As I have been educating people on "doctor-nurse" education and role, a confused laugh has become the expected reaction. Even I admit, I have referred to myself as doctor-nurse as a jocular shorthand to explain my credentials to colleagues. But why is it more amusing than a doctor-optometrist or doctor-physical therapist or doctor-pharmacist? I do not think it is the novelty alone as nurses have been getting educational and research doctorates for many years. Perhaps because in the clinical area, the two terms conjure up distinctly different images that do not easily meld. In yet another demonstration of how language is the way we view the world, I thought this deserved a little contemplation.
When people use the term "nursing" in the colloquial sense, they are usually referring to a nurturing role or healing process. Breast feeding, otherwise known as nursing, is a natural process of providing life-sustaining nourishment and immunity factors for growth and development from mother to child. We also use it to refer to consumption of adult nourishment, such as "nursing" a whisky all evening. "Nursing" may also refer to the need to nourish and nurture pragmatic matters like retirement accounts or mild illness and injury. Nursing, as in "back to health," brings to mind images of dressing wounds, holding hands, providing words of support and encouragement, or enduring the process by handling with care (such as nursing a hangover brought on by the aforementioned whisky!). People generally "nurse" others.
The colloquial use of "doctoring" often refers to fixing something. This is particularly the case with under-spiced or pre-prepared foods that one needs to alter or, "doctor up" in order to be palatable. In the realm of home improvements, "doctoring" refers to a quick fix, temporary patch-job, or a makeshift repair. It can also refer to tampering with or altering something, such as "doctoring" the evidence. People generally "doctor" themselves.
We have doctored the nursing title of advanced practice, and are nursing an understanding of the doctor title in advanced nursing!
Perhaps this is why being a doctor-nurse is usually met with a giggle. I have doctored plenty of canned pasta sauces in my day, and certainly nursed my share of spirits, but I cannot say vice versa. While I am not personally much for titles, I feel as one of the first crop of DNPs to hit the clinical setting, using the title is an important step to establishing an understanding of where advanced practice nursing is going on the (long) road to parity.
Saturday, January 19, 2013
Tuesday, January 8, 2013
A Better Command Hallucination
The other night a colleague and I were reflecting on some of the people we have worked with who have the bizarre, fun variety of psychosis and started brainstorming "wouldn't it be nice if" treatments. File the following under "why not?" Or delusional optimism.
An inspiring advocate for people living with schizophrenia, Dr. Fred Frese, who has lived with the disorder for several decades, provides one of my favorite descriptions of different types of psychosis by comparing them to different types of drunk. There are angry violent drunks, sad crying drunks, quiet withdrawn drunks, functional productive drunks, and (best?) of all, fun dancing drunks. Unlike intoxication, schizophrenia does not wear off, and the goal of most providers is to eliminate the symptoms. This is not always the primary goal of the patient. It is important to keep that in mind before labeling a patient as non-compliant.
Hearing a running commentary of behavior, judgements, and commands to act out anything from mundane to harmful behaviors is hard to fathom if you do not experience it for yourself. While schizophrenia is often referred to as the cancer of mental illness, the good news about the paranoid type is that it is the most treatable. The bad news is that it is paranoid schizophrenia and debatable the most difficult one to live with. While treatment options are improving, the older medication therapies either give you parkinsonian-like side effects including drooling, involuntary movement, and shuffling gait, while the newer ones make you fat, tired, stupid, and impotent. In addition to these expected side effects, other cumbersome factors may include cost, drug-drug interactions, regular blood monitoring, altering multiple lifestyle factors to prevent toxicity or ineffectiveness, or life-threatening adverse reactions. Oh, and more often than not, patients experience residual symptoms, or "breakthrough" psychosis. It is a high cost of doing business and I get why many folks would rather suffer the disease than the treatment.
So I got to thinking, maybe we are on the wrong track. Instead of elimination of voices through dopamine blockades in the prefrontal cortex, maybe what we need are to change the content of the delusions to something more health promoting. What if we could trigger the positive self talk areas of the brain, particularly the Broca or Wernicke regions, to create a better hallucination? Instead of hearing "your worthless" or "they are all against you" or "jump off the bridge," they could be replaced with "do 30 minutes on the treadmill," or "check that nutrition label for trans fats," or "get home by 10 so you can get your beauty rest!" Who would need Weight Watchers and a personal trainer with voices like that?!
Though I am sure if we did had that ability through medication, advertisers would find a way to have the voices promote their products.
So on second thought, maybe not.
An inspiring advocate for people living with schizophrenia, Dr. Fred Frese, who has lived with the disorder for several decades, provides one of my favorite descriptions of different types of psychosis by comparing them to different types of drunk. There are angry violent drunks, sad crying drunks, quiet withdrawn drunks, functional productive drunks, and (best?) of all, fun dancing drunks. Unlike intoxication, schizophrenia does not wear off, and the goal of most providers is to eliminate the symptoms. This is not always the primary goal of the patient. It is important to keep that in mind before labeling a patient as non-compliant.
Hearing a running commentary of behavior, judgements, and commands to act out anything from mundane to harmful behaviors is hard to fathom if you do not experience it for yourself. While schizophrenia is often referred to as the cancer of mental illness, the good news about the paranoid type is that it is the most treatable. The bad news is that it is paranoid schizophrenia and debatable the most difficult one to live with. While treatment options are improving, the older medication therapies either give you parkinsonian-like side effects including drooling, involuntary movement, and shuffling gait, while the newer ones make you fat, tired, stupid, and impotent. In addition to these expected side effects, other cumbersome factors may include cost, drug-drug interactions, regular blood monitoring, altering multiple lifestyle factors to prevent toxicity or ineffectiveness, or life-threatening adverse reactions. Oh, and more often than not, patients experience residual symptoms, or "breakthrough" psychosis. It is a high cost of doing business and I get why many folks would rather suffer the disease than the treatment.
So I got to thinking, maybe we are on the wrong track. Instead of elimination of voices through dopamine blockades in the prefrontal cortex, maybe what we need are to change the content of the delusions to something more health promoting. What if we could trigger the positive self talk areas of the brain, particularly the Broca or Wernicke regions, to create a better hallucination? Instead of hearing "your worthless" or "they are all against you" or "jump off the bridge," they could be replaced with "do 30 minutes on the treadmill," or "check that nutrition label for trans fats," or "get home by 10 so you can get your beauty rest!" Who would need Weight Watchers and a personal trainer with voices like that?!
Though I am sure if we did had that ability through medication, advertisers would find a way to have the voices promote their products.
So on second thought, maybe not.
Monday, January 7, 2013
20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers
Great guidance from a fellow Dr. Nurse and patient advocate:
20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers:
Thou shalt respect your client and not judge
Thou shalt increase the well-being, opportunities and happiness of your client
Thou shalt...
20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers:
Thou shalt respect your client and not judge
Thou shalt increase the well-being, opportunities and happiness of your client
Thou shalt...
Saturday, December 15, 2012
Roles in Healthcare: A Who's Who Guide to the Gray Area
With all of the posturing over who has more training hours, patient-satisfaction scores, positive outcome measures, and cost-effective care, something has been lost in the Dr. Nurse/Dr. Physician debate: Role of the Discipline.
First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter. Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.
What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.
When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job. While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care. There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.
Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes. Medicine is interventional at the disease level, thus the training is focused at that level of care. Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.
What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention. Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person. To be successful in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.
The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.
Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians. This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting. Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.
There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care. Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention. Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.
A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care? An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.
But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.
Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority. This is where medicine is the best choice.
So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.
First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter. Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.
What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.
When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job. While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care. There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.
Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes. Medicine is interventional at the disease level, thus the training is focused at that level of care. Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.
What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention. Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person. To be successful in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.
