Wednesday, May 13, 2015

On the shoulders of giants, we can do great things

It is only fitting that I start my next journey during Nurses Week. That on Florence Nightingale's birthday I was in class discussing using research and data to transform nursing practice. That this week that honors and celebrates the amazing work all nurses do, I was stepping out of my comfort zone, going from 'expert' back to a novice of sorts. While many were graduating programs and starting their journey as new clinicians or administrators or educators, I am purchasing books and software and attending immersion week.

Since making the decision to begin this journey I have come up with every reason why I should not pursue this path. I have rationalized every excuse. I have compared this experience with past ones; unfavorably of course. I have almost talked myself out of it...twice. Something I have wanted to do for years, I have almost quite before I have started. Because it will be hard? Because I will be busy (I'm already busy and used to piling on the work!) What is different this time? Is it fear of failure?

In my mind I know how I want to leave my mark on nursing - some of it I am already doing. Some is yet to come; that is part of the journey. This is the next step. I need more tools to accomplish my goals.

As I entered the classroom meeting my classmates for the next 18 months, I realized they were all questioning themselves also. They were also doubting their abilities and wondering "What am I doing here?" But as these past few days have unfolded, we have found out that we bring a variety of skills and experiences with us. We have amazing visions for nursing and what we believe advanced practice nurses can do to improve care for our patients and impact an ailing health care system that is still in need of repair to provide the necessary care for all.

It will be hard. At times we will be tired and frustrated. We will be inspired. We will change practice and do great things. And in December of 2016 we will be Doctors of Nursing Practice.

“How very little can be done under the spirit of fear.” ~Florence Nightingale

Sunday, May 3, 2015

Yes, I'm a nurse! Celebrating Nurses Week

Its that time again! To celebrate nurses and all the amazing things we do! Yes, we do amazing things. I don't usually like to brag about it; in fact what we do, whether you are an LPN, RN, CNS, NP, and administrator or educator it is hard work. We have all been there at the bedside doing things no one else would or want to do. We have cried with patients and families. We have gone home and put our uniforms right into the trash. We have cried in the shower, swearing we could not possibly go back and do the job another day. But we do. Again and again.

I told my husband just yesterday that even when I come home after being screamed at by a desperate family member who is watching her mother with progressing Alzheimer's turn into someone she no longer knows, that I still love my job as a hospitalist. Even when I spend over an hour explaining there are no more options to a patient and her husband, that it is time for hospice and watch the hope fade from their eyes, yes, I still love my job.

I love being a dual-boarded APRN. I love teaching future nurses and APRNs this incredible profession. I love using my voice so that one day my state will be 'green' too!

Photo credits: AANP State Practice Acts and Administrative Rules

There are so many amazing things that nurses can do beyond the bedside: clinical education, quality, health policy, academia, informatics, professional organization, special interest groups, leadership, community health and volunteering - I could go on!

So this week, we take a moment and celebrate all that nurses do for patients, their families and each other. We reflect on where nursing has been and what lies ahead. Nurses are leading the way with inspiring nurses leaders like ANA President Pam Cipriano PhD, RN, NEA-BC, FAAN who was recently selected among Top 25 Women in Healthcare and future and past AACN and AANP Presidents. We reflect back on history to influential nurses like Dorothea Dix who is attributed with creating the first mental health system and Mary Eliza Mahoney the first African-America nurse in the United States. And of course our beloved Florence Nightingale who became an advocate for the poor and infirmed, dedicated to improving the conditions for treating patients and used data to improve care. Our first nurse mentor that we still honor on her birthday.

Remember this week and every moment why we became nurses. Celebrate the good and amazing things we do. We have a lot of work to do but we are strong and compassionate professionals. And our patients deserve the best care we can provide to them.

Thursday, November 20, 2014

Just following orders? Is it okay to say no?

Recently the American Nurses Association (ANA) has publicly supported a Navy nurse that has refused to force-feed Guantanamo Bay detainees that have refused to eat and are on self-imposed hunger strikes.   Each case is reviewed by a senior medical officer and determined if force-feeding is necessary. If ordered, the detainee is strapped in a 5-point restraint system in a chair and the nurse then proceeds to place a nasogastric feeding tube and administers tube feed consisting of Ensure (according to the cited article: Top nursing group backs Navy nurse who wouldn’t force-feed at Guantánamo) The controversy in this case is whether the nurse was wrongly removed from duty for refusing to carry out the force-feedings. The ANA is supporting the nurse and believes that a nurse should not carry out an out that he or she feels is unethical. 

Reading this story I began thinking of patients in the hospital setting. How often do these type of situations occur? How often are nurses faced with situations that are dancing on the edge of being ethical? Whether it is placing a patient in restraints or feeding a patient that has already refused via an advanced directive or giving a medication for an unapproved use or performing CPR on a DNR patient; how many circumstances come close to being questionable? Maybe the actions are not as violent as restraining a patient to slip a tube through their nose into their gut so that liquid food may be given to them like a drug; however placing wrist or hand restraints on a frightened elderly woman with advanced dementia who keeps shaking the side rails of her bed could be similar.

