurse, 85(6), 21-21.

Chretien, K. C., Azar, J., & Kind, T. (2011). Physicians on Twitter. JAMA: Journal of the American Medical Association, 305(6), 566-568. 

Grow Up Missouri! Doctors are People with Doctorates!

This is from the Online DNP Community. While I personally do not define myself by a title and believe it is important to explain who you are and what your role is when you use one, I believe anyone who has achieved a doctorate has the right to refer to themselves as a doctor in whatever setting they choose.  Please support this action - id this passes it can be used as precedent the profession needs to avoid!

Hello everyone, 

I received a message from a colleague in Missouri, JoAnn Franklin, DNP, APRN, notifying us of some legislative plans that could transfer disciplinary authority over Nurse Practitioners, now regulated by the Board of Nursing, to the Board of Healing Arts - a physician run entity. This is her recommendation:

 334.092 needs to be completely removed because currently the judicial court system takes care of this issue and state boards should only discipline their licensees.  We do not believe the Board of Healing Arts can be the disciplinary for other professions.  Additionally the burden of proof is much less in an administrative hearing than it is in the judicial court system.

There's also a section of Senate Bill No 303 (Section 334.250 number 3) that would criminalize the use of the title Doctor. Here's the essence of that section: 

334.250 number 3.  Any person who uses the title "Doctor", "Dr.", "M.D.", or "D.O." within a hospital as defined by section 197.020, or within an ambulatory surgical center as defined by section 197.200, and is not now or has not been a registered physician within the meaning of the law or is not now or has not been licensed as a physician in another state or territory shall be guilty of a class D felony.

Here's a potential letter that we encourage you to send to the senators listed and linked below:

Senate Bill No. 303; 334.092 and 334.250 number 3

My colleagues in Missouri have notified me and other advanced practice nurses that have earned a practice doctorate degree of some of the language in the senate bill that is due to be voted out of your Financial and Governmental Organizations and Elections Committee. 

Please know that any language that criminalizes someone from using the title "doctor" is unnecessary and inflammatory. 

To make using the title a criminal offense negates the efforts and successes of an entire class of professionals. Missouri would be setting a dangerous precedent that could negatively impact the provision of health care services in the state. Health care providers that have earned a doctorate degree follow the policies of specific organizations such as hospitals to obtain privileges. The policy of the organization is more than enough to avoid any potential patient confusion due to a title. Trying to criminalize the use of a title is draconian without any evidence to show that harm has been done, or is likely to be realized on any patient or patient care organization. 

The motivation is not about safety. 

Please reconsider removing this section of the bill. Similarly, section 334.092 places disciplinary power with one profession over another. This is contrary to our tenets of democracy and definition of professionalism. 

Others outside of Missouri are watching and hoping that the citizens in your great state will not be stifled by unnecessary and ill conceived bills that have little value and a great potential to harm health care professionals and their patients. 

Thank you for reading my note and allowing me to share my concerns. 

Kindest regards, 

The following Senators are in the Financial and Governmental Organizations and Elections Committee

• Kevin Engler, 3rd, Chairman
• Jay Wasson, 20th, Vice-Chairman
• Jane Cunningham, 7th
• Will Kraus, 8th
• David Pearce, 31st
• Luann Ridgeway, 17th
• Bill Stouffer, 21st
• Jolie Justus, 10th
• Robin Wright-Jones, 5th

Thank you for your considerations and request to help our colleagues in Missouri. 

Best wishes to all,

David O'Dell

I Would Have Rather Been a Waitress

A Facebook pal and classmate posted this and I had to share. At just shy of 60 years from the writing of this passage, APRNs have almost managed to get the phrase "physician extender" out of the vocabulary, and RNs are continually ranked the highest in professionalism and respectability in the healthcare field. Enjoy how far we have come!

The Handmaiden 

Nursing is an extension or component part of medicine;

--Nurses are physical extensions of the doctors

--Nursing work is solely delegated medical work done under the close control of a doctor

--Nursing is a part of medicine’s business, and doctors can speak for nurses.

Because the nurse is no more than a participant in medical care, the nurse is expected to obey the doctor.

Nurses are not expected to challenge doctors even if they believe the doctor to be making mistakes which are endangering the patient’s life.

If the nurse carries out the orders of the doctor without question the nurse will not be at fault even if s(he) believes on reasonable grounds that the doctor’s orders are incorrect or immoral and may endanger the patient.

--Even if the nurse performs activities which s(he) knows to be morally wrong, the nurse can be exonerated if s(he) were ordered to do so by the doctor.

The nursing profession is the handmaiden of medicine and the final success of the treatment of disease is often bound up with the efficiency of both. Hon. Dr. Parr, Hansard, 9 September 1953.

ANA on Social Media and Networking

I just submitted a concept map on social networking for my concept and theory class that covered potential uses, boundary issues, and guidelines for creating an official position statement on social networking for nurses. Is a lot of it HIPPA/don't friend your patients/avoid posting naughty photos/keep the 3-day bender footage off YouTube common sense advice? Of course. But the AMA issued a policy on professionalism in the use of social media in 2010, and gee willikers, this is all the ANA had to say about it:

Social networking and the nurse. 
There is very little research regarding the new phenomena of social networking and its role in nursing practice.  The ANA HOD, in an effort to begin the dialogue, brought forth an informational resolution.  An informational resolution does not require the ANA HOD to take action, however, it does indicate action will be considered in the future as nursing research evolves and demands attention.

The nature of social networking is new to most everyone.  Nurses need to understand the potential reach of social networking sites such as Facebook®, MySpace®, and Twitter®.  Although social networking sites have positive benefits in the realm of mutual support and knowledge sharing, there are negative effects as well.  Some negative aspects include:  loss of privacy, legal liability, and loss of professionalism (Frohna, McGregor, & Spector, 2009).