The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.
Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians. This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting. Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.
There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care. Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention. Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.
A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care? An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.
But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.
Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority. This is where medicine is the best choice.
So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.
Sunday, December 2, 2012
VA Hiring Process
Prior to entering the DNP program, I knew I would have to make a choice between expanding my current private practice, or scaling back and seeking full time employment. I have derived an enormous amount of joy and freedom as an independent provider, and the practice has grown significantly despite an economic recession. However, an expansion in practice scope calls for major rebranding efforts that can result in more time, money, and emotional expense than starting a business from scratch. With the number of changes to health care coding and billing down the pike, and living in a state where we must have a collaborative (bribed) agreement with a physician to prescribe medications that are rightfully part of our independent scope of practice, I am not as bullish on private practice as I was a couple of years ago. Plus, it gets lonely working as a solo provider. I miss the camaraderie of coworkers and a stimulating environment that forces you to continually evaluate yourself as a provider, and challenges you to stay up-to-date on research, legislation, and best-practice.
Nurse practitioners have a lot of great options - some of my former colleagues have taken HRSA jobs in underserved areas, others are going academic, and some are like me. Just prior to graduation, I applied for positions in the VA after being encouraged by a few colleagues that are passionate about serving the veteran population. Having done the bulk of my clinical work with active duty soldiers, and being married to a (handsome, talented) veteran myself, it seemed like a natural fit for me. I was told the VA hiring process for healthcare workers can take a long time, and when I did some casual web surfing, I found the bulk of first-hand accounts came from LPNs and RNs. As a public service to anyone considering an advanced practice nursing career in the VA, I want to share my application and hiring process. Just keep in mind, "if you've seen one VA, you've seen one VA!"
April: I have a great conversation with a current NP who works outpatient and not only encourages me to apply, but provides excellent reassurance and advice regarding boards. Because I am already an FNP and will be eligible to take the PMHNP certification exam in 90-days, I quickly put in an application on April 24th to the one open position psych-NP, emergency and inpatient mental health consultations, to get my name in the system (open period 3/29-6/28). Had I been an RN only, I would not have applied until after graduation on May 25th.
May: I apply for 2 additional positions as they become available through USA Jobs, one on the 10th for an outpatient mental health clinic and the second on the 25th for the homeless veteran program (open period 5/7-9/17 and 5/18-6/18 respectively). In addition to the usual demographic questions, I was asked to provide my resume, 3 references, unofficial transcripts, a separate application for nurses/nurse anesthetists, declaration for federal employment, and copies of all licenses/certifications. Immediately after applying, the status in USAJobs is marked as "application received," and within a week they read "eligible - application referred to selecting official."
June: I have my interview on the 5th, which is conducted by 2 APRNs and 3 LCSWs. Before sitting down they joke about the formulaic nature of the interview, with each one asking standard questions in a round: "Why the VA?" Tell me about a time when you had a difficult patient and resolved it/collaborated for a positive outcome/had a conflict with an MD and managed it?," "What is recovery," "What is evidenced-based practice." Since I am also an acupuncture and Oriental medicine provider, they asked a few seemingly off-the-record questions about my practice. I also had a chance to ask them about why they chose the VA, involvement in national organizations, and what they do and do not love about working for the government. On June 12th, I am sent a disposition letter on the consultation position that another candidate was selected, and the status in USA jobs changes to "not selected." On June 20th I receive and official notification letter on the homeless veteran position stating "We have reviewed your application and found you qualified for the position listed above. Your name has been referred to the employing agency for consideration. THIS IS NOT A JOB OFFER."
July: This is where things get confusing. On July 3rd, I am sent an official notification email on the consultation position that states I am eligible (see above) and the status in USAJobs changes to "application referred." July 6th I am sent a disposition letter that I am not selected for the homeless veteran position. July 18th I am sent both the qualified notification and not selected disposition letters on the clinic job, then on the 30th I receive a notice that my application forms have been received and the USAJobs status changes from not selected to application received. I reach out to one of the APRNs, and am told that while my interview went well, they had an overwhelming amount of applicants who already had certification (my boards were scheduled for later that month) and/or were already VA employees. I am encouraged to keep my eyes out because more positions would become available.