The point is there are times when nurses can say "No, I cannot do this or that" for ethical reasons. Maybe the more appropriate question is how many times do nurses speak up or question the order? Is this grounds for dismissal or is there any recourse? 

I think that a fundamental question needs to be asked...will these actions either way harm the patient? If withholding care will result in injury or death the nurse has a duty and obligation to ensure the patient is safe and receives the care they need. However if the nurse is being asked to do something that could result in harm that would need to be reported that the order is not being carried out and why to the supervisor. Remember nursing practice should be guided by the ethical principles of nonmaleficence and beneficence - to "do no harm" and to be compassionate and "desire to do good." 

The story of the nurse and detainee is troubling because it makes me wonder the principle of autonomy is in this situation. Has that right been forfeited because he is a prisoner so the other principles are also null and void as well? As a nurse this is confusing and somewhat undermines are core values that guide are practice. I will continue to follow this story as the outcome is important to nurses as clinicians and decision-makers everywhere.

ANA Short Definitions of Ethical Principles and Theories 

Read more here:

Saturday, November 8, 2014

Can't we all get along? Making true collaboration work

I recently read a Blog posted on the Society of Hospital Medicine regarding relationships between physicians and non-physician providers, namely nurse practitioners. It was interesting as I could not agree more with the points in the blog as barriers to successful hospitalist or other collaborative care models. The author summarized well what I believe are key issues that can create toxic environments for nurse practitioners and physician assistants and ultimately affect patient care. I truly believe that there is a place for all providers and that are many successful   practices both in and out of the hospital setting in which physicians and nurse practitioners work along side of each other to delivery high-quality and cost-effective care.

The big winner in this is the patient. But so are all the providers if we can all get over ourselves and truly work as colleagues, together!

Monday, May 19, 2014

Why we are here

We have this thing, my husband and I. I protest that life is hectic and timing is impossible and that I am not 'feeling' that I am ready for the trip from the east coast. He talks me up and tells me how I will feel once the conference starts and I meet up with nurses from all over the country and begin networking. But my presentation isn't quite perfect. It will be, he coaxes. I have so much to do. You need to recharge your professional batteries he reminds me.

It takes little time to feel the energy of AACN's NTI. From the flight attendants giving a 'shout out' to the nurses on the plane, or the LED sign welcoming AACN Nurses to Denver or walking into the conference center and picking up your materials working out your schedules for the week.

It is day one of NTI2014.

On the phone he reminds me why am I here. And I have to admit he was right. Recharge and renew.

Why are you here? What will you learn? What will you take away?

Today we Step Forward in Denver together for NTI 2014.

Monday, March 24, 2014

Not a physician, not a nurse...what?

APRN Advanced Practice Registered Nurse
ACNPC Acute Care Nurse Practitioner-Certified
CCNS Certified Clinical Nurse Specialist
CEN Certified Emergency Nurse 
Are you following the pattern?  I could go on...
These are examples of just some of the many certifications for nurses in specialized areas of care. And please excuse the underlying snarky tone as I am not feeling so "happy" after this past Certified Nurse Day.

Disclaimer: I am very proud to be a nurse and promote clinical excellence through certification - this is not a swipe at certification  or certified nurses!

So let me set the scene. I primarily work as an ACNP specifically as a Hospitalist and part time as a CNS. I also work as nursing faculty at a local university. During this past certified nurses day a unit clerk asked in general to anyone in earshot is it CNA day? (meaning certified nursing assistants day)  I spoke up and said no, it's certified nurses day - a day to recognize nurses that have obtained specialty certification, I gave him examples of my certifications and the clerk pointed to a list on a wall and said I was not on the list and finished with "well you're a doctor". "Umm, well actually I'm not. I did not go to medical school. Well you're not a nurse anymore," was the reply. Wow! I was not prepared for that. As it turned out this person was not alone in this perception.

Interestingly, I am no longer considered part of the nursing staff but not "part" of the medical staff. I have to abide by the medical staff by laws. I am not allowed to eat meals in the medical staff lounge or get free meals in the cafeteria. I am part of the "Allied Health Staff" which includes NPs, PAs, CNRAs,  & CMWs; we all pay dues. But we have no leadership. No meetings. No organization. No lounge. And we are not welcome at either nursing meetings or medical staff meetings.

So if I'm not physician and not a nurse, what am I? I know that I am not the only nurse practitioner or clinical nurse specialist that has been experienced something similar? Please don't get me wrong, I have a great working relationship with most of the medical and nursing staff members and I love my both of APRN positions. And most of all I LOVE being a nurse.

I continue to educate the staff on my evolving roles (I started out as a staff nurse and worked my way through school and various positions).  And to either our determent or benefit, I think we [nurses] will continue to educate others on what we do at every level as we continue to diversify our roles in healthcare.

I know I am not a physician. I do not pretend to be. I am an acute care NURSE practitioner and clinical NURSE specialist and I believe that I offer my patients something my physician counterparts do not. I am proud of my roots and my education and experience...and most of all my certifications. All of them!