One DNP

Sneak Peek: Low Milk Supply AANP15

2015-04-19T07:33:00.000-04:00

Presentation submitted and accepted for CEUs for the American Association of Nurse Practitioner's annual conference in New Orleans June 2015. I have to admit, I do think my working title "When Liquid Gold Goes Bust" was a smidge catchier. Here is a sneak-peak for those of you coming to AANP15 and for those of you who will be there in spirit.

Counting Every Drop: Navigating Low Milk Supply from Jaclyn Engelsher, DNP

AANP Abstract Accepted!

2014-11-23T17:34:00.001-05:00

When I submitted my abstract, Counting Every Drop: Navigating Low Milk Supply, for consideration for the American Association of Nurse Practitioners 2015 national conference in New Orleans, I did not expect it to be accepted. Not only was this my first submission to AANP, but the conference presenters are the top of their field, and this topic is very much out of my daily professional expertise. I am surprised and honored to be selected as a podium presenter and to share the knowledge that I researched out of my personal struggles dealing with low-milk supply. Here is a look at my abstract submission:

Brief Bio
Dr. Jaclyn Engelsher is a Psychiatric Mental Health and Family Nurse Practitioner, and is nationally certified in Oriental Medicine. She has over a decade of experience blending allopathic and complementary evidence-based therapies for physical and emotional wellness.

Summarize why the topic is important
Current guidelines recommend exclusive breastfeeding for the first six-months of life, however many women are unable to produce adequate milk to meet this goal. Unlike initial difficulties or short-term factors that impact full supply, those suffering with chronic low-milk supply require a higher level of education, management, and support to increase or maintain production. The purpose of this presentation is to describe genetic, social, and emotional factors that contribute to low milk supply, and provide the practitioner with a summary of evidence-based allopathic and complementary interventions.

Summarize the literature on the subject
A review of the literature demonstrates up to 15% of women experience insufficient lactation, and 4-5% have chronic-low supply. The contributing factors can be categorized into issues of either production or extraction. Breast structure, previous breast surgery, certain medications, and pregnancy or postpartum complications contribute to production issues. Extraction issues may be related to feeding length and frequency, insufficient milk transfer, and incomplete breast emptying. Early detection and intervention with galactagogues, latch correction, and feeding or pumping optimization increase the likelihood of reaching full supply.

Summarize the focus of the presentation, such as management of condition, etc.
This presentation will provide evaluation strategies and review causes of low milk supply, including insufficient glandular tissue, infant lip and posterior tongue tie, postpartum difficulties, hormonal imbalances, diet, and emotional factors. Pharmaceutical, herbal, and food-based galactagogues, and lifestyle interventions such as feeding and pumping regimens, will be presented to help the practitioner identify appropriate management strategies. A list of patient education and peer-support references will be provided.

Describe the implications for practice, policy, education, and/or research
Low-milk supply evaluation and intervention has practice implications for the nurse practitioner specializing in pediatric, women’s-health, family, and mental health care. Differentiating transient from chronic supply issues, and early identification and management are key in choosing the appropriate intervention for the physical and emotional health of mother and baby.

APNA14: You Can't Learn Mindfulness in a Weekend Workshop

2014-10-26T14:53:00.000-04:00

Conferencing with an infant is certainly a unique experience! I had a blast reconnecting with many of my teachers and mentors while getting an infusion of professional and EBP goodness, though I must admit I missed my UT-DNP peeps. Every year I get to add to my list of memorable interpretive quotes and insights from the APNA conference, and APNA 14 was no exception. I am going to forgo an in-depth recap of this year's events and share some of my favorite gems. If you were there, you know who and where they came from!

We don't give enough credit to how difficult it is to be fully present

Mindfulness is the antidote to mind wandering and time travel

Nurses feel they have to be twice as good to be any good

Perfect is the enemy of good

Negotiation of difference is what we all have in common

Assessment tools without the patient narrative assess very little

In nursing, you can have a mid-life crisis every 7-years

If you can't squeeze water out of a rock, don't blame the rock

Nursing as a fall-back position is not exactly what you would call a career path

I hope to have at least two more disclosures by the end of the month

I am already looking forward to APNA15 in Disney World - if it isn't the happiest place on earth when the psych nurses get there, believe it will be by the time we leave!