August: All quiet.
September: Ten minutes from boarding a flight to London late in the month, I get a phone call from the VA telling me they would like to speak with me about an open position. After playing some telephone tag, it turns out the consultation position had been re-listed under a different announcement number. I speak with one of the mental health staff members responsible for finishing the hiring process who decides my previous interview is good for this position. I am tentatively given an offer pending credentialing, nurse professional standards board, and VetPro. Once that is all sorted out, I will be given an official offer. She cautions me that because I have to go through both nursing and mental health services the process can take awhile, and not to get caught up in Grade and Step, but to look at the salary and decide if I want to accept or negotiate. On the 24th I am sent the Qualifications Questionnaire with instructions to brag about my experiences as much as possible, because it can mean the difference of many steps and possibly a grade in overall pay. Up to this point, every person has been helpful and quick to respond to questions and concerns.
October: The first part of the month involves gathering and faxing documents, getting my physical, drug test, and fingerprinting done at the facility, and VETPRO. They anticipate I should be ready to start by November or December. I get a call late in the month informing me of my grade, step in salary, which is delightful. The process actually moved faster than expected, but as I have to give my private practice patients notice, I ask to start on December 3rd.
November: I receive my officially signed, in-writing offer letter dated for the 9th with instructions on where to go and what to bring for my first day of orientation. Hooray! I will have 2 weeks of orientation under nursing services before getting transferred to my official duty station in mental health services.
To sum up, from application to walking into orientation, it took 223 days (7 months and 9 days), though I could have started up to a month earlier if I did not have previous commitments to patients, conferences, and travel. Had I been certified as a PMHNP at the time I applied in April, I likely would have been hired initially and started within 90 days, give or take.
I have no plans to blog about my work at the VA from here on out unless it is relevant to nursing practice and complies with all the usual rules and regulations that come with working in government healthcare. As I have done all of this research and policy development on social networking for mental health providers, it would be utterly embarrassing to violate my own guidelines!
Nurse practitioners have a lot of great options - some of my former colleagues have taken HRSA jobs in underserved areas, others are going academic, and some are like me. Just prior to graduation, I applied for positions in the VA after being encouraged by a few colleagues that are passionate about serving the veteran population. Having done the bulk of my clinical work with active duty soldiers, and being married to a (handsome, talented) veteran myself, it seemed like a natural fit for me. I was told the VA hiring process for healthcare workers can take a long time, and when I did some casual web surfing, I found the bulk of first-hand accounts came from LPNs and RNs. As a public service to anyone considering an advanced practice nursing career in the VA, I want to share my application and hiring process. Just keep in mind, "if you've seen one VA, you've seen one VA!"
April: I have a great conversation with a current NP who works outpatient and not only encourages me to apply, but provides excellent reassurance and advice regarding boards. Because I am already an FNP and will be eligible to take the PMHNP certification exam in 90-days, I quickly put in an application on April 24th to the one open position psych-NP, emergency and inpatient mental health consultations, to get my name in the system (open period 3/29-6/28). Had I been an RN only, I would not have applied until after graduation on May 25th.
May: I apply for 2 additional positions as they become available through USA Jobs, one on the 10th for an outpatient mental health clinic and the second on the 25th for the homeless veteran program (open period 5/7-9/17 and 5/18-6/18 respectively). In addition to the usual demographic questions, I was asked to provide my resume, 3 references, unofficial transcripts, a separate application for nurses/nurse anesthetists, declaration for federal employment, and copies of all licenses/certifications. Immediately after applying, the status in USAJobs is marked as "application received," and within a week they read "eligible - application referred to selecting official."
