A Nurse Practitioner's View

Advancing Nurse Practitioner Practice

2012-02-07T21:56:00.000-05:00

I saw 2 notable articles in the news last week about nurse practitioner practice that I wanted to share. The first one is about two new bills introduced in Missouri that would eliminate the collaborative practice requirement between a nurse practitioner and physician and would allow NPs to prescribe controlled substances as indicated. Missouri is one of the most restrictive states when it comes to NP practice and if this legislation passes, they will move to the forefront of of autonomy. They will have substantial opposition but the bills would allow these NPs to practice to the full extent of their training and education.

The other article is about the first nurse practitioner to practice in Bermuda. She will begin this summer and work in King Edward VII Memorial Hospital. She is scheduled to be the first student to complete their NP program.

It is great to see NP practice evolve and have regulations that reflect a scope of practice that is congruent with the training and education of NPs. While there is much work to do (just look at some of the comments from the 1st article), it is becoming clear that NPs can make a meaningful difference in the health care landscape caring for patients.

2011 Reflections

2011-12-31T13:41:00.002-05:00

I'm aware that many people roll their eyes at another "year in review" blog post but it's been some time since my last post here and I think it is a good way to end the year.

2011 was an important year for me professionally as I completed my DNP back in May. It was a grueling 3 years (that I mostly chronicled here on this blog) and in my mind was the right choice for me at this point in my life. I approach clinical problems and scenarios through an alternative perspective and I have really embraced this philosophy. I hope to apply some of this new wisdom to the health care system and patients alike.

Because I'm a glutton for punishment, following the completion of the DNP, in the Fall, I enrolled full-time in one of the University Based Training programs that was part of the American Recovery and Reinvestment Act's HITECH Act. Technology has always been my passion and I am so interested in the integration of information technology and health - it is really the future of health care. Thus far, I have completed 1 semester and have 1 more semester to go which is slated to start in January. This has been an enormous amount of work on top of a full-time job and family stuff but I am certain that this post-grad certificate along with the DNP is where I want to be professionally.

In August, I also starting blogging over at Online Nurse Practitioner Programs. I've been posting about 2 entries a week about all things NP-related. It has been a fun experience to blog professionally and I look forward to continuing to expand my professional social media activities (i.e. Linked In & Twitter - feel free to connect with me there too.)

In November, I ran for and won the Chair-elect position for the Nurse Practitioner Association of New York. This is a 3 year term that starts in January 2012 as Chair-elect, 2013 as Chair, and 2014 as Past-Chair. I am looking forward to serving the organization and hope to further strengthen membership and and reduce the practice barriers in NY so that NPs can care for patients consistent with our training and education.

I was recently notified that I won the American Academy of Nurse Practitioners 2012 State Award for Excellence in New York State. I am so surprised and honored to receive this distinction!

Whew! And that is on top of balancing a family including three children (7, 5 and 2 years old) and the full-time job in occupational health. I lost a very close aunt to lung cancer earlier this month and there is no other way to put it that cancer just sucks. All of this has been challenging and has caught up to me to make it overwhelming at times. I am actively trying to find balance in both my personal and professional lives. It will be something I work on in 2012!

So thats a look back at 2011 and I am looking forward to 2012. I wish all my readers a Happy, Healthy, and Prosperous New Year!

Seeking NP Stories

2011-11-28T21:21:00.000-05:00

I am posting this for a colleague who plans on writing a book about nurse practitioners.

Seeking nurse practitioners of all specialties to submit stories about the experience of being a nurse practitioner. The NP may live in any geographic area.

This may include stories about the role of NPs, patients, circumstances or the health care system.

Selected NPs will be confidentially interviewed and audiotaped if agree to be part of the project.

Please contact mga11@caa.columbia.edu

Nurse Practitioner Evidence

2011-11-10T20:43:00.000-05:00

The latest nurse practitioner study conducted at Loyola found that "...the nurse practitioner reduced ED visits by improving the continuity of care and troubleshooting problems for patients."

These are the type of studies that need to be done. I am sick of the studies pitting nurse practitioners against physicians. The "us" versus "them" mentality is old, tired, and doesn't even belong in today's argument. The time has come to move past this and figure out a way to make the most out of available resources while ensuring that each profession practices to the extent of their education, training, and scope. Do we really need another study to show that NP practice is just as good or better than physicians or do NPs make more referrals or would NPs order more tests to arrive at a diagnosis? Please, this rhetoric is insulting to the entire US health care system.

In my opinion, nurse practitioners are not interchangeable with physician practice. We are different yet have many overlapping qualities. I have heard the argument that NPs practice medicine. Again, there are overlapping qualities but we are not analogous. How could we be when we are educated in varying models and practice settings for different lengths of time? We all deserve to be caring for the right patient at the right time and in the right setting. There are critical care NPs that do things that I cannot and I may be able to better care for a primary care patient in my setting.

As states realize that NPs can be part of the solution to the provider shortage and reduce practice barriers, I believe we will see increasing pressure concerning NP practice. NPs have a 40+ year history of providing culturally competent, evidence-based, cost-effective and high quality care. If someone wants to waste valuable resources researching this (again), then the turf battles will continue. However, my colleagues and I, as well as the many other stakeholders, would love to see more evidence proving how NPs increase the quality of care and reduce costs in this wasteful health care system of today.

Guest Post: Keeping Your Brain Fit After 65: 5 Important Memory-Boosting Ingredients Found in Common Foods

2011-11-07T19:12:00.000-05:00

Eat your fish, it’s good for your brain.” This is what every mother said to get the kids to finish their meal. As we age, there are many physiologic mechanisms that occur making memory a thing of the past. While remembering something your wife said thirty years ago is still there, what the heck did you do with your car keys? Here are five tasty ways to encourage memory after age 65, or before.

1. Vitamin B12

Cyanocobalamin (B12) is an essential coenzyme required in many bodily activities. It is necessary to make the heme part of hemoglobin and it is also an integral part of nerve repair. A deficiency leads to pernicious anemia. Subclinical vitamin B12 deficiency can cause pain, electric shock feelings, sleep disturbance, depression, fatigue and memory loss.

Your body needs a chemical called intrinsic factor to absorb B12 in the gut. Production of B12 declines with age, so foods containing B12 are essential to provide optimal absorption. B12 is found in meat, fish and dairy. Because of the fat issue in red meat, and calories in milk, fish is a great source of B12. See, mom was right!

2. Phytofoods

Many studies have demonstrated that one of the biggest effects in post-menopausal women is a decline in memory. Many men experience a decrease in testosterone production called the male climacteric. Estrogen and testosterone are in the same metabolic loop: one can be converted into the other depending on sex genes. Foods containing phytoestrogens are beneficial to both men and women providing hormonal stimulation that increases visual special memory. Ever wonder why rabbits eat clover? It is very high in phytoestrogens. Foods high in these beneficial nutrients are: soy beans, oats, barley, lentils, yams, rice, apples, carrots, pomegranates, wheat germ, ginseng, bourbon, beer, and fennel.

3. Phenol and Phytoalixin

Phenol and phytoalixin’s are chemicals that certain plants release in response to stress or damage. In humans they have been found to do many positive things. One significant positive effect is a neuroprotective action. It has been shown to decrease the plague formation associated with Alzheimer’s disease and improve other degenerative neurological conditions. They also have anti-aging properties. Several studies have suggested marked improvement in memory in test subjects supplemented with these chemicals. They are found in the skins of red grapes, blueberries, and other fruits. Unfortunately, red wine does not contain a large amount of these protective substances.

4. Quercetin

Quercetin is a naturally occurring compound that is found in many plants. A flavonoid, it works directly on neurons and increases synaptic conduction resulting in faster and better connections in the brain. Common foods containing high levels of this substance are onions, fruits, vegetables, leaves, and grains. Onions have long been used in India as a folk remedy to treat memory loss.

5. Omega Three Fatty Acids

Omega 3 fatty acids have been touted as a treatment for high cholesterol, metabolic syndrome, and a variety of other age related processes. Omega 3 fatty acids have a significant effect on brain function, specifically memory and mood. Foods containing this are fatty fish like salmon, (Mom’s still right), the oils from nuts, olive oil, beans, and squash.

There are other ways to improve cognitive function like getting off the couch and using your mind. Practice may not make it perfect, but it helps. All the training and mental effort can’t help a brain that is missing essential chemicals required to provide memory. Give your brain the building blocks it needs and maybe you’ll find your keys more easily!

Author Bio:
John writes for Assisted Living Today, a leading source of information on a range of topics related to elderly living and retirement care and facilities, such as memory care.

Potpourri & an Election

2011-10-26T16:13:00.000-04:00

I have certainly been keeping myself busy these days! First, I have been immensely busy at my clinical site. Hundreds of flu shots have been given in the last few weeks and I have been inundated with the change of season upper respiratory infections and allergies in what seems like everyone has (really, the care is largely supportive and conservative. I am a big fan of saline nasal irrigation!)

Second, school work continues in the Office of the National Coordinator for Health Information Technology post graduate certificate program as Clinician Leader that I am enrolled in. I am considered full-time and plan on finishing up in May 2012. The amount of work has been intense (an intensity that I thought I was done with following completion of the DNP this past May!) The course work isn't as demanding as the DNP, but there is just so much of it that is condensed into a relatively short time frame.

Third, I am running for Chair-Elect in the Nurse Practitioner Association of New York's (The NPA) election. Voting will begin next month and for the first time in many years, this is a contested election. It will be an interesting experience and am running against two other seasoned nurse practitioners for the position. (I am currently the Treasurer of the association). As any regular reader of my blog knows, I stand for transparency and accountability, with a sprinkle of common sense. My position statement is:

As your Treasurer, I’ve been responsible for guiding the Association through one of the most challenging economic times in our nation’s history. As a result, the Association enjoys financial stability to enhance member benefits and increase members.

In addition, our strong fiscal policies allows us to retain the best possible advertising and advocacy firms, as well as, professional staff, to ensure that our vision of barrier-free nurse practitioner practice in New York State is achieved. One of the greatest challenges we face are the often confusing and outdated laws that regulate nurse practitioner practice. The NP profession has and will continue to provide culturally competent, evidence based care that is of high-quality and cost-effectiveness.

Unfortunately, these regulations don’t accurately allow us to provide the care that we were educated and trained for. Therefore, it is essential that we have these laws updated to allow us to care for our patients of today and tomorrow.

If elected, I will work tirelessly to enhance communication and transparency within our association in part by taking advantage of new technologies. My goal is to empower members so that we are the ones shaping and defining our profession.

If there are any members of the NPA reading, I would appreciate your support in this election. (If you aren't a member and practice as an NP in New York, now would be a great time to join.

I will also be traveling to the NPA's Annual Conference this week and am looking forward to a great program.

Lastly, I've been regularly blogging (about 2 posts a week) at Online Nurse Practitioner Programs.com since August. Feel free to check that site out as well (if you haven't gotten enough of me already :)

Other than that, I am just trying to maintain balance between my professional life and personal one. My blog has always allowed me to reflect on professional issues, which I fully intend on continuing. It is quite therapeutic.

Wish me luck and I will be sure to post updates!

Instant Lab Results

2011-09-27T20:13:00.001-04:00

I recently blogged about the prospect of patients getting access to their laboratory results before the ordering clinician signs off on it. This certainly is a patient-centric approach but is it a wise one?

I am mostly in favor of this however, many details still need to be worked out. In our forthcoming electronic health records world, this may be the tip of the iceberg related to patient-centricity and access to their record.

I'd love to hear your thoughts and concerns.

Brief Update

2011-09-14T20:57:00.001-04:00

Hello,

I just wanted to provide a brief update as to what I've been up to for the last few weeks. After completing my DNP this past May, I was actually feeling a bit melancholy thinking that my days of a "student" were officially over. Well, not so much! Since my passion is technology, I happened to be researching Health Information Technology (HIT) and found these University-based training programs set-up by the Office of the National Coordinator (ONC) under the HITECH Act. These programs train either health professionals on the IT side or IT professionals on the health side. Even better, there is grant that helps to pay for the majority of tuition fees!

I've always had a passion for technology yet, have been all self-taught with no formal training. The program that I applied to and was accepted offers a clinician leader track. It's been about 3 weeks and the hybrid program is intense! (I thought I was done writing papers, etc!) Thus far, it really is a wonderful program. I've met key HIT policy people and have gained great perspective into the push for all things related to electronic health records. I will be taking 18 credits over the course of the next 2 semesters (can anyone say glutton for punishment?!?)

I'm sure I will be focusing my next few posts here on HIT. There are many smart people in Washington that are working on these implementation initiatives (meaningful use, etc) and I am confident that we will see the successful transition from paper-based record keeping to sophisticated and intuitive electronic health records. This holds the potential of improving the quality of care by adding decision support logic while driving down costs by eliminating waste and duplication. Stay tuned.

Also be sure to check out this site (onlinenursepractitionerprograms.com/blog), where I am also blogging.

Additional Nurse Practitioner Blog

2011-08-22T19:08:00.000-04:00

Hi All,

Please check out my new blog at Online Nurse Practitioner Programs! Also, like this new page on Facebook to automatically get new updates. I am very excited to further expand my blogging and audience in this new forum!

Not to worry, I will still continue to regularly update this blog with all things related to nurse practitioner practice.

As always, thanks for reading.

Stephen

More on Private Nurse Practitioner Practices

2011-08-18T11:19:00.000-04:00

A lot of nurse practitioners are finding my blog through searches regarding opening up a private practice from this January blog post. (I refuse to use the word independent since no clinician practices within a vacuum and requires multidisciplinary support to care for the whole patient). I happen to have a dear friend and colleague, Dr. Joy Elwell, FNP, DNP, who has her own private practice. I asked her a few questions regarding her experience and she was gracious enough to sit down and answer them for me and my readers.

1. Why did you decide to open your own practice?

Well, first, my experience was a bit unique, since I had my own practice within an institution, i.e. I worked for an institution and was able to see my own patients at that site. I decided to leave and open a free-standing practice in the community because at this point in my career, I believed I could serve the community better by being self-employed. I also believed that I would have greater satisfaction from my work by being self-employed. I can say, after being self-employed for a year, that both of these are true.

2. What are (were) the biggest challenges?

Finances are always a challenge, regardless of the business. However, I had an established patient base who followed me to my present location. I was also already credentialed by insurance companies, so I did not have to wait very long to start receiving reimbursement. I also had a business plan, which was part of the curriculum in my DNP program, and that served me very well. Things like setting up payroll, direct deposit for employees, tax payments were challenges because we, as clinicians, are used to others taking those responsibilities. When it's your business, you are responsible for it all.

3. What are some of your successes?

My practice is growing, Patients refer their families and friends. New patients tell me that employees at the insurance companies tell them, "Go to Joy Elwell; she'll treat you right". Last week a provider representative from a Managed Medicaid insurer walked in with a quality bonus check for $500. He said he wanted to hand-deliver it. And, I am able to practice the way I was educated and trained to; I can give each patient the time needed to provide quality care.

4. What advice do you have for someone contemplating opening a practice?

Write a business plan. If you can, build a patient base before you open. Avoid signing a "non-compete" contract with an employer. Be creative with space. Office rentals can be expensive; if you can obtain space in a school, or a church, consider it. I have a colleague in Arizona who has been given free office space in a firehouse. Be prepared to wait awhile to start being reimbursed by insurers. If you practice in a state requiring a mandatory collaborative practice agreement, take care with the financial arrangements. If you must pay the collaborating physician, a flat fee is always better than a percentage of your earnings. Develop relationships with as many physicians as possible. Network. In New York, with the constraint of the mandatory collaborative practice agreement, the NP must be prepared in case something goes wrong with that agreement. Consider signing agreements with 2 physicians. It is essential to protect the practice.

5. How much time did it take you to be up and running?

It took 4 months, from the point that I found the office space which met my requirements, to the completion of the lease, and renovations, that I was ready to open.

6. Describe the credentialing process.

The credentialing process is fairly straightforward. Contact the insurer. Ask for a credentialing packet. Do NOT ask if the insurer credentials NPs. Why? Sometimes misinformed employees will say "no", when they in actuality do credential NPs. Be prepared to provide copies of numerous documents, including your RN license, NP certificate, diplomas, DEA certificate, proof of malpractice insurance, and collaborative practice agreement. I keep folders with multiple copies on hand, ready for this process. There is also an online service, which is free, through the Council for Affordable Quality Healthcare (CAQH). The Universal Provider Datasource is a part of CAQH's credentialing application database project that seeks to make the provider credentialing process more efficient for providers as well as healthcare organizations. You will still need to have documents on hand to update your profile, but insurers will be able to verify and update your documents through CAQH. Check it out at https://upd.caqh.org/oas/.

7. Did you consider any other models of practice (i.e. private pay only, concierge, etc)?

I rejected of these models. First, 85% of the population is insured, and many pay significantly for their insurance. So, to be private pay only would cost me patients. I philosophically disagree with the concept of concierge care, so that is not something I would pursue.

And last but not least, can you provide a brief Bio?

A Family Nurse Practitioner with nearly 30 years of experience in nursing, Dr. Elwell holds a Bachelor’s degree in Nursing from Long Island University, a Master’s degree as a Clinical Nurse Specialist from Lehman College, a Post-master’s Certificate as a Family Nurse Practitioner from Pace University, and a Doctorate of Nursing Practice at Rush University.

Dr. Elwell designed, implemented, and directed the Primary Health Care Center at Concordia College, Bronxville, NY, where she served students, faculty, their families, and the community for 18 years. In 2010, she opened a community-based, NP-directed primary care practice in Scarsdale, NY.

Having taught in both undergraduate and graduate nursing programs, Dr. Elwell is a member of the faculty of Frontier Nursing University, Hyden, KY, teaching nurse practitioner and midwifery students.

She is the Government Affairs Chair for The Nurse Practitioner Association New York State, the Region 2 Director for the American Academy of Nurse Practitioners. She was selected as a Fellow of AANP in 2011. Dr. Elwell has worked to eliminate barriers to NP practice and increase access to health care. She was recognized in 2007 as “NP of the Year” by The Nurse Practitioner Association New York State. Additionally, she is a member of The North American Menopause Society and Sigma Theta Tau.

She serves the congregation of Village Lutheran Church, Bronxville, NY as Parish Nurse Practitioner.

Dr. Elwell lives in Eastchester, NY with her husband, Tim Elwell, and their 3 children, Diana, Ryan, and Ian.

How Not to Advertise a Career in Nursing

2011-08-12T18:57:00.002-04:00

I receive countless spam e-mail messages to my many e-mail addresses. The screenshot of the one that I received below is definitely one of the most bizarre and struck a nerve.

Really, this is not a way to advertise a career in nursing. It's unclear to me how or why doctors specifically, are in need of people like me. Perhaps the inference is that doctors tell nurses what to do and nurses are there to serve at their beck and call. We all know that the profession of nursing has a whole science unto itself and that nurses are front line care givers, influencers and advocates in the world of patient care. Sandy Summers is a nurse who runs the The Truth About Nursing website and she dedicates the whole site to correcting the vast negative portrayals of nurses in the media and in entertainment. I can envision her targeting this type of inaccurate portrayal due to the poor choice of wording.

I did not click on any of the links for fear of it taking me to some weird phishing site or to some inappropriate site. The e-mail address originates from Germany which also adds to the bizarreness.

My hope is for those who are truly considering a career in nursing, they have the chance to explore the many wonderful opportunities within the profession and that targeted advertisements accurately portray the profession and encourage individuals to become a part of it rather than be dissuaded.

File This Under Random

2011-07-31T21:55:00.000-04:00

I check out many health-related websites on a daily basis. I click on links from Twitter and Linked In and see the entrepreneurial ventures of fellow health care professionals. One of the things that irks me of late is the random stock image of health care "professionals" posted throughout websites (for example see below).

This woman has been featured on more websites that I can count. It's not that I doubt her professional credentials - she seems to at least have a legitimate Littman-type stethoscope and upgraded smoke finished clipboard. But is it that hard to post a picture of actual clinicians today? When we talk about patient-centered care, I believe patients deserve to see an actual image of their provider rather than the random clip-board touting, lab-coat wearing stock image that graces so many websites. I hope this woman is at least getting royalties from gracing so many sites!

So please, if you have a website and are a healthcare professional or entity, please use your actual photo rather than the one above - it helps regarding credibility. Patients know much better than that.

Preventative Health: Is it Really Preventative?

2011-07-20T22:22:00.000-04:00

Lately, there has been increased emphasis on "preventative" care in the US now that there are some mandates under the Affordable Care Act. There is even the U.S. Preventative Services Task Force (USPSTF) which is a panel of private sector experts who recommend evidence based preventative screenings for certain conditions based on factors such as age and gender.

As a family nurse practitioner, I base a large part of my practice on wellness and prevention in addition to episodic (or "sick") care. I believe in "wholistic" care - that is, care of the whole person including mental and physical states. Though lately, I question whether if "preventative" is really the best moniker for this type of care. Prevention assumes that one can completely avoid health conditions by subscribing to certain recommendations, screenings and/or tests. Is it naive or even obnoxious to think that we can prevent disease and illness? I have seen many patients follow all the recommendations only to end up with some other life threatening malady. Of course, we cannot avoid all sickness and illness as there are inherent non-modifiable risk factors (such as age, gender and heredity) that hold the potential to affect one's health.

I am not necessarily disputing any evidence or recommendations that have been introduced but the false sense that we have the ability to "prevent" an illness or disease from happening in the first place. This can lead to unrealistic expectations and negative backlash. Yes, we be able to detect an early cancer prior to it's spread or immunize individuals against certain infectious diseases. But prevent altogether? Sadly, I don't think so - in fact, I know so.

That's why I am using the term pro-active health rather than prevention. There are actions that individuals can take to lower their risks from disease and illness and I believe that is taking a pro-active part in one's health. We do this in the hopes of longevity, wellness, disease avoidance and early detection (if illness is identified).

Perhaps I am more hung up on terminology in my new post doctoral reflective state. I believe in open and transparent communication with my patients and other members of the care team. I don't want to purport to my patients that we can cure and prevent all illness. We can however, instill evidence based methods to increase patient activation, patient engagement, and ownership of one's health and behaviors to take a pro-active approach and present realistic expectations based on the available data.

I'm curious to know what you think. Am I too fixated on the words (and the resulting expectations from that title) or are we possibly setting patients up for let-down and failure if they do encounter illness after following all recommendations? Please feel free to comment below.

That's What I Call Access to Care!

2011-07-12T21:59:00.002-04:00

I am a huge baseball fan and my favorite team is the NY Yankees. Star third baseman Alex Rodriguez was recently diagnosed with a slight meniscus tear of his right knee. He has played through some pain over the last few weeks and was given conservative treatment by the Yankee training staff up until the point that it didn't really improve. Check out this timeline of events:

Friday 7/8/2011 - MRI reveals meniscal tear. I presume the team physician recommends surgery.
Sunday 7/10/2011 - A Rod gets a second opinion on SUNDAY with Dr. Lee Kaplan of Miami.
Monday 7/11/2011 - A Rod has successful surgery and is expecting 4 - 6 weeks of rehabilitation.

That is what I call access to care! From MRI to second opinion to surgery was a cool 72 hours (I surmise that he also needed a pre-op clearance thrown in there as well).

Yes, he is arguably one of the greatest players to ever play the game and is also the highest paid player but it is amazing how anyone can get a second opinion with an Orthopedist on a Sunday and have elective surgery the next day!

When we talk of health disparities, this is a prime example of what is wrong with our system. No, I don't expect a consultation to surgery time period of 72 hours, I just wish I can get some of my patients to just see an Orthopedist in the same month.

Calling All Shoppers - Redux Again!

2011-06-29T16:43:00.003-04:00

I had no sooner finished blogging about the announcement regarding the governmental plan to utilize mystery callers to assess access to primary care offices to find out that the survey has been put on an indefinite hold.

Being a conceptual proponent of this research, I am disappointed that the administration backed down from the seemingly large physician backlash. Then again, as I stated in my last post, will this really tell us anything that we didn't already know? If you have any doubts, just try calling any office on a Friday afternoon, stating that you are a new patient and would like to come in on the same day for an appointment because you suspect pneumonia - oh, and that you have no insurance. Maybe the proper thing to survey is how long it will take to be hung up on or laughed at.....

Calling All Shoppers - Redux

2011-06-28T20:54:00.004-04:00

One of the recent stories that spurred a lot of discussion was in the NY Times, U.S. Plans Stealth Survey on Access to Doctors. It is an interesting concept that will help to try and quantify how difficult (or easy) it is for one to get into to see a primary care physician. They will also evaluate if the office staff will give preferential priority based on the "patients" stated insurance.

I applaud this move and believe it will produce some evidence as to how hard it is for new patient to seek care. Many physicians aren't too pleased with this survey as I would imagine it will tie up their resources. I blogged about this concept a few years ago when the AMA came out against the notion of "mystery shoppers."

Health care needs to be patient-centric as the retail industry is consumer-centric. Why should health care be any different conceptually? I hope that this experiment isn't more of an exercise on provider's offices (i.e. poorly trained or rude staff) rather than the issue of access to healthcare due to not enough primary care providers. I see this as an opportunity to document the need for more primary care providers including physicians, nurse practitioners and physician assistants - though do we really think there isn't a problem there already??

Mobile Health Technology

2011-06-08T16:52:00.007-04:00

A little bit on technology and how it is impacting health and patients. As an admitted techno-geek, I am passionately following mobile technology and where it is popping up in health.

A cool app that I recently downloaded is Instant Heart Rate for my iPhone 4. This is a free app and requires no external hardware. According to their website, it works by placing your finger over the iPhone's camera and it "tracks color changes in the light that passes through your finger." I used it and found the readings to be fairly accurate. It is also available for Android as well.

The basic app is free and for a $0.99 upgrade it adds features allowing you to document what you were doing at the time of recording, viewing graphed results over time, and auto-posting the results to Twitter.

As a clinician, apps such as this can help patients keep accurate data to review with their providers at their visit. It is exciting to watch this technology develop. Today it is heart rate monitoring and ECG recordings with tomorrow bringing endless possibilities. It is certainly in clinicians best interest to be aware of these apps since patients are using them. Further, perhaps it is an opportunity for clinicians to become involved with this developing technology and help steer it to ensure evidence-based and clinically sound apps.

Is this Patient-Centered?

2011-05-18T19:41:00.010-04:00

My physician's group utilizes an on-line patient portal to schedule appointments, view lab results, and to communicate with my provider. Fortunately, it is very rare that I need to actually schedule an appointment. I've only been a patient of the practice for just about 2 years and I thought I'd schedule my second annual physical. (In fact, I've been there once, a year ago, for a physical on a Saturday). Now, I do question the real value of the annual physical examination but as we all get a year older, there are certain screenings that are recommended.

Nonetheless, I fired up the handy patient portal web address and requested a physical examination for any early Saturday appointment in June or July. Since I do work Monday through Friday with my own patient load and responsibilities, I don't think I should need to take a day off to have a physical. The practice has Saturday hours and I thought this would be ideal for me and my schedule. This is the response that I got back from the office staff:

Dear Mr. Ferrara: We don't have our schedule in for June yet. Our schedule for Saturdays will go in at the end of May. I'm not sure which Saturday Dr. X will be working. We don't usually do physicals on Saturdays because it's a short day he likes to keep it open for emergency sick visits so if you could come during the week Dr. X is late on Monday nights. Thank you.

So what is one to do? I am extremely annoyed at this response. Mind you, I have absolutely no current medical issues, am not on any medications, have health insurance, and in all likelihood, I would be in the waiting room longer than I would actually be in with the clinician. They can even code higher for a physical than for a sick visit! I am not asking for any favors or special treatment, just to have a Saturday appointment - up to 8 weeks from now. Is that too much to ask? Apparently so.

And some wonder how to fix the many problems of the health care system today. How about we start with access and getting our foot in the door.

DNP Series: Published!

2011-05-13T15:04:00.005-04:00

The systematic review that my colleagues and I have been working on (for what seems like forever!) was finally published in the Joanna Briggs Library of Systematic Reviews!

It is very gratifying to have an official peer-reviewed publication under my belt. The title of our Review is, "The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: A systematic review."

The work that we studied on group medical visits (GMV) is truly interesting and can serve as a viable model to aide in type 2 diabetes management.

Graduation is just over a week away and we just have one more presentation standing in our way. I will be posting some of my reflections on the program and on the DNP in the weeks to come. For now, I will enjoy this moment!

Poll Results on the NP Modernization Act in New York

2011-05-08T12:32:00.008-04:00

Here are the poll results from the show New York NOW on the the NP Modernization Act Bill that has been introduced in the New York Legislator. I particularly like the comment from "Stephen" - for obvious reasons ;-)

National Health Service Corps

2011-05-02T20:52:00.005-04:00

I was recently contacted by a member of the National Health Services Corps (NHSC) and asked to highlight their program here on my blog. It certainly sounds like a wonderful opportunity for NPs regarding loan repayment. So here it goes:

The NHSC is a federal program that offers primary care providers financial support in the form of loan repayment or scholarships so they can practice in underserved areas of the country without the burden of educational debt.

The NHSC is currently expanding to help meet the need for primary care professionals. The current application cycle for loan repayment closes on May 26th and applications are now being accepted for the NHSC scholarship program.

As the country faces a shortage of primary care providers, the NHSC plays a critical role in bringing primary care medical, dental and mental health professionals to communities in which people would otherwise have to travel miles for health care, or go without help. In return, the NHSC offers help in repaying loans. For example, clinicians who join the Corps can receive up to $60,000 for a two-year full time commitment and up to $170,000 to help back loans for completing a 5-year service commitment.

If you have any specific questions, contact me and I can put in you in touch with someone who would be able to answer them. There is a definite need for eligible providers and loan repayment helps those struggling financially. It's a privilege that primary care NPs (as well as PAs and other health professionals including physicians, dentists and more) are recognized for this important and meaningful program.

Guest Post: 10 Free Online Tools for Nurse Practitioners

2011-04-14T18:15:00.005-04:00

10 Free Online Tools for Nurse Practitioners

There are several online sites that offer a wealth of tools and resources for nurse practitioners-

-and many of them are free. Here is a list of 10 sites that advanced practice nurses might find useful.

NursingCenter.com - Created by nurses for nurses, this site is an excellent place to find professional resources, clinical information, and continuing education activities. Other features include free peer-reviewed journal articles, free eNewsletters, job listings, daily news, and a search engine that searched more 100 nursing-specific websites vetted by other nurses.

NP Central - This site is operated by a non-profit organization that supports the development and advancement of nurse practitioners. NP Central offers job listings, education information, a list of nurse practitioner organizations by state, and other helpful resources.

eMedicine - A branch of WebMD, eMedicine is a highly respected online medical resource. You can browse many topics related to medicine, surgery, and pediatrics, and they can also view slideshows and get up-to-date medical alerts and news.

Epocrates - This free iPhone (and iTouch) application is a trustworthy mobile drug reference. This application features pill identification, drug interactions, and a medMath calculator.

Healthline - Healthline offers valuable information on a variety of subjects from drug treatments and interactions to healthy living. This site also features several videos and articles on current health-related topics.

Med-Source - This user-friendly site features posts on numerous medical subjects, and it allows users to browse those postings by subject, making it simple to find helpful information.

MedStudentNotes.com - MedStudentNotes.com offers a variety of resources, including online dictionaries, journals, medical notes, university libraries, and much more.

Mednotes.net - This site offers a comprehensive collection of free lecture notes and study guides in nearly every medical science. The primary goal of Mednotes.net is to educate nurses and medical students and help them study and prepare for exams.

MedicalStudent.com - On this site, you can find a large selection of online medical textbooks, journals, and a list of professional organization links. You can also view a variety of case studies, patient simulations, and more.

Clinician 1 - Clinician 1 gives you: job listings geared to specialty, free continuing education, the latest news, must-see articles, money-saving and earning opportunities, enjoyable social interaction, informative posts, and thought-provoking dialogues. It’s the only online community for physician assistants and nurse practitioners to connect, consult and converse on personal and professional levels.

Guest post from Bailey Harris. Bailey writes about health insurance quotes and related topics for www.healthinsurancequotes.org.

DNP Series: Down the Stretch

2011-03-20T07:50:00.004-04:00

It's been a while since I last posted and it's because I've been somewhat bogged down with the last few projects for school. To briefly update: We completed our systematic review and meta-analysis on the effectiveness of group medical visits for patients with type 2 diabetes (specifically the ABCs: Hemoglobin A1c, Blood Pressure and Cholesterol[LDL]). We have received peer-review feedback and have edited and resubmitted and are anxiously awaiting their response. We implemented an actual group medical visit model in our clinical agency site and are gathering data and tweaking accordingly via the PDSA cycle. Plus, I am trying to get motivated to work on the last individual paper which must be submitted for publication to a peer-reviewed journal (rough draft is due this Friday and I don't have much thus far - which completely explains why I am blogging right now!) Finally, we are working on our final presentation for the group medical visit project.

Whew! We are also getting ready for graduation which is very exciting. As the first DNP cohort, we are discussing things like whether to rent or purchase cap and gowns (I'm renting), nursing pins (probably not going to get), and all other things related to commencement. All of us are pretty much fried on this nearly 3 year journey and cannot wait to formally apply our new knowledge to our patients and to the health system alike.

As of today, there are 63 days until graduation (but who's counting)! Now it's off to procrastinate some more on this final paper and hopefully get something written that makes decent sense. Wish me luck!

Target

2011-02-27T11:54:00.007-05:00

Lately, it seems there is ratcheted up rhetoric on nurse practitioner practice making us prime targets for all things anti-NP. The WSJ reports on a study that examined the prescribing habits of NPs and whether there is Pharma influence on those habits. The study found that of the 263 surveyed NP respondents, 93% reported that free gifts had no effect on their likelihood to prescribe the medication that was being detailed by the representative. The study concludes that since many NPs had regular contacts with these reps in the form of face to face and industry backed lunches/conferences, there could be a degree of subconscious influence on prescribing habits - findings that are similar to prescribing habits of our physician colleagues.

As you can see in the comments section that follows the story on the WSJ, some are using this study to once again attack NP practice. The comments are laughable as the insinuation is that NPs aren't really educated on pharmacotherapy and therefore are likely to prescribe whatever medication that the really good looking sales rep sponsoring the free lunch is pushing.

I was curious as to why the author, a nurse practitioner, chose to focus on a fairly volatile topic of Pharma and NP practice. Some searching found that the author, Elissa Ladd, PhD, NP, is out to educate about some of the deceptive practices of Pharma. Here is a YouTube clip of her speaking about this and an on-line interview as well. She serves as the principal investigator of peRx, Prescribing evidence-based therapies. According to the website,

The program was developed to improve awareness of drug development and pharmaceutical marketing practices and to positively impact prescribing behaviors, specifically among advanced practice nurses. An innovative, multi-media, interactive web-based pharmaceutical curriculum has been developed that targets advance practice nurse students and other clinician audiences.

This looks like an interesting program comprised of 4 modules and is sponsored by The Consumer and Prescriber Grant Program. It is available for continuing education credit and I plan on soon completing them.

So here we have a Nurse Practitioner trying to promote evidenced-based practice (that should improve the whole prescribing community practices by focusing on the evidence) yet NPs as a whole are getting slammed as it presents an opportunity to take a shot.

Meanwhile, our NP colleagues (with physicians, patients and our health care allies) in Florida rallied yesterday to garner support for a bill that will allow them to prescribe controlled substances in the state. Florida is currently only 1 of 2 states that do not allow NPs to prescribed controlled substances. The quote that I love goes to Timothy J. Stapleton, executive vice president of the Florida Medical Association:

"Allowing unqualified nurses to play doctor and putting patient safety at risk is not in the best interest of our citizens.”

This one is so easy that it bears no further comment.

As more become aware of nurse practitioner practice, the attacks will also increase. I guess that comes with the territory. It's not really new though as this link to a NY Times article from 1988 referring to the legal recognition of NP practice in New York State also has it's share of opposition. You'd be hard pressed to know it was written nearly 23 years ago since the same arguments remain.

NP Ranked in Top 5 of "America's Most Loved" Health Care Provider

2011-02-11T17:02:00.004-05:00

Congratulations to NP JoAnne Lutz of the Oregon Medical Group for being named in the Top 5 rankings of providers at DrScore.com. According to this press release, DrScore.com is "...an interactive online survey site where patients can rate their physicians, as well as find a physician based on their service level preference."

Steve Feldman, MD, founder of DrScore, states, "This year marks the first time a nurse practitioner has been in the top five runners up,” Dr. Feldman said. “This may reflect an important trend for medical practices as health care continues to evolve —everyone on the frontlines is vitally important in improving patient satisfaction.”

Important trend indeed and some additional proof that NPs are highly regarding by their patients. It's also time to expand these rankings to other providers beyond physicians to include nurse practitioners and physician assistants to name a few.

Snow Day

2011-01-27T13:45:00.007-05:00

On my snowy commute into work this morning for what seemed like 100th snow-laden car ride of this winter, I chuckled when the radio newscaster urged people to stay home. As a healthcare professional, we rarely see a "snow day." Hospitals and clinics don't close.

So to all of my healthcare, EMS, police and fire (and anyone else needing to get to work) colleagues: Please stay safe out there when Mother Nature throws this nasty weather our way. Some people must get to work whatever the circumstances are.

Private Practice

2011-01-11T09:35:00.005-05:00

There is an interesting trend that I'm observing and don't necessarily see how this is going to turn out. I'm seeing more and more nurse practitioner's opening their own autonomous practices. Many of these offices set out to offer care that is personalized, covered under insurance, and of course high-quality. I'm also seeing more NP specialty/sub-specialty practices such as house calls, incontinence, and women's health.

This is in a time when more physician practices are joining together in these conglomerations that aren't necessarily tied to hospitals. You'd be hard pressed to find a solo primary care physician these days yet nurse practitioner solo practices are popping up. The talk about the formation of accountable care organizations can be attributed to health care reform and the spurring of large multi-physician practices.

What to make of this? I honestly don't know. Many people and patients have said to me "you should start your own practice." Right now, that is not something that sounds very appealing to me. In my mind, I know how I would envision my own practice, patient flow, focus, etc. However, I hear the insurance company barriers, the paperwork hassles, the initial start-up costs, finding a new collaborating physician and see solo physician colleagues joining large practices and think that is not what I want to do right now.

What are your thoughts? Will you be starting your own practice? If you are a patient, would you go to an NP practice? For those NPs interested in starting your own NP practice, I highly encourage you to check out fellow blogger and NP practice owner, Barbara Phillips' website at http://www.nursepractitionerbusinessowner.com/. She offers tips and networking opportunities to give you the best chances for success.

2010 End of Year Reflections & A Look Ahead

2010-12-29T21:05:00.006-05:00

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!

NP Residency

2010-12-05T13:20:00.006-05:00

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.

Guest Post: North Carolina Nurse Practitioner Fights for Change

2010-12-02T18:32:00.003-05:00

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.

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

2010-11-24T20:15:00.004-05:00

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.

Social Media

2010-11-17T19:47:00.005-05:00

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:

Clinician 1
NPs2NPs
FaceBook (the many pages dedicated to different advanced practice nursing groups)
LinkedIn (NP groups)
Advance for NPs & PAs
The American Academy of Nurse Practitioners (has a networking site that is difficult to find)
The ENP Network
Many NPs on Twitter
Allnurses
NP Central Listserv
NP blogs

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!)

Guest Post: The Pros and Cons of Legal Nurse Consulting

2010-11-11T18:47:00.002-05:00

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.

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

2010-11-10T20:22:00.003-05:00

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.

DNP Series: Onward and Upward

2010-11-05T19:50:00.005-04:00

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).

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

2010-10-27T20:13:00.002-04:00

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.

The IOM Report: The Future of Nursing

2010-10-06T20:25:00.004-04:00

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.

Funny and Sad

2010-10-04T21:27:00.005-04:00

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?

Precepting Students

2010-09-16T19:49:00.004-04:00

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.

The ER Study

2010-09-02T00:56:00.014-04:00

"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.

Egg Safety and the Egg Recall

2010-08-24T15:31:00.006-04:00

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?

More on Patient Centered Care & Homes

2010-08-19T13:44:00.006-04:00

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.

Team Work

2010-08-18T09:37:00.006-04:00

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.

Dysfunction

2010-08-03T17:32:00.004-04:00

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).

DNP Series: The Search

2010-07-19T07:19:00.009-04:00

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?)

(Above image borrowed from: http://healthinformatics.wikispaces.com/file/view/pyramid.gif/33219015/pyramid.gif)

Passé or is it?

2010-07-06T08:54:00.005-04:00

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

2010-07-06T08:42:00.004-04:00

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.

Let Down

2010-06-26T10:58:00.006-04:00

No, this has nothing to do with breast feeding. This post is really a non-healthcare topic but I just needed to vent. Back in the Winter, I blogged about my passion for technology and looked forward to the new iPad coming out. To preface, I have always been a PC guy and never really understood the whole Apple fascination. I had many PCs and was very comfortable troubleshooting any issues I had. Though, I did have many different of the iPod models and had purchased the 3G iPhone back in October 2008. Well, I did decide to purchase the 32 GB Wi-Fi iPad and hopped on board the Apple gravy train. I woke up early that Saturday in April and headed on down to wait in line at my local Apple store. Overall, I am happy with my purchase as I knew it wasn't really a replacement for any device that I'm currently already using. This for me was really a "nice to have" rather than "need to have" purchase.

I do have an issue with the device which is known by Apple and they still haven't adequately adressed it: the iPad loses my WiFi connection frequently. Apple's response has been to blame the router or to adjust the screen brightness. These "solutions" haven't worked for me. I have been able to find a work around of sorts: when the signal is lost, I press the sleep/wake button and then turn it back on. It reconnects without me having to re-enter my network password (which is highly annoying to do repeatedly). As far as I'm concerned Apple's response is to place blame on anyone but them.

In May, my Dell laptop crapped out and I was forced to look for a replacement. I decided to jump aboard Apple again and purchased a 15" MacBook Pro. This by far is the best laptop I've ever owned and am very pleased with it.

This brings me to my recent iPhone 4 upgrade. I was one of the lucky "few" to reserve a 16 GB iPhone 4 (via the Apple Store app on my current iPhone). I ended up waiting about 1 1/2 hours total on Thursday 6/25 at the Apple store from start to finish - which wasn't that bad considering that some people were waiting many many hours in line. The phone is beautiful itself and is so much faster than my old 3G. But, I am experiencing the dreaded loss of signal reception issue when I hold the phone in my left hand. This is a major issue. To date, Apple's response has been again to blame everyone else ("hold it in your other hand," "you are holding it wrong," or "get a case for it.") Incidentally, I would've bought their $30 piece of rubber they call a "bumper" but they were already sold out at the Apple store when I got there. I ordered one on-line and I am still waiting for it to ship. (Still, $30?!?!)

I am profoundly disappointed in Apple's responses to these well known and ubiquitous issues. To shift the blame to others in completely unacceptable. As a clinician, I take the responsibility for the care that I render and the buck stops with me. Apple should do the same and quickly.

Happy Father's Day - Get a Prostate Exam

2010-06-18T12:38:00.003-04:00

With Father's Day just around the corner, now is a great time to remind all men about prostate health and screenings. Follow the link to a video from the Prostate Cancer Foundation.

Happy Father's Day to all Dad's out there!

Obama: "America's Nurses are the Beating Heart of our Medical System."

2010-06-17T10:38:00.005-04:00

Here is President Obama's speech to the American Nurses Association from 6/17/2010.

He specifically refers to NPs by stating:

Now, there is more work to do. And that's why today my administration is announcing a number of investments to expand the primary care workforce. This includes funding to allow students training part-time to become nurse practitioners to start training full-time. (Applause.) We want to speed up the process where folks go from the classroom into the exam room. And we’re going to provide resources for clinics run by registered nurses and nurse practitioners. (Applause.)

More work to do indeed.

NY Newsday Article on NP Practice

2010-06-14T11:22:00.007-04:00

Here is an article from NY's Newsday about NP practice and the goal towards the elimination of statutory collaboration in New York. It's a fairly predictable piece with the typical opposition from the organized medicine playbook (How many times do we have to see "If they want to play doctor, they should go t o medical school" in print? Seriously).

Nonetheless, thriving NP practices are mentioned and show the significant impact that NPs are making in the lives of patients and in the health care system.

I will mention it again as I've done countless times in my blog: NPs do not want to replace physicians and are NOT looking to change scope of practice (The presence of a collaborative agreement or not will have no impact on the quality of care I deliver but not having one in place simply renders me unemployed). I do hope that the vocal opposition eventually understand this so that we may begin to deliver care that is truly patient centered.

UPDATE: I did something that I told myself not to do: I gave in and read the "comments" section following the article. Wow. There really is a total lack of understanding about nurse practitioner practice, education, licensure, and certification requirements. So sad. We need to do a much better job so that the public understands who we we are, what we can and can't do and not be portrayed as a less than competent option.

Guest Post: Nurse Walkout Highlights Conflict With Hospitals and Health Insurance Plans

2010-06-14T08:58:00.003-04:00

Nurse Walkout Highlights Conflict With Hospitals and Health Insurance Plans

Ideally, all interests in the health care system should work together towards a common goal: the welfare of the patient. Unfortunately, nurses have been pitted against hospitals and the health insurance industry.

The Obama administration's healthcare reform legislation will squeeze insurers and hospitals alike. Medicare payments to facilities are set to be cut over the next several years, and private health plans are set to follow suit.

In order to prepare for these changes, many hospitals are looking for ways to maintain their margins. One of the most common methods is through staff cuts. Nurses, being on the front lines of providing health care services, are largely vulnerable.

Nursing unions in Minnessota and other states are going on strike to protest staffing cuts. While they are certainly concerned about their own pay and benefits, some hospitals may take their cost cutting too far and put patients at risk.

Although it makes them look good to health insurance plans desperate to lower provider payments, understaffed hospitals with overworked, tired nurse practicioners may result in higher rates of medical errors, or even death. Among the nurses' demands during the one-day walkout is a minimum nurse-to-patient ratio. However, the ideal level of staffing is subject to significant debate.

This is a complex issue, especially since the cost of health care has only continued to soar. Health insurers, hospitals, and the subset of well-paid licensed nurse practicioners have each been targeted as the source of the current predicament American health care finds itself. Healthcare reform has only exacerbated the conflict, encouraging the blame game. Regardless, patient safety cannot be sacrificed in the midst.

Guest post submitted by: Yamileth Medina, VitalOne Health Insurance Blog

Submit a guest post to anpview at gmail dot com.

Guest Post: Ageism in nursing, oh my.

2010-06-11T09:04:00.004-04:00

Any “older” PhD students out there? This is my latest update in my quest for funding. Enjoy the humor of it all.

As SNL host at the age of 88, Betty White proved she still has it; UConn Coach Calhoun, age 68, is going to get it (5 years and 13 million). So, it is with some cheek that I submit this treatise on aging in the world of academia. I mean, after all it is 2010; but a funny thing happened to me on the way to a fellowship. I am not a victim; I am an unabashed overachiever. I have no apologies for striving for more: more life, more liberty, and more happiness. The happiness for me comes in part from my family, a new “grand” coming in August, my work, my scholarship and my research. My work as a Nurse Practitioner is caring for the vulnerable aging, and the patients, families and communities suffering with dementia. My scholarship and research is from my new road to academia, specifically a Doctorate in Philosophy. My community knows I am striving to be a Doctor-Nurse. I started the PhD curriculum at the wizened age of 50, after an accomplished military career and success in critical care nursing.

I believed I had all the tickets punched, after all, I had been a Commander in the Navy Nurse Corps, ran rings around the residents in the Intensive Care Unit, carried a full academic load, volunteered at professional organizations and helped coach novice YMCA scullers to boot. I developed a program of research. My conceptual framework is nursing theory based, and embraces an achievable comprehensive model to diagnose, treat and support dementia families. I chose incredible advisors, coursework and research projects. I combined my forte of networking with that of grantsmanship principles for a pre-doctoral scholarship application to a prestigious geriatric foundation. I personally commend any and all candidates for merely completing any submission for scholarships or fellowships. Aging is not for sissies and neither is the arduous grant application process. But, I digress.

The upshot: the review board did not select me. My personal failure was not that I submitted an inadequate, sloppy or mediocre package. No seriously, the critical factor I failed was my age; I wasn’t five or ten years younger. That word trickled down to me from conflicted reviewers, who just about whispered the secret, fearful of backlash. When I called the chair and board on it, they didn’t deny it. And what I have since realized is that some people think I am being too dramatic (oh really!); it is only a trivial infraction (really? really?); the board practices in a utilitarian manner (really.); if you fuss, you are burning bridges (so, really.); and, get over it (reeeally!). So be it. But I love a cause and the dialog is good substance for my journaling (and sharing with you). Again, I digress.

Ironic, isn’t it, that in a geriatric rich field of clinicians, educators and researchers, we too have to deal with ageism? We, as nurses, are challenged to think outside the box, tasked to see every person as an individual, and make meaning from each unique experience. We are bound to principles of ethics, honesty and parity. President Obama remarks that in healthcare we need to make difficult choices for stewardship and it’s about odd-ratios and gambling with money versus long odds for a potentially small payout. I counter that we do need to make difficult choices, but we need to be inclusive, culturally competent, and see the individual as just that, an authentic individual.

I was eager to bond with that geriatric foundation because of their superb alumni, their critical acclaim of success, and a shot at professional connection to awesome role models, which naively I thought to demonstrate in my own career. Their stipend would help… hey I have a mortgage payment and financial commitments too! So did the foundation fail me? No, they were playing the odds… and life can be unfair. It is so apt (and LOL), that while I suffer the blues from premature aging, we are deciding a new Supreme Court Judge who will most likely rule until they are 85. So, anyhoo, I am not part of the club, but I am on to other fruitful endeavors and challenges.

But, I would add in conclusion, the foundation is underachieving. It dismisses hardy candidates, clings to unwritten antiquated rules, has cautious agendas and devalues precious assets. It is what it is: ageism. My final salvo: Read the literature and let’s address this head-on, because in our profession when the average nurse age is 47, age discrimination affects hiring, promotion, retention, academia, tenure, research grant money, and fellowships. Oh, and by the way, to the scholarship selection reviewers and advisory board: remember each year I get older, you do too.

Now I’m done… really.

This is just my opinion, I may be wrong (nod to Dennis Miller’s rants). Go Huskies Coach Calhoun. Betty White, you rock.

Living the dream. Elle

Guest post submitted by Elle who blogs at Doctor-Nurse (PhD:o)

Submit a guest post: anpview at gmail dot com.

The DNP for Me

2010-05-31T20:40:00.010-04:00

It seems these days, anyone and everyone is willing to share their thoughts and opinions about the Doctor of Nursing Practice (DNP) degree. These include non-nurses and nurses alike. Well, I thought I'd take a stab at it as well since I am now 2/3 through my pursuit of the DNP. If you were to strictly listen to some of those opinions, you would have a very poor view of just what exactly this academic degree is and what it can (and can't) do. Perhaps I can dispel or at least clarify some of these points, at least from my view.

First, no one is "forcing" anyone to go back to school to get this degree. The 140,000+ already practicing NPs will continue to practice without the need to return for formal academic education. However, starting in 2015, it is presumed that MS programs will transition to the DNP.

Second, there is some variation in the DNP program types. This is incredibly frustrating to me since not all programs are created equal. The DNP is not synonymous with nurse practitioner only practice, creating further confusion. For some great fact gathering, look at the AACN - Doctor of Nursing Practice section. One must throughly research the program and decide if it is congruent with their own practice philosophy, learning & lifestyle.

Third are the financials - it does indeed cost a significant amount of money for doctoral education. However, there are loans and grants available for those willing to search them out. In keeping in line with the financial aspect, no one really knows what the additional education will translate into when it comes to salaries. I'd say, if that is your main motivating factor, the DNP probably isn't for you. (As an aside, I've started reading the book, "Drive" by Dan Pink and he asserts that autonomy, mastery and purpose are the real long-term successful motivating factors rather than financial incentives when it comes to non-task oriented work). I don't think I know one NP who became one for the money (because the reality is, some RNs are making significantly more than NPs). Of course, one would want to know what their return on investment would be but it just isn't that simple. I believe that it is safe to assume that somewhere & sometime, a doctorally prepared clinician can make more than one who is not and will have a number of new opportunities at their door.

So, why did I decide to return to school for a DNP? Here is a little background: I have been an FNP for 10 years and have held a variety of positions in correctional health, college health, men's health, retail health and occupational health. I've seen many patients in many different settings and I've been able to build upon each experience. However, I was growing increasingly frustrated with conflicting published data, major dysfunction of the health care and system and at the end of the day, wanted to be able to provide the absolute best care for the patients I served. I vehemently refused any additional "residency" type of education. In fact, I had very mixed feelings when I first heard about the creation of the DNP. Not to be coy, but I already had the education and training to take traditional care of my patients in the family practice setting. I could manage my patients with asthma, diabetes, and hypertension just fine. But I felt that I wasn't using the latest proven evidence in my care. The research classes I took as a student were generally pretty dry and seemed to have little applicability to direct practice. For me, it was critical to take my practice to a new dimension. This is the essence of the DNP for me and I was fortunate to find a program that I believed would take me where I needed to go.

The last two years of doctoral education has been both grueling and exhilarating. I am viewing my patients, their health concerns and the health system through different lenses. Didactic coursework included health policy, informatics, economics, legal/ethical, and teaching/learning/mentoring. One may look at this sampling and say that it isn't very "practice" based. I'd say that is quite a naive view of health care today. It would be easy to "just" take care of patients' health issues and ignore the rest since patients are multi-dimensional and never just present as an illness or disease. In addition to subtle differences in pathophysiology, patients bring their own cultural, societal, and beliefs to each and every encounter with a provider. The key is being able to navigate these complex intertwined systems and team together to best care for the patient for that time and place.

I am now onto the practicum portion of the program and am excited to take all of this new knowledge and integrate it into a patient care initiative. For the summer, I am part of a group that will be conducting a systematic review of the current evidence (related to diabetes care) utilizing the Joanna Briggs Institute method of systematic review. We have met and will continue to meet with the practice locations' key stakeholders (including patients) to implement an evidence based, culturally congruent practice improvement plan that will be assessed and reassessed. We are hoping to uncover some great evidence and have it affect our patients in a positive way. I am also hoping for a few publications from this process as well!

I am going to try chronologize some of the general themes over the next year and post them here.

To sum, the DNP will make me a more adaptive clinician. I will still see the same patients that I've already been seeing and will still collaborate in a multidisciplinary environment. What has changed is a truly evidence-based, patient-centered approach. Pink's concepts of autonomy, mastery and purpose resonate with me and are in alignment with my philosophy. At the end of the day, I want to be able to care for patients in the way that they should be cared for. I believe I am on the right track.

A Lesson

2010-05-27T12:31:00.005-04:00

Here is an article that refers to the NP led clinics that are flourishing in Canada. Canada established NP run clinics in 2007 and is continuing to add more as they are filling an important void in primary care. The article wonderfully points out that this initiative is collaborative an is not looking to supplant anyone else (for those worried about that).

Great read. I'm hopeful that people are paying attention.

Proceed with Caution

2010-05-26T11:08:00.003-04:00

One can find a myriad of commentaries written on the future of primary care now that health insurance reform has passed. Many of these refer to nurse practitioner led clinics and how this can be one possible solution to care for the millions of Americans that will now have health insurance. Of course, I am a proponent of NP guided care and believe that patients form long lasting partnerships with NPs to help make choices about their health and wellness.

As I've stated before, NPs are not brand new to the health system and have a 30+ year history of providing high quality care. A number of NPs right now own their own practices while others can be found in school-based clinics, hospitals and physician's offices. Unfortunately, NPs face many of the same types of issues that has driven physicians out of primary care. Dr. Karen Li wrote a wonderful column, "Why I Left Pediatrics," that describes the reality of the barriers in health care.

We simply cannot expect NPs to fill the void in primary care settings while maintaining the widespread dysfunction of the health system. It will only be a losing battle as we try to care for our patients. I do however, remain optimistic that we have taken an incremental step in the right direction. We realize that maintaining the status quo is no longer an option. NPs will hold increasingly significant roles in the system. To avoid ending up in the same situation, we need to ensure that all stakeholders are at the table as we write the next chapter in health care.

Guest Post: The Future is Bright for Careers in Nursing

2010-05-24T11:02:00.002-04:00

The Future is Bright for Careers in Nursing

If you listen to the media pundits, you probably think that now is the worst time in recent history to be entering the job market. With our country experiencing a definite financial downturn and the global economy in serious jeopardy, this is true for most career options. But some occupations are holding steady and even seem poised to expand in the coming years. Nursing is one such line of employment.

From becoming a registered nurse in an ER or private practice to offering assistance and education to children as a school nurse to entering a caregiver situation in a private home, opportunities in nursing do not seem likely to subside over the next decade and here’s why. For starters, everyone needs health care. Maybe not today, maybe not tomorrow, but we’re all going to contract an illness, have an accident, or simply experience failing health at some point in our lives. We’ll need a nurse (or at the very least, our doctor will), and some of us more than others. The sizeable generation known as the baby boomers is currently hitting retirement age. As they continue to age, the number of senior citizens requiring medical care in this country is going to skyrocket, creating a need for more medical professionals. And since this time is nearly upon us, nurses will soon be in high demand.

But there’s more to it than that. The recent passage of health care reform has guaranteed that previously uninsured Americans will now have access to medical care through the implementation of a public program. This means that millions of people who avoided hospitals and doctor’s offices in the past will soon be seeking preventive care and other medical services. This bodes well for nursing, which will surely become one of the few occupations to offer employment in unparalleled numbers over the next several years. In fact, there is a good chance that our country will experience a deficit of qualified individuals as college recruiters scramble to fill the gap.

So if you’re still trying to figure out your college curriculum and you’re considering nursing, or even if you set to embark upon a career, getting into the job market should soon be even easier. A few years ago, people going into web design were taking their pick of jobs and demanding higher salaries due to a small supply of qualified workers facing an overwhelming demand. Nursing is set to experience a similar situation in the coming years. Those who are qualified will certainly experience the benefits of coming into the profession at just the right moment to capitalize on what looks to be a wide open field.

Guest Post by: Sarah Leonard of the Nursing Degree Website.

Submit a guest post: anpview at gmail dot com.

Thank You!

2010-05-17T09:00:00.002-04:00

Just wanted to say Thanks to anyone who voted for my blog at Lydia's Uniforms site. My blog won the Top Nurse Blog! Again, thank you for reading and voting.