Traumatic Birth Experience: APNA28

2014-10-14T17:38:00.002-04:00

This was very much a professional departure and a personal journey

Grieving Through Grateful: Reconciling the Traumatic Birth Experience from Jaclyn Engelsher, DNP

Community and Peer Support Reference Links:

Baby Center Community Disappointing Birth Experience

Pinterest Traumatic Birth Resources

Facebook

Solace for Mothers

Website: http://www.solaceformothers.org
Forum: http://mothers.solaceformothers.org

Twitter

ICAN: International Cesarean Awareness Network

Additional references:

Trashing the CAPA-NS!

2014-07-16T17:00:00.000-04:00

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

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

Abstract Accepted!

2014-04-12T11:21:00.000-04:00

For the fourth year running, I am honored to have a presentation accepted for the American Psychiatric Nurses Association annual conference. As with most topics, you can tell what is going on personally by what I present professionally. This one is especially meaningful because I am stepping out of my clinical comfort zone to do the research while having the perspective as both provider and patient. In keeping to my roots, references will be available via my social network sites - stay tuned for the pinterest board!

Grieving Though Grateful: Reconciling the Traumatic and Disappointing Birth Experience

Purpose*

When a woman experiences a traumatic or disappointing birth, there often exists an emotional dichotomy between gratefulness for the child and grief toward the the experience. This presentation describes characteristics that contribute to traumatic birth and resources for the PMH nurse to aid in prevention, diagnosis, treatment, and collaboration.

Summary of evidence*

Though up to 30% of women world-wide experience traumatic birth, a review of the literature reveals a paucity of research, and the DSM-5 lacks discussion in the sections on perinatal mood disorders, trauma and stress-related disorders, or bereavement.

Description of practice or protocol*

Traumatic birth may be missed or mistaken for other postpartum mood disorders by clinicians, and under-reported by mothers due to stigma. Platitudes such as "all that matters is a healthy baby" minimize and invalidate the mother's grief toward the experience and contribute to feelings of guilt, anger, helplessness, or diminished self-esteem.

Validation of Evidence / Method of Evaluation*

Factors including psychiatric history, unplanned or emergent obstetric intervention, pain, loss of control, and lack of interpersonal support contribute to negative birth experiences, and put the mother at risk for ineffective maternal role attainment and mental health disorders.

Relevance to PMH Nursing / Results*

A comprehensive understanding of traumatic birth provides the PMH nurse a foundation for enhanced assessment, intervention, integrative strategies, and interdisciplinary collaboration to help women at risk for or experienced traumatic birth.

Future implications*

Birth is not a mearly a means to an end, but an experience independent of the outcome. Understanding the risk factors, characteristics, and resources results in refined diagnosis, effective treatment planning, and the opportunity to build connections with peer obstetric clinicians.

SB7 Passed! A Small Step with a Huge Compromise

2014-02-11T15:03:00.001-05:00

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

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

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

Patience is a nuisance.

APNA 2013 Poster

2013-10-06T20:03:00.000-04:00

I have been on a writing hiatus. Between the new position at work and being 28 weeks pregnant, I am out of the habit of blogging. Though I would have really enjoyed doing a podium presentation again, I had a feeling it might have been more than I could tack on to an already packed schedule. . . as evidenced by the fact I just completed and ordered the hardcopy today and am leaving on Wednesday for the conference. This was really a fun one to research over the past few months, and I am looking forward to another great APNA conference. See you there!

Will the DSM-5 Define Normal?

2013-05-10T13:39:00.002-04:00

Or rather, neuro-typical?

I realize phrases like "I'm not normal" and "Who wants to be normal?" and "I never wanted a normal life" are often a person's way of differentiating themselves from what they believe is mainstream (i.e. boring) living. Yet there are many, many people living quiet little wild lives unbeknownst to their neighbor. What looks like the white-bread nuclear family to the casual observer may be anything but. People get altogether too comfortable in their assumptions of how others live and think. Fact is, most of us are actually normal in that we feel a full range of different emotions, can generally trust our senses, have desires, and respond to the trials and tribulations of life with some balance of primal instinct and societal expectation.

