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

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.

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!

BarefootNurse on list of 30 BEST NURSING BLOGS OF 2014

BarefootNurse Blog named 1 of 30 Best Nursing Blogs
Nurse Practitioner category


Thank you!

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.

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!

Put one foot in front of the other...

I have to admit that is what I first thought of when the President-elect new theme was unveiled. Then I gave it more thought..Dare to Step Forward...nice. The themes fit very well. Of course all of the themes fit well...these are very smart woman and NURSES!

It was a week a firsts for me. My first trip to Boston. My first time sightseeing in a city by myself and see the path of great Patriots. My first time presenting at NTI. A week of stepping out of my comfort zone and into something bigger. I can hear all the past themes running through my head.

We are once again reminded that we, as individuals not to mention as unified group can do great things. Each one of us. We all matter. We deserve to be happy. And we must rest. Wow...powerful stuff.

In the weeks before I left for Boston, I was struggling with whether or not I still wanted to go and if I had it in me to present at NTI in the API track (step forward). Whether I wanted to travel to a city that had suffered a brutal, cowardly attack (together, stronger, bolder). Whether I wanted to go essentially alone, save my colleagues and friends from my AACN Chapter. I was so wrong...I not only wanted to go, I needed to go (dare to).

I learned so much - not just about clinical practice and being an advanced practice nurse but about myself (act with intention)

There are so many things that left an impression on me. So much that touched me and is pushing me to work harder and to do more (stand tall)

So the big questions is how will you Step Forward this year?

One foot in front of the other

The NTI countdown begins

So we are just days away from undoubtedly the largest gathering of nurses - the AACN's NTI conference in Boston, MA.

I have to admit, I have been slow to get excited for this conference; especially since the bombing occurred. Glued to the TV for days as the events of the attack unfolded, I was shocked and horrified and angry that yet again a senseless tragedy occurred on American soil. Relief poured over me when details emerged and the suspects were caught.

As many of my nursing colleagues have thought about I'm sure, I have prayed for not just the victims but the numerous nurses, paramedics, physicians, and other healthcare providers impacted by this act of terrorism. No doubt we will hear more this week from these frontline providers that worked tireless to save lives.

This is my first time presenting at NTI. Part of me is terrified. But I am starting to feel a tiny bit of excitement build deep within me...I am after all presenting on something I feel very patient about.

Over the past week or so I have given much thought about this trip to Boston...specifically NTI. I was reminded by someone very dear to me that it is a time to recharge my nursing batteries with many strong and powerful nurses. He's right. Nurses are strong and overcome crises and struggles everyday to care for patients and ensure the best possible outcomes. We are passionate and forward moving.

It turns out that Boston is a great place for NTI this year. Nurses and other providers always rise to the occasion and remain strong and resolute. So has Boston.

Yeah, I think I'm ready.

Boston Strong                                 Nurses Strong

Patient safety lessons from Starbuck's

Anyone who knows me, would agree that saying I like coffee is an understatement. In fact, coffee is truly one of my life's pleasures. Right up there with anything chocolate and the beach. A good cup-a-joe, anytime of the day - hot or iced, frappuccino or espresso, I'm guaranteed to love it.

So what does my love of coffee, Starbuck's and healthcare have in common? Probably very little at first glance; besides the fact that coffee is the fuel of healthcare providers and clinicians everywhere...we may be able to learn something from the highly rated java-giants.

A typical shift day for me begins with a trip to the local Starbuck's for my usual special latte for one last jolt of caffeine to get through my unpredictable day. No matter what time I visit, I am always greeted by a friendly voice in the drive-thru that identifies themselves first and says something like "Good morning or welcome, my name is so-and-so, how may I help you today?" WOW! It always impresses me...really. Every day. All the time. No matter the person taking my order. I respond the same...."Good Morning! (It's contagious you know) I'll have...I won't bore you with my special coffee needs" And here's the best part...wait for it.....the friendly barista READs BACK & VERIFIES my ORDER! (RBVO) Ta-Da! Yes, they verify what they heard you say. Amazing. And if it is wrong they correct it on the spot and you get the wrong drink in addition to the corrected order. Now granted, no one is going to die or be injured with the wrong coffee-drink, but that is not the point.

In our clinical practice settings we give and receive orders or diagnostic results or other patient-related communication all the time and it is extremely easy to misinterpret or transcribe them incorrectly. The difference is, we can't take back the wrong treatment, medication or diagnostic result and it can most definitely harm the patient. I give telephones quite frequently and I am surprised at how many times they are not read back & verified. I often ask them to repeat the order back to me or I repeat it myself.

If Starbuck's thinks it is important enough to Read, Back & Verify your Order (RBVO) shouldn't it be important enough to us where the stakes are much higher? Incidentally, those of use that work in the acute care (hospital setting) know that CMS and The Joint Commission already think so...this was a National Patient Safety Goal for many years; it is now part of the Provision of Care Standards and yes a hospital can actually be penalized for not demonstrating evidence that a verbal or telephone order was RBV.

Startbuck's greets their customers with kindness and reads back their orders to maintain a high level of customer service and satisfaction, not because people will die. Clinicians and providers at every level should make reading back and verifying communications a natural part of their practice and a priority for patient safety.

Hard pill to swallow???

For many Americans sweet dreams are not obtainable. They complain of poor sleep everyday - or more appropriately every night. The elderly are much more likely to report sleep problems. Due to a myriad of reasons, most physiologic sleep is altered and they find themselves up at night when they should be getting restorative sleep. For that reason the use of sleep aids has increased...and so have the consequences. Many drugs leave patients with 'hangover' effects impairing judgment and physical mobility long into the daylight hours after taking these prescription sleep aids - especially long-acting formulas. For the elderly this can be especially dangerous leading to increased risk for severe injuries related to falls, mismanagement of medications and other accidents. Some hospitals have reduced the use of such medications in hopes of reducing confusion, falls and other sequelae (especially in the elderly). In the hospital setting, patients often do not recover from untoward events. 

Cascade Iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline. It often results in a poor outcomes for the patient or inability to return to pre-illness level of functioning and is preventable. Many of these events are precipitated by medications - either a new medication, too many medications (polypharmacy) drug-drug interactions, over-sedation, so on and so on...
As for the use of sleep aids, especially in the acute care setting, it cannot be overstated - we must be vigilant and cautious when utilizing these or any medications in the elderly patient. Having an a lower dose option may be helpful, however we should really be considering alternatives rather than adding one more pill to the the medication soup

See the following:
Wall Street Journal: Citing Dangers, FDA Requires Lower Doses for Certain Insomnia Drugs http://online.wsj.com/article/SB10001424127887324081704578233652166139618.html?mod=dist_smartbrief 
National Sleep Foundation: http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia