Wednesday, December 29, 2010

2010 End of Year Reflections & A Look Ahead

I believe it is important to look back at the challenges and successes of the outgoing year to set goals and plan for the new year. I partly attribute this to my DNP program as we have been required to reflect on each semester and completed year of the program.

To say that health care was a hot topic in 2010 certainly is an understatement. We witnessed the passing of historic legislation that will help shape how care will be delivered in the years to come. I am hopeful to see better coordinated and more efficient care with an emphasis on preventative services and screenings. I am hopeful that all of the members of the multidisciplinary team refine and hone their collaborative skills so that we may better communicate and work together to provide the best possible care to our patients.

2010 saw nurse practitioners thrust into the spotlight as one possible solution for the influx of newly insured patients coming into the system. The discussions have been interesting to follow and it is apparent that many still have a poor understanding of the NP role. The IOM provided the current state of the profession and lays the framework to a road of barrier-free NP practice. I hope that we are finally able to move past the turf battles and patronization of the NP role to focus on the multidimensional aspects of patient care.

On a personal note, my DNP group and I saw our systematic review protocol accepted and published on the Joanna Briggs Institute's website. Looking ahead, I will graduate with my DNP in 2011 and will continue to incorporate those new layers of knowledge into my daily practice. Unfortunately, I still have a significant amount of work to complete before May but I look forward to soon finishing up our systematic review/meta-analysis and the implementation/evaluation of group medical visits in actual practice for patients with diabetes.

I am so happy that more and more people are finding and reading this blog. When I started the blog 3 years ago, I didn't know where I would go with it. Now 3 years later, I believe that I accomplished in part of what I set out to do: advocate for the NP role, correct many of the published inaccuracies and offer a NP voice on healthcare issues. I will continue doing this in 2011 and look forward to the successes and challenges that it brings.

Thank you for reading & Happy New Year!

Sunday, December 5, 2010

NP Residency

The healthcare system of today is so complex yet so dysfunctional that I believe the time has come to educate and train the NP providers of tomorrow in a way that is reflective of that complexity. We have done a good job up to this point but need to bring that to the next level.

Residency.

I'm not necessarily referring to the typical residency training of physicians which takes place in hospitals but a residency-type of program in an out-patient setting (ironic that we use the term residency). We realize that healthcare is not exclusively delivered in hospitals. It takes place in independent providers offices, in community health centers, in mobile health vans, and in retail settings. It takes place in people's homes and places of employment. It takes place in many of the health decisions that we make on a daily basis. I found this NP residency program in Connecticut that claims to be the first NP residency in the US. The programs admits 4 NPs each year and trains them to handle scenarios encountered in Federally Qualified Health Centers (FQHCs). The residency lasts 1 year and appears to be a wonderfully structured program and setting.

So why are NP schools still relying on the preceptor model to train NP students? It comes down to money. The majority of medical residency's are funded by Medicare & Medicaid (I don't purport to know the full details of funding but do know that it is largely our tax money supporting physician residencies). For what I'm sure is a myriad of reasons, NP training just wasn't appropriated. Enter the Patient Protection and Affordable Care Act. Section 5316 authorizes a demonstration project to replicate the NP Residency Model. This at least is a start.

There is no doubt that the residency model in proven and tested to train professionals in the real world. In fact, a recent article in the Las Vegas Review Journal discussed residencies for new RNs working in Vegas-area hospitals.

Patient's haven't necessarily become more complex, its just that our understanding of the multidimensional aspect of them has. There are nuances in physiology, culture, health beliefs/disparities and socioeconomic standing. Taking care of disease processes is relatively easy - taking care of an individual is the real challenge. Not to mention the importance of collaborating, communicating and interacting with all the members of the multidisciplinary care team. All of our training needs to encompass and embrace these factors so that we may provide the best culturally competent and evidence based care possible to our patients. Perhaps residencies will provide us with guided real world training to take all of this complexity into account. It certainly will be interesting to follow.

Thursday, December 2, 2010

Guest Post: North Carolina Nurse Practitioner Fights for Change

North Carolina Nurse Practitioner Fights for Change

Pediatric nurse practitioner Sandy Tripp has decided to do something about the childhood obesity crisis. She is reaching out to health care providers, public school administrators, and politicians to try and initiate change in Beulaville, North Carolina.

As part of her efforts, she has been giving presentations in local schools. Her slide show features pictures of acanthosis, clogged arteries, fatty liver disease, and Blount’s Disease. She tries to educate students and staff about nutrition and the importance of exercise.

She is also trying to persuade schools to offer their students fewer hot dogs and French fries and more broccoli and carrots. She is working to get a la cart offerings and vending machines removed from schools completely. She’s even trying to recruit Jamie Oliver, the international go-to guy for changing menus in schools!

Tripp already has one politician on board, North Carolina House Representative Stephen LaRoque, a Republican from Lenoir County. He says, “If we can tackle the nutrition standards in the schools, it will benefit the entire community … the things [Sandy] showed me in her presentation were pretty powerful in terms of what our kids were eating at schools.”

Tripp has been a Kinston Pediatrics nurse practitioner for 14 years, and a nurse for 24 years. She is now working toward her doctorate in nursing at Duke University. You can follow Sandy on Twitter. I’m sure she would welcome your input and advice. We are all in this together.


Robin Merrill is a freelance writer who writes for Wisconsin Dells Hotels.

Wednesday, November 24, 2010

Guest Post: Why You Should Consider Becoming a Certified Registered Nurse Anesthetist

Why You Should Consider Becoming a Certified Registered Nurse Anesthetist

Many registered nurses can tell you about the stress that comes with a profession where being overworked and under appreciated comes with the job. However, there is one nursing specialty where nurses report high levels of satisfaction with their jobs, their patients, and their salaries- Nurse Anesthesia. A Certified Registered Nurse Anesthetist is a registered nurse who has completed his or her Masters of Science in Nursing degree specializing in anesthesia. Today, between sixty and seventy percent of anesthetics are given by Certified Registered Nurse Anesthetists, according to the American Association of Nurse Anesthetists. Thanks to the high skill level required by the position, Certified Registered Nurse Anesthetists are highly independent, very well paid, and in demand all over the country.

Certified Registered Nurse Anesthetists say that the field requires a lot of upfront commitment to receive the training required of nurses in this field. However, once you have completed your training, there are endless job opportunities, and the job satisfaction
levels among nurses is very high.

CRNA’s practice anywhere where anesthesia is administered, such as operating rooms, obstetrical delivery rooms, surgery centers, and in the offices of private practice physicians such as dentists, podiatrists, ophthalmologists, plastic surgeons, and other physicians. In many states, a CRNA can administer anesthesia without the supervision of a physician, which means that a CRNA does nearly the same job as an anesthesiologist.

CRNA’s who work in the field say that the bond formed with patients is a huge reward, and knowing that they are able to relieve a patient’s pain helps nurses to feel a real sense of satisfaction. Unlike other nursing positions where you are often running from patient
to patient, working as a CRNA means that you will focus exclusively on one patient at a time, not only providing anesthesia but comforting injured or ill patients.

More so than other nursing positions, working as a CRNA can offer flexible hours. Many who work as Certified Registered Nurse Anesthetists have a full time position but also accept on-call positions at other facilities. The demand for Nurse Anesthetists is so
high that these positions are easy to find.

As with most nursing jobs, the need for Nurse Anesthetists in rural areas is extraordinarily high. In many rural areas, a Nurse Anesthetist is the only option for anesthesia provision in the area. Working in these areas takes a high level of dedication, but the payoff is equally large.

Becoming a CRNA does take a significant amount of training, but there are more than one hundred programs in the US that you can attend. In general, you will need to have a bachelor’s degree and at least one year of nursing experience in an acute care setting. Most programs last between two and three years and include clinical training. Upon completion, a CRNA must pass a national certification exam. When you begin working, you can expect to make more than $100,000 annually, and the demand for CRNA’s is so
high that you can work virtually anywhere you want to.

This was contributed by Sandra Stevens. Sandra writes about CNA Training and
Certification on her blog over at CNA Training Help.

Wednesday, November 17, 2010

Social Media

On this unofficial Facebook "Unfriend Day" I thought I'd take brief stock of the different social networking platforms geared to nurse practitioners. There are a plethora of sites out there with varying degrees of engagement & activity. This list below is by no means meant to be exhaustive, it is just a sample of what I have come across:

These sites are primarily geared to the NP with the hopes of networking with fellow NPs. I have personally been a part of every one of these sites - more so as a lurker - to see what my NP colleagues are talking about and discussing. It's rare that I feel compelled enough to comment about an issue (well, I take that back - that's what my blog is for!) There are the regular participants and the occasional flamers.

I generally come away disappointed with the lack of participation and relatively low engagement. (The only way that I can quantify the number of "members" is by looking at the largest NP group on FaceBook that has a paltry 2100 or so - not to mention that the majority of postings is from recruiters trying to fill positions or someone trying to promote or sell something health related). Is it because NPs are too busy to spend time posting on forums? Is it lack of awareness of the various sites? Are there just too many sites to track and be active on?

Is it all of the above?

It's obvious that social (and professional) networking sites aren't going anywhere anytime soon (FaceBook touts 500 million uses). However, there needs to be increased participation and discussion for them to be meaningful before people give up on them altogether - at least from a professional standpoint.

I'd love to hear your thoughts on this. Do you participate in these sites? Were you aware of the varied social networking landscape? Do you have any ideas to increase user engagement and if so, which site(s) would you choose?

(By the way, of my FaceBook friends, it looks like I had one person unfriend me. I'm not sure who it was, but then again, I guess I'm not missing out on much if I can't figure out who it was!)