Yeah? Well prove it.

Unfortunately, the one diagnostic reference that tells you all of the ways you are abnormal fails to provide guidelines for what is considered within normal limits.

While physical health is somewhat generically considered absence of disease, there are any number of standardized, objective tests that show clinicians where a patient falls within the range of normal. You know if someone's blood sugar has been in control for a few months by drawing a Hemoglobin A1C. You know if someone has a blockage of their coronary artery by performing a cardiac catheterization. You know if someone has a broken arm by getting an x-ray. With mental health disorders, it is subjective report of symptoms coupled with the observation and interaction skills of the clinician that leads to a diagnosis. There is yet no blood test for depression - though we certainly know that low thyroid or Vitamin D levels can contribute. While we can detect brain injury and atrophy, there is no MRI that can yet detect the difference between hallucinations from schizophrenia, bipolar disorder, depression, or substance use. We know certain lifestyle factors correlate with development of mental health problems, from malnutrition, infection, or drug use while in utero to taking too many blows to the head playing football, however thresholds of these biological factors have not been established.

Perhaps if we had a definition of normal mental health, we could identify high-risk individuals and provide primary mental health prevention with education, screening, and management prior to onset or exacerbation of a disorder. Normal grief, normal sadness, normal anger, normal worry, normal happiness - all emotions are appropriate throughout the lifespan, the issues is helping people get in touch with those emotions and be able to evaluate for themselves individual normal limits.

In the meantime, we have yet another tired update to the Diagnostic and Statistical Manual of Mental Disorders, a book developed by the American Psychiatric Association in collaboration with, well, no one except their own psychiatrists, to let the thousands of non-physician mental health providers (you know, the ones that comprise the bulk of the field - social workers, therapists, psychologists, nurses) know how to consistently label people for the purposes of proper billing and coding. Not treatment. Just billing and coding.

It is unsurprising that the National Institute of Mental Health has come out with harsh criticism and calling for more of a biological base to classifications and thereby increase the validity of diagnosis to guide effective treatment. Though they have not formally entered the competitive ring, it is time the American Psychiatric Association monopoly on mental health definitions fall into line with what is happening in the treatment room. It’s called collaboration. This includes interdisciplinary input from clinicians as well as the lived-experience of the mental health consumer.

Let’s see if the NIMH can do better: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

The DSM-5 is scheduled for release on May 27^th – will you get yours?

Amazon.com Widgets

APNA27 Abstract Accepted

2013-04-17T16:43:00.001-04:00

Wow! Three years running I have been honored to have my work accepted at the American Psychiatric Nurses Association Annual Conference. I have put to rest my social networking research and gone back to my roots of practice and interest. Check out the summery, and get ready for APNA27 this October in San Antonio!

Serotonin OTC: The Latest in Mental Health Nutraceuticals

Abstract: The U.S. vitamin and supplement industry grosses nearly $30 billion per year with a growing number of products targeted to the prevention and alleviation of mental health related conditions. Although the industry is regulated by the FDA and products must adhere to Good Manufacturing Practices (GMP), broad claims of efficacy for mood, sleep, concentration, and other general psychiatric symptoms are not subject to scientific validation. Popular nutraceuticals including GABA, n-acetylcysteine (NAC), and Ashwagandha are advertised as natural alternatives or augmenters to standard psycho-pharmacy, and while consumers who self-medicate without informing their providers may experience a measurable benefit, they put themselves at risk for deleterious outcomes. Consumer interest, desire to decrease pill burden, and product proliferation in the marketplace have encouraged increased research to substantiate health claims, determine potential interactions with medication, and provide a basis for recommendation. This presentation will provide an overview of the functions of 10 common and novel mental health focused nutraceuticals, evaluate the base of evidence for implementation into practice, and provide strategies for educating patients on appropriate use of OTC supplements.

Presentation Summary: This presentation provides an overview of the functions of common and novel mental health focused nutraceuticals, evaluates the base of evidence for implementation into practice, and provides strategies for educating patients on appropriate use of OTC supplements.

Objective 1: Identify the key functions of 10 nutraceuticals supplements frequently used in management of mental health disorders.
Objective 2: Describe potential interactions between classes of psychiatric medication and OTC mental health nutraceuticals.
Objective 3: Evaluate the evidence base for use of OTC mental health supplements in PMH practice

Rats! Foiled Again.

2013-04-02T17:35:00.000-04:00

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

This is why I can never run for office.

Here is the official press release from the AANP:

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

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

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

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

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

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

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

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

Kentucky Battle Cry . . . Y'all

2013-03-13T16:02:00.002-04:00

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

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

Laugh and Discuss

2013-03-04T14:00:00.000-05:00

A few years ago I ran across this video that humorously illustrates the dangers of narrow focus. I was reminded of it the other day when discussing frustrations related to provider communication issues and stigmatization. There are a number of similar scenarios between different specialties that pop up after the video, including some amusing psychiatry vs. physical medicine interactions, but this remains my favorite.

I needed a laugh today - have one with me:

Countdown to Vegas!

2013-02-26T13:31:00.000-05:00

RIP 2006

Those of you who know me in the real world are pretty clear that I love Las Vegas. I first visited in 2001 when a friend announced "my nephew is eloping at Mandalay Bay in Las Vegas and I really want to go support him, but there's no way I can afford it." Being young, spontaneous, and flush with student loan money, I replied "if you want me to plan it, I will and we're going. What's you budget?" Of course, he did not believe I was serious until I was about to click the purchase button on the SWA package for 2 nights at the Stratosphere (IP and Sahara were the close runner ups) with car and flight from Albuquerque for something like $400.

We had our first beer on the flight up and I am pretty sure I stayed pleasantly inebriated for the entire trip. I remember his family felt guilty for the drama that made them want to run away and wound up coming anyway. The mentionable events that stick out:

Walking the strip, thinking "I hope I can afford to stay at a fancy place like Treasure Island . . . how do families afford to stay here at $200/night?"
Aerialists hanging from the ceiling at Ra in Luxor (now LAX) and finding myself in the center of the dance floor with a handsome partner and an attentive audience
Going to the Stardust showroom to see if it was dark. Yep. To this day I often pack for my trips with Nomi Malone!
The yellow brick road at MGM, a wizard sticking out of Excalibur, and general theming on the south side of the strip
Carrying a cup of change with my whole $20 in gambling/drink tip money (I left with $16).
Wait, the drinks are free?!?
Seeing "Bottoms Up", the topless afternoon show at Flamingo where admission was only a $7 Heineken with coupon.
Taking a ride on the Big Shot at Stratosphere
Learning that marriage in Vegas is not the place for sentimentality. These people have a schedule to keep and your 30 minutes start the second you hit the dressing room (yet I still teared up!)
Taking off at twilight and while we were taxiing down the runway, I gazed longingly at the strip as the lights came on, sad to be leaving but thinking, "I will see you later, Las Vegas strip. I will see you later."

And I have. A lot.

While the strip has changed dramatically since that first visit, the vibe of Las Vegas holds the same promise of excitement, the same respite from everyday reality, and the same unpredictable wonder that keeps me coming back.

You woke up. Celebrate.

When the American Academy of Nurse Practitioners announced they were having the 28th national conference in my favorite destination city, there was no question I would be attending. However when I started talking up the conference to colleagues, I received a lot of negative feedback on our host city. Much like tequila, folks have a visceral reaction when you mention sin city: "It's smoky," "Nothing to do there but gamble,""It's so manufactured," "Way too stimulating" "So crowded," "Everyone's drunk," "Such a hassle to get around," and my personal favorite, "Ugg, Vegas."

So for those attending the conference who have never been to Vegas and for those reluctant to revisit, I have started board on Pinterest to help make the most of the free time you have have. And maybe even entice you to spend a couple of extra days exploring the Entertainment Capital of the World!

The Most Restrictive Environment

2013-02-18T11:33:00.003-05:00

The psych ward. The nut house. The loony bin. The asylum. Whatever you call it, it is not the place most of us want to be, yet it often becomes the dump site for the stigmatized. Although we are trending toward more blended medical-psychiatric and gero-psychiatric inpatient units that allow more medical management to take place concurrently, the ideal environment for mental health management is in the outpatient setting.

