Dr. Nurse at Work

After months of board exam preparation, applications, interviewing, and soul-searching, I recently accepted a position as a hospital mental health consultant, or as I like to call it, Mighty Mouse. I start Monday.  I am excited to get to practice and am ready to meet the challenge of what I see as an enormous responsibility to ensure patients are followed by the correct services to meet their immediate needs.  When working as an RN in Emergency Psychiatric Services, I saw first hand how having "bipolar" or "schizophrenia" on one's chart would often result in being immediately shipped from ER to EPS, even if chest pain or severe headache was the primary complaint.  This stigmatization (or perhaps clinical laziness) can lead to disastrous outcomes for patients with mental illness who are actually having an emergent physical issue.  Psychosis, delusions, and mania are not exclusive to a DSM diagnosis and are often a secondary symptom to a primary medical problem.

In preparation for my new position, I have been reviewing many of my favorite references from school - Stahl, Carlat, Caplan. Most recently, I picked up the Massachusetts General Hospital Handbook of General Hospital Psychiatry. Since the bulk of my work will involve consultation in an emergent and acute-care setting, it is important to bone-up on all things psycho-somatic.  The book reviews essential skills  with a breakdown of assessment, diagnosis, and treatment by symptom and medical disease process. I particularly appreciate that while this is a physician-focused text, much of it is devoted to holistic assessment and communication, mindfulness, and follow-up beyond the initial evaluation and disposition. It also addresses ethics, legal considerations and collaboration issues, such as disagreement over diagnosis and interventions.  As with most Elsevier publications, you can activate the expert consult online, which includes a searchable text feature.  All that is missing is an integrated app!

Nurse Fight, Revisited.

At the 2010 APNA conference I was a newb to the plight of the Clinical Nurse Specialist phase-out. I listened, I empathized, and I agreed wholeheartedly that it was not fair. However, very little is fair in healthcare, and roles in all disciplines are continually merged, eliminated, grandfathered, or otherwise changed for the greater good of the consumer and the economy. Two years later I am hearing the same arguments resentments and resistance to continuing education and not a single course of action beyond "someone should do something."

Yes, the CNS role in mental health was there before the NP. While I profess enduring gratitude to these pioneers, being first is not a relevant reason for continuance of a role that is being incorporated into the now-dominant nurse practitioner certification. The psychotherapy skills at the core of CNS education are now part of most NP programs and total more hours than were required in the first CNS programs. This is particularly true for those pursuing the DNP. Individual future-NPs may be drawn to one aspect of practice than another, and can choose programs that fit their emphasis area of interest, but the core requirements set forth from the ANCC must be met, whether you want to write scripts all day, facilitate therapy, or lead process improvement projects. If you are in healthcare, you should be dedicated to life-long learning whether it is to maintain or update certification.  I am sure at some point, the American Board of Comprehensive Care exam - a ridiculously conceived and unvetted rip-off of the 3rd step of the USMLE -  will be required for certification or recertification in Family/Adult NP practice, at which time I will have to suck it up and take it (but not one second sooner than mandated, and I will be protesting it up to that second).


Yes, the CNS has paved the way for expansion in scope of practice by consistently providing cost-effective, outcome-driven, patient-centered care. Again, we would not be where we are today without these leaders, however, maintaining the high level of respectability and competence that has been cultivated comes from didactic and clinical education at the graduate (soon doctoral) level, and finding mentors in the first years of practice - the roles are not mutually exclusive. PMH providers are already thought of as the "not-a-real" arm of our parent disciplines, do we really want to separate ourselves further by advocating for two of the same with a different name? Are taking any of the 3Ps and sending off for a transcript really that professionally insulting? Could it not be viewed as an expanded practice update, just as our yearly CEU requirements are mandated? I went to a PMHNP/DNP program that was attended by CNSs who wanted to keep current. They did not have to retake clinical hours or classes, and their educational plans were tailored to their experiences. The money and time spent to convert from a CNS to a NP (with a DNP if you want to keep REALLY current) would provide all the necessary CEUs for state licensing or national credentialing and, depending on the program, cost less than a couple of national conferences.

Yes, the CNS in PMH is different than the CNS role is in other nursing specialties because of the emphasis on direct patient care rather than nursing education, organization, and leadership. The current roles of the NP and CNS in mental health have become increasingly redundant because we let it get that way. It is too late to go back in time and decide not to start PMH NP programs and restrict advanced PMH practice to the CNS designation, or to ensure the PMH CNS role stay in line with the CNS role in other advanced nursing specialties. It is ridiculous enough that advanced practice nursing is divided into four roles with six population foci (instead of one APRN designation with specialization - a soapbox for another time), but having 2 roles with the same foci is just sloppy. This is why the consensus model supported the retirement of other CNS specialties that overlap with NP practice (adult health, adult psych, child/ado psych, gerontology) and retirement or amendment of NP specialties that were too specific or did not include lifespan.

Yes, by supporting the APRN consensus model, the APNA did not advocate to keep the PMH CNS educational programs open throughout the country nor petition the ANCC to keep the certification exam active. I understand being upset at APNA for not advocating to keep the credential - every one of my mentors is now or started as a CNS - but the organization represents all psych nurses from vocational to doctoral degree. At any given time, some of the groups within the greater organization are going to feel their interests have been ignored. The APNA cannot dictate to profit-driven universities and certifying organizations how to conduct their business. The ANCC, who is responsible for administering, maintaining, and offering the certification, made the decision to discontinue the CNS designation, in part because universities have been phasing-out or incorporating CNS education into NP programs long before LACE. We can talk about how great CNS's are valued to patients, peers, and healthcare systems, but the hard truth here is the only argument that really matters is the economic argument. Frankly, I am shocked the AANP did not develop a limited-time bridge-exam for CNS-to-PMH just for the financial competition (tell me again why nursing has 2 certification bodies for advanced practice? Another soapbox for later). Universities and certification organizations are not making enough revenue to keep the PMH CNS viable. No money, no ticket.

Yes, nursing changes the rules more than other health discipline. Why? From entry to master, there are more people who call themselves "nurse" than any other health profession. We have to change to keep current and to define, grow, and protect our scope of practice. This often-labled "betrayal" of our own may be more common, but it is not at all unique to nursing. If one were to ask bachelors-prepared physical therapists, masters-prepared psychologists, pharmacologists without an MD or other doctoral healthcare degree, a masters prepared pharmacist before 1994, or MDs who find their primary practice certifications compartmentalized into new ABMS categories, they would empathize to varying degrees with what is happening to the CNS certification.  Doubtless there was and is outcry among our peer professional and some misunderstanding during the process, but I doubt most of them were calling shenanigans and recycling arguments years after the decision was made. I would like to think nurses, especially psych nurses, could figure out how to demonstrate resiliency and adaptation by finding ways to work the system to make the new system work for them.

For great background and perspective from someone involved in the development of the consensus model,  check out the LACE Dialogue for CNS blog by Dr. Kelly  Gourdreau, CNS.

APNA 26 Pre-Conference Presentation: Pushing the Point

Pushing the Point: Integrating Acupressure and Oriental Medicine in Psychiatric Nursing Care.

Pushing the Point: Integrating Acupressure & Oriental Medicine in Psychiatric Nursing from Jaclyn Engelsher, DNP

Useful Links
Finding a qualified acupuncturist: NCCAOM.org 
State Laws: Acufinder.com
General acupuncture information: Acupuncture.com 
Research, news, CEUs: HealthCMI.com 
Supplies: LhasaOMS.com

Handouts and presentation graphics from Acupuncture Media Works 

Poster Preview: What Were We Tweeting?! The Social Networking Patterns & Perspectives of Mental Health Providers

Though I have been advising senior leadership students on capstone posters for years, this is the first one I have personally presented at a national conference. Since I was asked to submit last minute, I have to pat myself on the back for not only getting it done, but uploading it to the online gallery 2 days early. Here's hoping I get a blue ribbon . . . and a publication nod!

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.

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!

Authorizations and Dispositions

Getting Certified
I received my ANCC authorization to test. This is my last board exam ever, ever, ever. That is my official plan. I have less than a month to prepare and am using a combination of test preparation tools from both nursing and medicine. While the diagnostic and pharmacological facts remain consistent across disciplines, the differences in practice ideologies are immediatly evident just from the areas of focus and types of questions presented.

The psychiatric reviews by Kaplan and Saddock are heavy on etiology and pathology of the system with precision diagnostic differentials. The "why" of the diseases are given the greatest attention, as are the historical contexts of various disorders. Questions are posed first with rational presented later.  Well care and prevention are not highlighted though they are addressed in some sections.

The nurse practitioner reviews by the ANCC focus on manifestations of disorders in the individual, the therapeutic alliance, and holistic factors of treatment adherence and compliance.  The "how" of the diseases and interventions are given the greatest attention. Introduction to concepts are given first and questions later.  Neural pathways and biochemical aspects of disease and treatment are given some attention, but are not in-depth.

What it boils down to is what it always seems to boil down to: Treat the disease with medicine. Treat the person with nursing.

Potato. Potato.

Getting Employed
Of the three positions I applied for, I received one disposition letter informing me they chose someone else, than a notification letter for the same position stating I was still in the running. I received another notification letter for a different position informing me that I was qualified, followed by a disposition letter stating they hired another candidate. No word yet on the third position, but I should hear something one way or the other next week once the announcement closes.

While the clock ticks, I am working on my marketing-for-employment-to-do list. This includes exciting such as renewing several licenses and certifications, updating all of my online profiles, getting published by a journal that that allows a high-word count with several tables and figures without charging a reviewer fee, investigating the postings from a number of locum companies that have me on their list, and rebranding my private practice identity for my new expansion of scope.

Getting Zen
My July mantra: I will be exactly where I need to be, doing what I am supposed to be doing.