The ANA Code of Ethics outlines ethical responsibilities of nurses in practice relating to social networking (ANA 2005).   Crossing over through personal and professional boundaries can represent a conflict of interest for the nurse.  Nurses have accountability for individual actions, professionally and personally.  Nurses have the responsibility to behave consistent with personal and professional values to protect the integrity of self and profession.

The HOD supported this informational resolution.  Social networking remains unfamiliar territory for the ANA.  Research is needed to guide and inform policies and practices in the utilization of social networking on the national stage as well as at the local level.



Referring to the ANA Code of Ethics is like saying "wear your cap and keep your mouth shut"- I venture to guess less than 5% of all nurses have read the thing (ohh, good idea for a survey!). I do not think we need to go through the whole finger-shaking nursing diagnosis way of creating a position on this. The time is over-ripe for the profession to play a dominant rather than handmaiden role in the healthcare marketplace and stop relying on the old "most respected profession (so why change?)" pat-on-the-head. Responsible use of social media can make that happen. Let's put it in writing!

Updated DNP Explanation Link List

Say that 3 times fast!


After sending survey monkey out to my soon-to-be students for psych/mental health, I nearly pulled my hair out after reading some of the results to the question "If you plan to attend graduate school, what field of graduate study?" A number of people said "DNP" without naming an area and others answered things like "either CRNA or DNP" as though they had nothing to do with one another.


I had a talk with some of my current students in my clinical group for leadership, and received the same uncertainty when I asked them what the DNP was. My on-going explanation has been something like this:


The DNP is a clinical doctorate much like the MD, PharmD, DPT, DDS, etc - nursing is just the last one to the party. Instead of having a masters degree as the entry to advanced practice nursing, they are expanding the education and clinical experience to a doctoral level to be on par with our peers in other healthcare disciplines. Much as the MD signifies a type and level of education, it is useless without residency in specialization. Likewise, the DNP does not stand alone, but rather uses a core curriculum integrated with one of the four APRN foci: CNS, CNP, CNS, and/or CRNA. We are currently in transition as universities phase out the advanced practice MSN, states start creating grandfather clauses, and certification bodies start amending their requirements,  but the goal is to have this streamlined and uniform by 2015.


Sounds good in my head, but I am not sure I am communicating the message. Thankfully, there are a host of people specialized in this sort of explanation and interpretive dance.




Understanding the Doctor of Nursing Practice (DNP): Evolution, Perceived Benefits and Challenges
From the National Association of Neonatal Nurses - an excellent review of the why, what, where, and when of the DNP.



AACN Fact Sheet
Updated March 2010, this provides the current state of affairs on the profession. There is also a powerpoint presentation with greater detail.


APRN Consensus Model FAQ Sheet
This may be a bit off the point, but for folks who are trying to get into an MSN program and graduate before the 2015 deadline, the language used in here should give you pause. We here at OneDNP to take exception to item 5 on the grounds that multiple sets of initials makes one appear like they are trying to compensate for something 


Sincerely,


Jaclyn Engelsher APRN, CPN, FNP-BC, PMHNP-BC, DNP (my anticipated 2012 credentials minus BSN, RN-BC,  MSOM, CAc, DOM . . . hard to take that seriously, isn't it?)

Plagiarizing Blackboard Discussions

I am plagiarizing myself from my leadership and health policy class, so no honor code violations have been broken! I am most excited to see that the battle is back on for eliminating the anachronistic and undermining collaborative agreement between physicians (who are educated and practice in medicine, thus have no more basis to supervise nurses than they do any other health profession they themselves are not masters of) and advanced practice nurses, many of whom have been charged thousands of dollars a year by opportunistic physicians for the privilege of prescribing within their already given scope of practice. I guess when you make the kind of money primary care physicians don't make, you have to plunder every potential revenue source you can. Nicky the Stick would be jealous. 


I will have much more to say later, meanwhile, check out the LEO article MAD Money for the spicy pre-fight analysis. 


Last year in KY, a number of state and national nursing organizations put up a unified fight to get rid of the need for physician oversight of NPs in regard to prescribing. House Bill 556 (sponsored by May Lou Marzian, an RN) and Senate Bill 75 bill were written with the intention of compromising to exclude scheduled medications. The MDs on the board put up the usual objections to "giving a bunch of nurses the same privileges as an MD," but it managed to pass in the house committee.  Documentation showing APRNs received less complaints, made greater use of KASPER to decrease narcotic "doctor shopping," and equal outcomes as compared to primary care MDs were presented. A few handshakes and some bourbon on the rocks in the back office made the smear campaign that began shortly afterward sure to get the bills  stalled - nursing may have had the greater head-count, but the MDs had more bucks. 

The good news is, the fight is back on for 2011 and the passage of health care reform (whether you like it or hate it, use what you can of it to your advantage) has put APRNs in a much better bargaining position. The shortage of primary care physicians  is not going to get filled  because the pool of medical students willing to  spend their youth and money on education with a payoff of  less than $200K/year is getting smaller and smaller. MDs should use that education to  specialize and focus on disease care and pass the baton to ARNPs for the wellness care. This is going to be a nasty fight!

Drake, S. (2010). Courier Journal. Bill to expand nurse practitioner duties advances in Kentucky. Retrieved from http://www.spapn.org/blog/?p=171 

Shaw, S. (2011). LEO Weekly. Mad medicine. Retrieved from http://leoweekly.com/news/mad-medicine 

Thomson Reuters. (2010). 2010 Kentucky senate bill no. 75, Kentucky 2010 regular session. Retrieved from  http://www.midwife.org/siteFiles/legislative/Kentucky_bill_S_75_2010.pdf