I believe in the principle of least restrictive environment for mental health care. Some providers are confused and feel psychiatric floors should be the depository for issues they do not want to deal with or are not interesting enough for medicine. Certainly, chronic mental illness is an issue of management rather than cure, and acute-care physical health providers are often intimidated by conditions that cannot be eliminated by pharmacological or surgical interventions. Many would prefer to pass people off rather than deal with complex matters of mind-body interaction. Perhaps if some of them visited a psych unit, they might get a fresh perspective. Let's review what happens when a person is admitted to a psychiatric ward versus a medical ward:

We take your clothes
We search your belongings and lock them up
We lock the doors and windows to the unit so you cannot get out
We take your phone, e-reader, laptop, music player, and electronics
We restrict when and who can visit you
We tell you when you can and cannot talk on a common, public phone
We tell you when you get up and when to go to bed
We put you in a room with 1-3 other people in beds that do not adjust
We tell you what you can and cannot watch and when on a common TV
We take away your right to smoke
We take away your food choices and deny outside delivery
We take away your right to breath fresh air
We label you as a "psych patient" for life with all the privileges of stigma therein

In short, we take away your constitutional liberties. So why do we do that?

Sometimes, it is because it is the only way to keep a person safe. Psychosis, suicidality, homicidality, mania - these are viable reasons to put someone in this most restrictive environment with the intent and hope of finding the right treatment plan as quickly as possible to get this person stable and back in the community. Sometimes we do it when the person really feels it is in their best interest because they feel unsafe or unstable and want to prevent escalation of symptoms. These are the two scenarios where admission is the right thing to do.

However, not everyone who has delusions, suicidality, or mania needs to be admitted. Just because it is in the brain, does not mean it needs to be managed by psych. For example, seizures are seizures - whether from epilepsy, alcohol withdrawal, or psychosomatic origins, they need to be monitored by the medical team. Keeping the old Maslow's Hierarchy of Needs care theory becomes particularly useful in holistic, individualized treatment planning for patients with complex and co-morbid disorders.

These days, to be in a hospital for more than an outpatient procedure, you better be sick. This goes for physical and mental illness. Unfortunately, many providers take a cavalier attitude when it comes to dispositioning someone on a locked psychiatric ward and use a DSM diagnosis as a basis to gloss over a through medical assessment and justify an inappropriate admission to a psychiatric unit. Two areas that seem to be ripe for controversy are dementia and substance abuse.

Being confused is not justification for taking you freedom. If it were, half the hospital staff would qualify by Thursday afternoon. This confusion about the confused occurs frequently with the elderly, who will often manifest altered mental symptoms as a result of multiple drug interactions, any number of physical condition, or just plain physical neurodegenerative changes related to a specific disorder or the normal aging process. When medicine tries to label all hallucinations as psych in origin, I harken back to a high school biology class where we discussed the how visual and tactile hallucinations were linked with everything from UTIs to syphilis. This was repeated and detailed multiple times through the course of my nursing education in the family practice and mental health specialties. Plus, I have seen Trainspotting at least 5 times. See it if you haven't.

Needing to dry out from a bender is also inappropriate not only from the aspect of liberty, but competent care for withdrawal symptoms. Most psychiatric facilities and wards have restrictions on medical interventions or devices. IVs, catheters, ports or lines, telemetry monitoring, uncontrolled seizures, and unstable vital signs are just some common limitations that warrant the patient seeking a medical rather than psychiatric management, no matter what their state of mind. When medical teams refuse to medically detox a patient "because they are psych," I get miffed.

They may have psych issues. They are not themselves psych. They are people who need placement in the least restrictive environment possible to provide positive outcomes for long-term management.