Thursday, November 11, 2010

Guest Post: The Pros and Cons of Legal Nurse Consulting

The Pros and Cons of Legal Nurse Consulting

I’ve spent years pursuing different avenues in the health care industry. I spent my high school years studying to become a CAN, I was at one point a EMT, and I eventually turned to alternative practices like massage therapy, herbs and general fitness and nutrition. Not long ago, though, I heard a term that was relatively new to me – legal nurse consulting.
My aunt told me about her pursuit of a legal nurse consulting certification. Her goal was to pass the certification exam and open her own business, partnering with lawyers around the country to help them understand medical charts and the medical profession as a whole.

Sounds great, right?
I’m wondering if it really is.

I urge anyone who is considering legal nurse consulting to consider the pros and cons. While it is certainly an admiral and profitable career path, it may limit your future choices.

First of all, legal nurse consulting is not a get-rich-quick solution to your problems. If you feel overworked and underpaid, odds are you may feel the same way while working with lawyers – especially when it comes time to chase down your payments.
Another thing to consider is the fact that you are basically turning your back on the industry you work in. Nurses and doctors do make mistakes, but if you label yourself as someone willing to point out those mistakes (in practice or in paperwork), employers may be hesitant to hire you as a nurse in the future.

Legal nurse consulting isn’t an easy job. It’s for organized, professional individuals who have time and who are dedicated to helping those who have been injured by the medical profession find vindication. The job can be cold and lonely and – honestly – simply isn’t for everyone.

Take some time to think about your chosen career path and don’t jump to legal nurse consulting simply because of the claims that you will make $150 per hour for your work. The reality is that you’re going to work incredibly hard for your money – just as hard or harder as you would work on the hospital floor. Make sure you’re making the right choice for you.

Deborah Dera is a full-time writer specializing in personal finance, credit repair, online degrees, health, fitness, and nutrition. She is the founder of Write on the Edge and offers unique content solutions to business owners who want to strengthen their online brands.

Wednesday, November 10, 2010

Guest Post: CareFirst Insurer Expands Role of Nurse Practitioners, IOM Recommends Same

CareFirst Insurer Expands Role of Nurse Practitioners, IOM Recommends Same


Last week, CareFirst BlueCross BlueShield, an insurer in Baltimore, Maryland, announced that it would enable nurse practitioners to serve as primary-care providers in Maryland, Northern Virginia, and the D.C. area. In response to both the physician shortage, which is expected to take a turn for the worse in the coming years, and to the health care reform law, which will produce an huge spike in insured patients by 2014, CareFirst made the decision to grant more authority to nurse practitioners.

As quoted in a recent FierceHealthCare article, CareFirst Senior Vice President for Networks Management Bruce Edwards noted:


"With these developments ahead and an existing need to expand access to these services, allowing nurse practitioners to practice independently as primary-care providers is a logical move to serve our members better."


The CareFirst decision to recognize nurse practitioners as primary-care providers, meaning patients will no longer have to see physicians before receiving care, was made in tandem with Maryland Coalition of Nurse Practitioners (MCNP) and the Nurse Practitioner Association of Maryland.

In related news, the Institute of Medicine released a report earlier this month, entitled "The Future of Nursing: Leading Change, Advancing Health", which recommended the expansion of nurses' roles as well. The report urged both federal and state governments to ease regulations that impede nurses to practice to the full extent of their educational capabilities.

Although many physicians were critical of the report, claiming that a physician's education and field experience cannot be equated to that of nurses', the IOM panel argued that its recommendations were not meant to be divisive.


Reporting on the IOM's recommendations, an American Medical News article quoted Dr. Donna Shalala, who headed the panel that collaborated on the report. Shalala asserted that "This is not about one profession substituting for another...This is about a collaborative effort among those who represent medicine in this country to make it better and to improve outcomes for every patient and every American family."

Another key component of the IOM's report is expanding nursing education so that nurses will be able to meet the demand of newly insured patients with a knowledgeable skill set. It went on to propose that nursing education be better integrated with physician training such that nurses will be better prepared for more collaborative roles as care providers. The report furthermore underscored the need for encouraging nurses to pursue doctoral degrees.


This guest post is contributed by Kitty Holman, who writes on the topics of nursing schools. She welcomes your comments at her email Id: kitty.holman20@gmail.com.

Friday, November 5, 2010

DNP Series: Onward and Upward

Just wanted to update anyone following me as I am finishing up the DNP (graduation is May 2011!) The work is intense. Trying to juggle school, work and family life, is a challenge. However I know that it is already worth it. My perspective on my practice has changed for the better and I now incorporate evidence-based practice and culturally competent care in all of my interactions.

My group of four are knee deep into the data analysis/synthesis of our systematic review. The statistical portion is mind numbing after looking at all of these clinical trials and trying to synthesize them into something that will make sense. We are also incorporating non randomized controlled trials (RCTs) into our write up which brings additional challenges in answering our clinical question (focused on diabetes and group medical visits). We have been busy reading and re-reading clinical studies, crunching numbers, e-mailing study authors (many who don't actually write back to you), making forest plots, consulting with our clinical agency for getting the project off the ground, completing IRB certification modules, and many many conference calls. Anyone who thinks that the DNP lacks the rigor of a PhD or another other doctorate, I can tell you that it is just not true. The goal of this degree is translating evidence into practice, implementation science and stakeholder engagement, to name just a few of the highlights.

We are hoping to complete the write up for our systematic review by the end of the year. Our protocol was recently approved and registered by the Joanna Briggs Institute which is a small victory. We continue on and are working hard to finish the systematic review this semester which will leave next semester to focus on our individual projects and to monitor the status of our clinical projects.

As I am submerged in this, healthcare reform and discontent are at a high. Patients have many unanswered questions, some physicians are attacking anyone and everyone that tries to disrupt the status quo and many clinicians continue their daily work of trying to manage too many patients in not enough time with increasingly complex conditions. I still believe that we are getting closer every day to a paradigm shift in health-care where we recognize that all members of the health care team play an integral and collaborative role and we must partner with patients and their families to deliver care that is truly patient-centered (and not just use that as the latest buzzword).

Wednesday, October 27, 2010

Guest Post: 5 Ways to Make Your Life as a Nurse Easier

5 Ways to Make Your Life as a Nurse Easier

It’s a profession that most people find daunting and challenging, which is why they choose to give it a miss. Not everyone is cut out to be a nurse because it involves long hours, grueling work, and a fair amount of emotional stress. But on the plus side, it’s a calling that warms your heart and makes you a better person. You see so much suffering and pain that you’re grateful for the healthy life that you and your family have, and you develop your kinder side because of your interaction with your patients. Even so, it’s a stressful job, and if you don’t make the effort to make your life easier, you’re likely to burn out. So here they are, a few tips on how you can make your life as a nurse easier and more relaxing:

· Leave the office behind when you go home: As a nurse, you see so much going on in hospitals and in the lives of patients. You’re busy running around tending to them and taking orders from and following the instructions given to you by doctors and administrators. In short, your life in the hospital as a nurse is far removed from normalcy. But when you turn in your uniform for street clothes at the end of the day, you must divest your job and climb into your own skin. Only then can you relax and refresh yourself for the new day to come.

· Learn to draw the line at the right spot when it comes to your patients: Most nurses struggle to maintain the right distance from their patients, especially those who stay for long periods of time in healthcare centers and hospitals. They become emotionally involved in their lives and take on their mental pain and suffering too. This makes each day an emotional rollercoaster for them, and by the time they’re through for the day, they’re drained both physically and mentally. In order to relax, you must learn to draw the line between empathy and deep involvement with your patients.

· Do your job wholeheartedly: Unless you love nursing with all your heart, you’re likely to end up resenting parts or the whole of your job and doing it only because you need the money. This makes it harder for you come into work every day and summon up the enthusiasm you need to do a good job. So if you don’t love and enjoy nursing, it’s time to look for a new profession.

· Be aware of what you’re getting into when you become ambitious: If you decide to pursue a graduate degree and advance your career, you must be aware that with the promotion and raise, you’re also going to be getting additional responsibility. This may mean more demanding work, longer hours, and much more stress. So unless you’re prepared for all this, it’s best not to look for professional advancement.

· Spend time with your family and friends: And finally, it’s imperative that you spend enough time with loved ones. Family and friends make you feel loved and rejuvenate your tired and sometimes disillusioned soul and make it easier for you to go back to the hospital and deal with the sick and the infirm on a day-to-day basis.

By-line:

This guest post is contributed by Maryanne Osberg, who writes on the topic of RN to MSN Online Programs . She can be reached at mary.anne579(AT)gmail(DOT)com.

Wednesday, October 6, 2010

The IOM Report: The Future of Nursing

The big news this week in the world of nurse practitioners and health care was the release of the Institute of Medicine's (IOM) Report, "The Future of Nursing: Leading Change, Advancing Health." It's a logical read and echos what NPs, patients, and some other professions have been saying for years: let NPs do the work they are already educated and trained to do without arbitrary and archaic state and/or federal barriers. This is not a "scope of practice" issue, it is allowing us to practice to the full extent of our education.

For example, when I reflect back on my NP education, there was no course entitled, "How to sort of take care of chronic conditions but when you get in over your head, make sure you have your collaborating physician's number on speed dial." We were taught to function as primary care providers that included acquiring the knowledge base to evaluate, diagnose and treat our patients and their conditions using the skill sets and tools needed to care for our patients. NPs don't practice witchcraft or voo-do - we are providing high-quality, cost-effective and culturally congruent care.

Predictably, organized medicine is playing the "patient safety" and "quality of care" card. Bad outcomes occur when there are breakdowns in communication and from care that is uncoordinated - not usually because the clinician is incompetent.

The bottom line is (at least in NY where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can't legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen and I promise pigs wouldn't start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and make the tough decisions that will enable greater access to care.

Monday, October 4, 2010

Funny and Sad

I recently ordered an ECG along with routine blood work for a patient who needed a pre-op workup. I received the ECG results today with the interpretation by the cardiologist. I thought it was funny and sad that he felt the need to cross out the default "Dr." preceding my name on the report. Of course, I am not a "doctor" as in physician, nor do I ever purport to be. I will soon have my doctorate in nursing practice (7 months to go!) but that will have no impact on how I interact with my patients or colleagues. I wish reports, and even prescription bottles for that matter, correctly referred to the credentials of the ordering clinician. Our patients should be able to identify their clinician without further confusion. But until then, I guess providers will self enforce who gets to be called "Dr." I can't help but to imagine a rogue pharmacist crossing out the "Dr." on every prescription label for prescriptions that are written by non-physicians. Surely, we have better things to do with our limited time and resources....right?

Thursday, September 16, 2010

Precepting Students

I've precepted many NP students during the years and usually had pretty rewarding experiences. (There was that one student that just didn't get it...I guess I can save that one and how I handled it for another post!) I like to think of precepting as a two-way street: my student is getting the hands on experience of patient care with guidance while I can further hone my precepting skills. Precepting a student is not simply telling them how to treat a condition or how to prescribe a medication. It is helping that student critically think to formulate differential diagnoses and treatment plans. Precepting can often be overlooked as part of the education and training of health professionals yet it is a critical part of acquiring the necessary skill set of patient care.

I think back to my experiences as a student and have found supportive clinicians that helped to shape me into the clinician I am today (I was precepted by a Doctor of Osteopathic Medicine, an OB/GYN, a family nurse practitioner and a emergency department physician). I wish I had more time with a nurse practitioner preceptor but one simply wasn't available to me. I believe that made it harder to find my identity as a NP since I had to constantly bring in the nursing perspective melded with the medical piece. However, that enabled me to create that identity from scratch and make it my own.

Now I am curious. As a clinician (MD, NP, PA, etc) do you precept students? What do you look for in a preceptee? Do you feel that it is your professional responsibility to help train the next generation of providers? As a student, what qualities do you look for in a preceptor? What were some examples of good or bad experiences?

I'd love to hear your feedback.

Thursday, September 2, 2010

The ER Study

"Hey, How are you doing today?"

This is supposedly the way that many nurse practitioners (and physician assistants) introduce ourselves to patients according to Gary Larkin, M.D. who recently conducted a study published in the American Journal of Bioethics entitled, "Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: Does the assumption of assent have an empirical basis?"

This study is a thinly veiled turf attack on both nurse practitioners and physician assistants. From the beginning of the article, the authors write:

"...physician substitution has often been covert in the emergency department (ED), confusing patients as to provider identity and appropriate scope of practice. This confusion may be heightened as junior doctors and nonphysician clinicians alike wear the same long white coats and Littmann stethoscopes as experienced physicians."

I retrieved the article myself to understand their methodologies and conclusions. Predictably, they found that their sample (n=507) of already waiting patients in area Emergency Departments would prefer to see a physician for their ER condition rather than NPs, PAs or medical residents. (They also sampled PAs & medical residents (n=212 & n=251 respectively) who also showed preference to an attending ER physician for moderate to complex conditions). The authors are under the assumption that all NPs and PAs are out to dupe patients into thinking we are "real doctors" without ever introducing ourselves or stating our credentials. They even go so far as to suggest that informed consent should be obtained from patients whenever a non-physician provider is caring for a patient. (Here is a post by a fellow blogger who is a PA and he points out some very well stated other methodological issues about the study.)

Do we really need a study like this? Does this add anything to the body of evidence for improving care? Perhaps we should be asking questions like, "Why are you using the emergency room for minor cold symptoms?" This study is from the same author who in 2001 surveyed medical residents with similar questions about care from NPs, PAs & medical residents and found similar results. In addition, approximately 1/3 of those residents viewed NPs & PAs as professional threats.

I clearly introduce myself literally dozens of times throughout my day and my patients still refer to me as "doctor" - even after I correct them each time. (Perhaps its my neatly pressed long white coat and fancy gray Littmann Cardiology II stethoscope?) I am addressing my patients health care needs, working with them on treatment plans/solutions and that is perhaps who they identify as a "doctor."

There are plenty of folks who need care from all members of the health team. I can't help but wonder what drives this physician-centric mentality.

And this comes out on the heels of a new study by the RAND Corporation that concludes 13.7% of all ED visits can be treated at a retail clinic. (As a reminder, most retail clinics are staffed exclusively by NPs and/or PAs). In addition, the two major retail clinic chains claim to have seen millions of patients since their inception. While quite unscientific, this fact seems to suggest that some patients actually chose to have care provided by NPs/PAs.

NPs & PAs have different education and skill sets than physicians (this is perhaps the only point that everyone can agree upon). If you as a patient are seeing an NP or PA in a health facility, you can assume that the provider in duly licensed, credentialed and/or board certified in their respective profession. These are not providers in training. They have met certain educational and training requirements and are ultimately held responsible for the care rendered. Why must it always be one or the other mentality? To put it simply, we are all similar but different. We all must coexist in order to deal with the many complexities and intricacies of the dysfunctional health care system. We spend far too much time focusing on professional shortcomings rather than strengths. Maybe if we did this, we wouldn't have millions of patients with such poorly controlled diabetes, hypertension, etc. It's easy to place blame on the patient, it's time for providers to take accountability, responsibility and start working together as a system rather than the mess we have today.

Tuesday, August 24, 2010

Egg Safety and the Egg Recall

We find ourselves in the midst of a massive egg recall. Current estimates say that 500 million eggs have been recalled. The CDC is the place to go for the latest information on these recalled eggs and salmonella.

Foodsafety.gov also is a great resource with updated information. Here is a link to the FDA site on how to identify if you are in possession of any of the recalled eggs.

Food safety surveillance must be vigilant and people deserve to have access to reports, citations, and above all the ability to consume food that is safe from contamination. Who is to blame in all of this - governmental red tape, the food industry, the distributors, the FDA for lack of oversight? Politico has an article that suggests a slow moving Senate may be the culprit.

Will this latest recall affect how/where you purchase food?

Thursday, August 19, 2010

More on Patient Centered Care & Homes

Here is an op-ed piece that I wrote some time ago that unfortunately didn't get published. However, this blog is a great place to put it!

Patient-Centered Health Care

Patient centered. To the average health care consumer, the notion that they themselves are the main focus of the care received is a no-brainer. However, the reality that exists in health care today is quite the opposite. More often, interacting with the current health care system is often a deeply dissatisfying and frightening experience, fraught with errors, miscommunication and waste. As a community-based nurse practitioner for 10 years, I practice within the fragmented confines of an inefficient and costly system and know how this current system is too often harming people. Fundamental reform is needed. According to the Institute of Medicine, care is often delivered in silos producing poorly coordinated and overly complex care. The current healthcare system is fraught with opacity and is unnavigable for most of us. For example, oftentimes patients don’t know how much a procedure or office visit will cost.


I imagine a near Utopian health care system where a patient can complete registration forms just once, have their complete health record accessed from virtually any Internet connection, communicate with their providers at their convenience and have their care coordinated by a team of professionals whose main objective is to improve health outcomes, decrease costs and deliver patient-centric, evidence- based health care. Such a system is currently undergoing pilot studies known as the Medical Homes Demonstration Project.

The time and cost savings potential of these Homes are virtually limitless. Technology will play a major role within the Homes, allowing for health systems to engage in rapid learning, so common in other industries. For example, imagine visiting your health care home, and then reviewing your laboratory results online the next day while your health care provider explains the meaning of the results by phone or by instant message. Text message alerts can be used to remind you when it is time to take your medications or get a colonoscopy. More importantly, practices will be better able to track the outcomes of care they are providing and consumers will be easily able to compare health care homes for quality.

Patients who are members of a patient centered home will take far more responsibility for the direction of their care. Gone will be the days of asking for the latest and most expensive and largely unproven medication because of their fancy commercials. Patients will have the opportunity to hear and evaluate the evidence for their condition and will make informed decisions, just as when you go to an accountant or lawyer, who provide options and a cost-benefit analysis.

Continuity of care will also be a hallmark of the Home. Your team of providers will know you and your medical history. Visits to specialists, dentists, and other health care professionals will be coordinated and integrated into a single repository of your health data. Along with the team, you will make the important health decisions.

The Medical Homes Demonstration Project is an exciting model of team-based, coordinated, high-quality and cost-efficient care. While the initiatives in the model aren’t new, the collective sum is unlike anything we have today. We a model that is patient-centered and where the exchange of data is efficient, coordinated and examined so the optimal care is delivered for that individual, time and place. We also need to ensure that the foundations of the homes are sound. That is, the physicians and nurse practitioners guiding the care must be available to care for the many patients who will utilize this model. Finally, for true health reform all the stakeholders – patients, clinicians, lawmakers and insurers must be willing to work together. Every American should have a such a home.

Wednesday, August 18, 2010

Team Work

The NY Times recently wrote about pharmacists expanding roles on the health care team. This is one example of a concept who's time has come that has the potential to make a significant positive impact on health care outcomes. Conceptually, this makes sense since as we all know, health care doesn't just take place in hospitals or in private offices. Patients are constantly making choices about their health in their everyday actions such as choosing what and when to eat. Pharmacies are located in the communities where people live and work and having access to a health care coach or guide in the form of a pharmacist (or other professional) gives people the opportunity to discuss their options and perhaps make better every day health decisions.

Community health nurses have long known this as they visit patients in their homes and assess their living environment and offer recommendations that could eliminate safety hazards for partially paralyzed patients following a stroke for example. They have also spent countless hours teaching patients about their medications including how, when and where to take them. One of the biggest obstacles for home care nurses is the limited insurance coverage and restrictions that dictates how many visits a patient would receive (if any). Now the concept is taken to the next level by getting members of the health care team out into the community. This has been done for years by federally funded community health centers but now is gaining traction in the mainstream.

I believe the more access people have to health care providers, the better we can focus on disease management and wellness as long as patients are engaged in their own health. Perhaps constant reminders, visibility of providers and access could drive individuals to play a greater role in the provision of health care. However, the costs of this increased access remains unknown. Common sense would dictate that the greater access people have would increase utilization of services thus increasing costs. Maybe this is true under our current fee-for-service payment structure but we know that this structure is flawed. As new payment models are introduced that incentivize wellness, active patient engagement and a focus on evidence-based outcomes, we can finally move beyond the mindset that health care only takes place during a visit with a provider.

Finally, remember there is no "i" in team. A multidisciplinary approach is needed to have the right subject matter experts teaching, educating, treating and caring for patients. That means no "captain of the ship" or "ruler of the roost" - just a team of professionals partnering with patients to meet their health needs.

Tuesday, August 3, 2010

Dysfunction

Nope, not a post on the dysfunction of the health care system, just on the wonderful New York State politics at play. Today, accidental governor Patterson vetoed a bill that had passed both NYS Senate and Assembly that would have allowed NPs to sign DNR orders.

There were apparently some language/technical issues with the Bill. However, the most disturbing piece here is the Governors complete and total lack of understanding what NPs do (no real surprise there). He was quoted,

"Finally, I am not convinced that this is an appropriate function to be carried out by nurse practitioners. Decisions of life and death should be made by physicians, not nurse practitioners.”

Not convinced?!? Didn't you just sign a bill that eliminated collaborative agreements between physicians and nurse midwives? (That would be life). Ever hear of hospice care? (That would be death). I wonder if he understands exactly who is spending time with hospice patients in their final days of life. It is the team of professionals largely comprised of nurses, NPs, and physicians. (For a wonderful read about hospice care, see this piece written by an NP colleague.) In times when some Governors are blazing the trail to reduce barriers to NP practice (think PA Governor Ed Rendell), we are literally stuck here in NY to maintain the status quo, all the while when they are crying that there aren't enough providers to care for patients.

Of course, I am waiting for organized medicine to claim victory on this one touting how New Yorkers will somehow be "safer" because NPs won't be able to sign the DNR (I predict they will paint a ridiculous picture where NPs would sign DNRs left and right and slowly kill off New Yorkers one by one - maybe thats one way to keep health care costs down!).

Dysfunction. Election day can not come soon enough so that New Yorkers will hold elected officials accountable for their incompetence and narrow-mindedness. Oh, and hopefully we'll have a budget passed by then too (the one that was due on April 1st - April Fool's Day - go figure).

Monday, July 19, 2010

DNP Series: The Search


I recently wrote about my pursuit of the DNP and my rationale for it. As promised, here is the first brief installment of posts chronicling my final year of school (I actually have 10 months left now but who's counting!)

Part of the final project is writing a systematic review. Since one of the principles of our program is evidence-based practice (EBP), our final project must be framed in the form of a PICO question. That is, Population, Intervention, Comparison, and Outcome. My group and I are still tweaking our question but it is centered on adults with type II diabetes. (Plus, I do need to maintain some level of suspense throughout these posts!) In order to gather the evidence, a comprehensive, systematic, and exhaustive search of the literature must be performed using key words and MeSH terms to narrow down the number of hits we get on our search. This is a critical part of any systematic review since the evidence gleaned will lay the groundwork for the review.

We are searching health/medical databases including Medline, CINHAL, & Cochrane. I grossly underestimated the amount of time this would take as we refined our key words and MeSH terms a few times - it's been about 4 weeks or so that we've been working on it. This process has been much more involved than say going to Google and typing in some search words. We were fortunate to have a group member very adept at searching and have taken advantage of the university librarian for additional tips. We are now confident that we are on the right track and are capturing the abstracts to read to determine if the article is applicable for inclusion in our review.

This searching resulted in 400+ abstracts to review. We have each individually read the abstracts and are meeting to discuss the ones we disagree on to determine whether we retrieve the actual article or not. We also need to search the "gray literature" for additional articles that weren't published in peer-reviewed journals to see if any other evidence exists. We will then enter them into the Joanna Briggs Institute software for tracking and as a way to get started on the actual write up. Next, we will critically review the article to see if it makes the cut for inclusion into our systematic review. (Note: this is a lot of reading - so much for being off the summer!)

I am excited to see what the evidence suggests regarding our focused topic. While all this is going on, in the Fall, we hope to implement the intervention at the clinical agency we are partnered with and are calling that "a small test of change" (STOC). Lots of work ahead but there is definitely a small light at the end of the tunnel (did I mention that I will be done in 10 months?)

Tuesday, July 6, 2010

Passé or is it?

I started to write this post and then said to myself, I'm not going there...its so passé. I saved it as a draft with little intention of completing it. Then I come across this "media kit" posted on the American Academy of Family Physician's (AAFP) website and just can't believe my eyes with their approach. They have set out to point out the obvious: NP education and training is different than that of physicians! Who knew?!?!

I am so disappointed in the AAFP. Perhaps no other specialty works as closely together as NPs and family practice physicians. Up until now, I've generally come across very supportive family practice physicians of nurse practitioner practice. This is a slap in the face of sorts.

And now the original post: Another day, another article about nurse practitioner's filling roles traditionally held by physicians, and another physician-centric theme by organized medicine. It's nice to read an article with some NP input and perspective. However, here we see the proposal of a pyramid with a physician sitting atop to "supervise" and develop protocols. Does that even deserve any further comment?

I am not completely without despair though. I found a blog by Dr. Lin, Common Sense Family Doctor, and his recent post about Primary Care Dream Teams. Without specifically mentioning NPs, he captures the essence of collaboration and working together in the best interest of the patient, not the profession - I don't think that should ever become passé.

Guest Post: How Hospitals Can Better Retain Their Nurses

How Hospitals Can Better Retain Their Nurses

America is in the middle of a nursing shortage that is only expected to worsen as baby boomer nurses reach retirement age and a burgeoning population requires more healthcare. Here are just a few statistics that highlight the serious problems facing the healthcare industry:

· More than 581,000 new nursing positions are expected to be created by 2018. This growth is much faster than any other industry, and there just aren’t enough nurses to fill the positions.

· U.S. nursing shortage is projected to grow to between 260,000-500,000 by 2025.

· Over the next 20 years, the average age of the RN will increase and the size of the workforce will plateau as large numbers of RNs retire. Because demand for RNs is expected to increase during this time, a large and prolonged shortage of nurses is expected to hit the US in the latter half of the next decade.

· There are more than 100,000 vacant RN positions.

· 55% of surveyed nurses plan to retire during this decade.

· 1 in 5 new nurses quit within a year

You get the point.

With so many nurses leaving, hospitals are put in a position where they have to do everything they can to increase nurse retention. Simply put, they can’t afford for any more nurses to quit.

But how can they achieve this? What can hospitals do to keep nurses happy and interested in their careers? Here are some of the most effective nurse retention strategies.

· Offer longer orientation periods for new nurses—Starting a new career as a nurse can be overwhelming. Nursing is a hectic job, and lives are on the line. With about 20 percent of new nurses quitting within a year, that’s a strong indication that new nurses just aren’t prepared for the job. By having a longer orientation period for new nurses, hospitals can help them adjust at a comfortable pace to the job, increasing the chances that they’ll stick around.

· Have rapid response support teams for new nurses—New nurses often find themselves in tough situations where they don’t know what to do. These situations can be very stressful, and if handled improperly, it could break the nurse. By having rapid response teams available for nurses who find themselves in a pinch, you can help guide them through these tough situations.

· Reduce nurse to patient ratios—One of the most common complaints nurses have is that they’re responsible for too many patients. Keeping up with too many patients can place extra stress on the nurse, and it could even cause the quality of patient care to decline. Whenever possible, hospitals should strive to reduce the nurse to patient ratio so everyone will benefit.

· Conduct exit surveys for nurses who quit—An exit interview with nurses who quit should be a standard procedure. This is a great opportunity for hospitals to gain insight into the factors that lead to a nurse moving on from their job. By identifying the things that are causing nurses to quit, the hospital can hopefully take steps to correct these issues and improve nurse retention.

· Get feedback from nurses on a regular basis—Don’t just wait until a nurse quits to talk to them; hospitals should also get feedback from current nurses on a regular basis. They should set aside time to talk to the nurses to hear what they have to say about the job. This can be helpful for identifying problems early on and correcting them before a nurse decides it’s time to quit.

· Offer opportunities for nurses to further their careers—If nurses feel like they have a chance to grow in their career, they’ll be likelier to stick around and keep moving forward. The best hospitals offer professional development programs for nurses to help them improve their careers and stay interested in their jobs.

· Be flexible—Nursing jobs carry a lot of stress with them. They can be very harsh on the personal lives of nurses. That’s why hospitals should strive to be more flexible and accommodating to nurses. By offering flexible scheduling and assistance with various personal issues, hospitals can keep their nurses happy.

What are some other things hospitals can do to retain more nurses?

Guest post submitted by John Smith. John manages the Nursing Scrubs store located at NursingUniforms.net.

Submit a guest post to anpview at gmail dot com.