June: I have my interview on the 5th, which is conducted by 2 APRNs and 3 LCSWs. Before sitting down they joke about the formulaic nature of the interview, with each one asking standard questions in a round: "Why the VA?" Tell me about a time when you had a difficult patient and resolved it/collaborated for a positive outcome/had a conflict with an MD and managed it?," "What is recovery," "What is evidenced-based practice." Since I am also an acupuncture and Oriental medicine provider, they asked a few seemingly off-the-record questions about my practice. I also had a chance to ask them about why they chose the VA, involvement in national organizations, and what they do and do not love about working for the government. On June 12th, I am sent a disposition letter on the consultation position that another candidate was selected, and the status in USA jobs changes to "not selected." On June 20th I receive and official notification letter on the homeless veteran position stating "We have reviewed your application and found you qualified for the position listed above. Your name has been referred to the employing agency for consideration. THIS IS NOT A JOB OFFER."
July: This is where things get confusing. On July 3rd, I am sent an official notification email on the consultation position that states I am eligible (see above) and the status in USAJobs changes to "application referred." July 6th I am sent a disposition letter that I am not selected for the homeless veteran position. July 18th I am sent both the qualified notification and not selected disposition letters on the clinic job, then on the 30th I receive a notice that my application forms have been received and the USAJobs status changes from not selected to application received. I reach out to one of the APRNs, and am told that while my interview went well, they had an overwhelming amount of applicants who already had certification (my boards were scheduled for later that month) and/or were already VA employees. I am encouraged to keep my eyes out because more positions would become available.
August: All quiet.
September: Ten minutes from boarding a flight to London late in the month, I get a phone call from the VA telling me they would like to speak with me about an open position. After playing some telephone tag, it turns out the consultation position had been re-listed under a different announcement number. I speak with one of the mental health staff members responsible for finishing the hiring process who decides my previous interview is good for this position. I am tentatively given an offer pending credentialing, nurse professional standards board, and VetPro. Once that is all sorted out, I will be given an official offer. She cautions me that because I have to go through both nursing and mental health services the process can take awhile, and not to get caught up in Grade and Step, but to look at the salary and decide if I want to accept or negotiate. On the 24th I am sent the Qualifications Questionnaire with instructions to brag about my experiences as much as possible, because it can mean the difference of many steps and possibly a grade in overall pay. Up to this point, every person has been helpful and quick to respond to questions and concerns.
October: The first part of the month involves gathering and faxing documents, getting my physical, drug test, and fingerprinting done at the facility, and VETPRO. They anticipate I should be ready to start by November or December. I get a call late in the month informing me of my grade, step in salary, which is delightful. The process actually moved faster than expected, but as I have to give my private practice patients notice, I ask to start on December 3rd.
November: I receive my officially signed, in-writing offer letter dated for the 9th with instructions on where to go and what to bring for my first day of orientation. Hooray! I will have 2 weeks of orientation under nursing services before getting transferred to my official duty station in mental health services.
To sum up, from application to walking into orientation, it took 223 days (7 months and 9 days), though I could have started up to a month earlier if I did not have previous commitments to patients, conferences, and travel. Had I been certified as a PMHNP at the time I applied in April, I likely would have been hired initially and started within 90 days, give or take.
I have no plans to blog about my work at the VA from here on out unless it is relevant to nursing practice and complies with all the usual rules and regulations that come with working in government healthcare. As I have done all of this research and policy development on social networking for mental health providers, it would be utterly embarrassing to violate my own guidelines!
Wednesday, November 28, 2012
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.
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!
Tuesday, November 20, 2012
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, 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.
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.
Friday, November 2, 2012
APNA 26 Pre-Conference Presentation: Pushing the Point
Pushing the Point: Integrating Acupressure and Oriental Medicine in Psychiatric Nursing Care.
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
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
Wednesday, October 17, 2012
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!
Thursday, October 11, 2012
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.
Subscribe to:
Posts (Atom)