How the DNP Improves Nursing (Not Medicine)

2013-02-11T10:33:00.000-05:00

Anyone who has met me in person has heard (and tuned-out) my impassioned soliloquies advocating nurses embrace role and practice purpose during one of our most critical periods in professional identity. Though I am a DNP and support the transition of making it the minimum entry to advanced practice, I do not automatically endorse current NP practitioners to pursue it. For those starting NP education in 2015, they will not have a choice, but for those with an MSN, there is likely no foreseeable benefit to pay thousands of dollars in tuition and to take time out of their current clinical role to return to school. For a brief history on this changeover and the controversy, read Dr. Nurse: Development and Implications for the Clinical Nursing Doctorate

Afaf Meleis, one of my favorite nursing theorists, has long been an opponent of this transition (ironic, since her theory IS transitions!). I respectfully disagree with her contention "if it ain't broke, don't fix it." I do not believe the MSN is broken, but it is getting worn around the edges, particularly for those in leadership and clinical roles. I am on board with residency or supervisory models toward full licensure in NP practice provided they are guided by peer-NPs, but why would we beef up the MSN rather than incorporate these improvements into a degree when the MSN is one step below parity with every other mainstream and complementary health care provider?

This is the same for nursing leadership. There is so much more to running a hospital than staffing, mediating personnel conflicts, and generating patient loyalty. Expertise in emerging technology for care delivery and communication, initiating clinical research, implementing evidenced-based practice, and meeting the ever-growing core measurements for reimbursement are no longer realistic as an RN "with a little extra training" at the MSN level. When you see more and more MDs going back to school for MBAs so they can meet leadership demands, you know times have changed. We have to change with them, and take responsibility for our educational choices.

Though many argue the DNP is not a pure practice or clinical doctorate because it is not for APRNs only, remember that a significant portion of clinical nursing involves education and mentoring of other nurse clinicians rather than direct patient care and management. Running the hospital is clinical practice. In the leadership role the focus is on providers who treat all populations rather than on the individual patient. While the DNP leadership clinician may not directly deliver interventions to the individual, they must be just as versed in clinical practice guidelines and standards of care among all nursing levels and specialties as those that work at the bedside and clinics.

For those that believe there is no added benefit for making doctoral study the minimum entry to practice for FNPs because it will not help us catch up to physician training, you are right. It should be obvious but it bears repeating: it is not a medical degree, it is not supposed to become a medical degree, it is not a replacement for a medical degree, it is not a short-cut to becoming a physician equivalent, and it does not now nor ever will train you to be a medical doctor. Again and again, role crossover does not equate to role redundancy. There are many NPs who incorrectly believe they practice medicine, or worse, actually do. This is partially because we have allowed medicine to oversee our advanced practice and have accepted the inappropriate role of physician extender. I am an advocate for our discipline practicing independently to the full scope of our training, but not beyond it. Know what a nurse is and what the role is supposed to entail. See the Guide to the Gray Area

Just as the BSN improves on the ADN in overall knowledge and delivery of RN-level care, the DNP improves upon the MSN with the increased focus on role, systems, theory, and clinical-based research.

When you become a better "thinker," you become a better provider.

Associations That Care About You, Not Your Lawn

2013-02-05T10:30:00.000-05:00

Yep, I live in a traditional town neighborhood. I love the throwback architecture and planning, that I can walk to my clinic, do not need to worry about driving if I have a few cocktails at one of the restaurants, and can get all kinds of unique gifts from small business owners without having to fight traffic at the mall. And yep, I pay a higher dollar per square foot for my house and business properties and owe yearly and monthly association dues for the privilege of living in a southeast replica of The Truman Show. Every once in a while, someone gets complaining about dog messes, unapproved plants, fences painted the wrong color, or some other inane issue that makes the front office puff up their chest and point fingers with threats of "or else." When this happens, my husband starts pulling up the real estate section and yearning for a couple acres of property away from people and their meddling rules. Make that Federation Rules, if we happen to be on a Star Trek kick.

So the point of this mini rant is the question, "what do nursing associations really do for me?"

As an RN student, I did not see the point of membership in professional nurse associations, largely because it was never emphasized in my leadership class. With loans coming due and taking on a new mortgage payment, spending money on membership was not a priority. Shortly after getting my license, however, I did become a member of the American Holistic Nurses Association as it fit with both my new nursing role and practice as an acupuncture and Oriental medicine provider. I also joined Sigma Theta Tau when I was nominated both from my undergraduate and doctoral programs. Other than a free journal and random emails, I was too busy getting my nurse legs to really look at the whats and whys of these organizations or to get involved in any way.

When I started my FNP training, one of the first things we discussed was the importance of joining state and national associations and what they do for us. Advocacy for NPs to practice autonomously to their full scope of training is one of the main activities. Live and distance continuing education applicable to practice is another important aspect, and membership typically provides substantial discounts. On-line member forums to collaborate on practice and legislative issues, find mentors, and cultivate relationships that often start from live networking at conferences is one of my favorite benefits. There are also some discounts or freebies on re/certification, related memberships, journal subscriptions, and other tangible goodies.

Despite these incentives, if I were to join every association that represented my professional interests, I would have to give up a lot of my discretionary time and funds. Here is a sampling of just some of the key ones in nursing:

American Nurses Association ($291 /yr with mandatory state membership in KY)
Kentucky Coalition of Nurse Practitioners and Midwives ($95/year)
National League for Nursing ($115/yr),
American Holistic Nurses Association ($125/year)
International Society of Psychiatric-Mental Health Nurses ($125/yr)
Nurse Organization of Veterans Affairs ($105/yr)
Sigma Theta Tau International Honor Society of Nursing ($104.50 and $109.50/yr for both chapters)

While I have been or would like to be a current member of these organizations, like all good nurses, I have to prioritize. My basis for choosing an association is related to my current role and what I feel I can contribute the most time toward as an active member. I am continually a member of the American Psychiatric Nurses Association ($125/yr) because they represent all psych/mental health nurses, not just NPs. The conferences are well organized and clinically relevant, the member bridge is functional and informative, they really try to involve all members in task forces and outreach representations, and they fund the state organizations to promote involvement at the local level without additional dues. The mission of APNA is educational, rather than political, so the dues are 100% tax deductible. They use social media effectively to promote the profession and increase care quality while reducing stigma of the population we work with. Plus, its an evidenced-based fact that psych nurses have more fun, which is why I have not missed a conference since joining!

I recently decided it was time to join the newly merged and powerful American Association of Nurse Practitioners ($125/yr). Now that the two main NP organizations have agreed to speak with one voice, there will be a stronger, more cohesive representation our collective interests. The AANP is another organization active on social media, they have direct legislative involvement so some of the membership dues fund the push for independent practice, they run a daily RSS feed to keep members current on activities applying to all practice aspects, and they represent all APRNs so those of us who may be loosing a skill here and there can catch-up or acquire new competencies at the annual conference.

Did I mention the AANP decided to have their annual conference for 2013 in Las Vegas? That's right. Vegas, baby. The Venetian better be ready for OUR action!

For those of you going, make sure you live-Tweet using #AANP13 - lets get it trending!

Nurses are the most populous of health providers, yet we have one of the weakest voices and are underrepresented throughout the LPN, RN, and APRN practice levels. Most of us want higher pay or reimbursement, more respect, and the ability to practice to the full scope of our training. Increasing the number of active member nurses from all educational levels is essential for strengthening our position at the legislative table and owning our profession to accomplish these goals.

Join and be active!

The Trouble With Interdisciplinary Studies: Everybody

2013-01-26T11:21:00.000-05:00

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

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

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

Abstract

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

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

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

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

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

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

Proposed Guidelines

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

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

Beyond Nouns: The Role of Language on the Role Itself

2013-01-19T11:10:00.004-05:00

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.

A Better Command Hallucination

2013-01-08T22:21:00.000-05:00

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.

20 Commandments for MentalHealth workers: 20 Commandments for Mental Health workers

2013-01-07T17:12:00.001-05:00

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...

Roles in Healthcare: A Who's Who Guide to the Gray Area

2012-12-15T16:50:00.002-05:00

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.

VA Hiring Process

2012-12-02T13:14:00.000-05:00

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!

Dr. Nurse at Work

2012-11-28T12:26:00.000-05:00

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!

Amazon.com Widgets

Nurse Fight, Revisited.

2012-11-20T11:17:00.001-05:00

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.