Stephen

Guest Post: Nurse Practitioners

2010-05-14T12:10:00.004-04:00

I was saddened to see an advertisement in the local paper for a new clinic which will be opening up. I'm very happy about the clinic and the fact that a good friend of mine will be the Nurse Practitioner (NP) there. She starts in a couple of weeks. Until then, another NP friend of mine is filling in. They had a ribbon cutting ceremony and pictures were taken outside the building for the local paper. This photo included staff members from the clinic, including a very professional-looking NP, the clinic manager, a "supervising physician," and some local "important people." All this looks great on the surface to the casual observer. Then I read the article. The only mention of the NP was to say that she is "a good listener." Well so what?? Plants are good listeners. Don't get me wrong, listening is a skill that all medical providers need to master, because most of our work is accomplished and proper diagnoses are made because we listen; but one must have an education and some experience with diagnosing and treating illness to go along with those listening skills. I happen to know this particular NP has excellent diagnostic skills, which is what a patient needs to be assured of when seeking out a healthcare professional. Why do you think patients seek out the most qualified person for the job when looking for a healthcare provider? I can listen to her all day, but if I don't know how to diagnose or fix the problem, I'm not of much use to the patient.

The second issue I have with this article is the fact that a medical doctor was interviewed for the article and will have very little to do with the operations of this clinic. You see, in Tennessee, nurse practitioners are required to have a doctor come in and sign off on 20 percent of our charts (100 percent of any charts where a narcotic is written). This does not mean we are working "under the doctor," as so many imply. We are working under our own license and our own DEA prescribing number. They are simply paid to review some charts and put a signature on them. You see how ludicrous this is. Don't get me wrong, the doctor they interviewed is a wonderful guy, and a great doctor. I simply find it so sad that we feel we must give patients the illusion that a "real doctor" is somehow involved in operations of the clinic.

For those of you who don't know, NPs have at least at Master's Degree, which is 6 years minimum. For many of us, it also includes several years as an RN before completing those years of school for the NP degree, which was a priceless part of my educational process. I want to spread the word that we are here to stay, we don't need to hide behind a doctor's name, we have one of our own. Patients have a choice to see us or not, we are not pulling the wool over their eyes and trying to be deceitful just to get patients.
Most NPs, like most MDs do a good job. I urge you to see the difference for yourself. You may not notice any. You may have a bad experience. You may find the provider you want to stick with as long as you live. I just ask that you know who you are seeing and that you give the credit to that person alone for the care they provide.

Kim is a Nurse Practitioner and writes her own blog at KIMblogery. (This post originally appeared on KIMblogery on 12/15/2009 and was reposted with permission).

Submit a guest post: anpview at gmail dot com.

Submit a Guest Post

2010-05-11T15:30:00.003-04:00

Have you ever wanted to write a blog but didn't have the time to keep up with it? Do you already blog and would like to get some additional exposure and cross-readership? If the answer is yes, I invite you to submit a guest blog post! E-mail me at anpview at gmail dot com and submit your post. Here are some guidelines:

Have your writing be related to something you are passionate about (in the health care field)
A minimum of 250 words

That's it! So, put on your writing caps and send me your post. Please include your contact information too (it won't be published unless you request it).

Hope to hear from you soon!

Stephen

Bring It

2010-05-03T22:21:00.003-04:00

An op-ed piece was recently written by the president of the Nurse Practitioner Association of New York, entitled, Take Advantage, New York, of our nurse practitioners. As if on cue, the medical society in New York played the same old card under the guise of "patient safety" and responded with their take on the issue, Rules exist to protect patients.

Any regular reader of this blog knows the countless times I have pointed out the bogus claims that organized medicine uses as scare tactics that ultimately translate into turf protection. In this article, the author claims a "maldistribution" of the physician and nurse practitioner workforce. See, we don't really have a problem, its just that patients are in the wrong areas of the state! Perhaps we can find some grant money to redistribute patients to where there are so many providers in the vast utopia where most of us in NY live. This of course is where no one needs to wait for an appointment and access to providers is instantaneous and efficient.

They seem to suggest that only physicians are "those best suited to render care to patients." How about that? I wonder how that one will work out. If you think there is a shortage of physicians now, its going to be real tough to find one when they will be staffing hospitals in place of nurses, respiratory therapists, physical therapists, dietitians, etc since supposedly they are the only ones best suited to "care" for patients.

The facts are that nurse practitioners have been and will continue providing high-quality, efficient and evidence-based care and this largely doesn't have anything to do with mandatory collaboration but with our experience, education and training. If that wasn't the case, we would not be granted licenses or certifications from the state that allow us to care for our patients albeit with an arbitrary restrictive barrier. (If my collaborating physician moves out of the state, retires, or one day simply decides to stop collaborating with me, my patients are left without a health care provider and I am left with patients whom I treated yesterday, but can't today).

To them, it's all about maintaining the status quo in a dysfunctional system fraught with disparities, inequalities, and waste. For anyone who can't blatantly see past that, I know a good primary doctor that I can get you to see on the same day who even accepts your health insurance.

Another Media Piece

2010-04-30T23:11:00.004-04:00

Here is another positive view of NP guided care specifically in New York. Of course, it is not without the organized medicine tagline of playing the "quality of care" card under the guise of protecting patients. However, we know that retrospective chart reviews (the current requirement in NY and in many other states) is not about quality of care.

In fact, peer chart review should be a requirement for all clinicians. Every professional should engage in ongoing chart reviews (I actually prefer benchmarking and looking at actual data/outcomes against versus simply reviewing a chart).

I just don't understand the constant undertones that NPs are prone to making mistakes or will "miss something" and that having a collaborating physician review the chart 3 months later somehow will "ensure quality." NPs see thousands of patients every day and we have proved and will continue to do so that we provide quality evidence-based care.

And now to the video...

Susan Apold, PhD, ANP on Fox and Friends Debating NP Role

2010-04-25T15:17:00.006-04:00

Wonderful job by Dr. Apold, Chairperson of the Board of Directors of the Nurse Practitioner Association, New York State (The NPA). Dr. Motta of the Massachusetts Medical Society also did a good job for making the case for fully utilizing NPs in the health care system and couldn't give any evidence-based reasons not to.

Great Read

2010-04-22T13:29:00.002-04:00

Maggie Mahar writes a wonderful column, "The Battle over Letting Nurse Practitioners Provide Primary Care." I couldn't have summed it better myself.

Reflections

2010-04-20T09:49:00.007-04:00

With the recent increased media attention regarding nurse practitioner practice, I've noticed many inconsistencies and misconceptions in the media. Here are some of my own clarifying points:

Nurse Practitioner practice is not brand new. The profession has been around since the mid 1960's. Therefore, all of these intimations that we are doing something (or looking to do something) new is inaccurate. There is a 40-year history of NP practice.

NPs are not individuals who one day arbitrarily started writing prescriptions. There is a standardized education, training, licensure, and certification process that allows us to perform in that capacity. There are differences in each State practice act that sets the standard for what we can (and can't) do in each state. Note that the majority of State acts have these regulations that haven't been updated to reflect current education and training.

The Doctor of Nursing Practice (DNP) degree is often linked to these conversations but this is really a separate issue. Yes, this is a relatively new terminal clinical degree for the profession. There used to be to be the Doctor of Nursing Science (DNS) that has pretty much fallen out of favor to the DNP. Why in the world would this be a bad thing? (Oh right, because we are trying to confuse everyone into thinking we are really a "doctor" which I guess is some how synonymous only with a "physician" these days.) Now, this educational degree in and of itself does not change existing practice. There are many opinions about the DNP degree out there (of which I will share mine soon) but the bottom line is that the degree does not change the requirements of current state licensure/certification and to the already existing 140,000+ NPs.

Our approach to patient care is not the allopathic model. We utilize a synthesis of both nursing and medical knowledge to care for patients. I as an NP, generally feel that lifestyle modifications, health education and communication, disease prevention/treatment, wellness preservation and a partnership approach are driving principles of my philosophy to practice. NP education has largely adopted the evidence-based practice (EBP) model of care. That is, using proven interventions in the provision of care rather than doing something the way it's been done forever. Does this allow us to spend more time with patients? Perhaps. But maybe the evidence suggests that spending more time with patients produces better outcomes.

NPs face the same reimbursement issues that primary care physicians face (albeit at an even more reduced rate - Medicare reimburses NPs at 85%) yet the majority of NPs choose primary care or closely related field to work in. This, of course, assumes that every NP wants to own their own practice. I will go out on a limb and say that most want no part of this. The push for autonomous practice stems from out-dated and arbitrary barriers that negatively affect patient care. For example, the NP working for a physician in Florida with no intention of starting their own practice but with their own panel of established patients. The NP sees one of their patients determines that the patient needs some pharmacological pain medication intervention yet cannot prescribe this to their patient since there is no physician in the office that day (Florida NPs cannot prescribe controlled substances). The patient is ultimately out of luck here and suffers since they cannot have their pain managed. It also puts the NP at an unfair disadvantage since patients knowing this regulatory issue may choose another provider based on this.

NPs are filling a void in primary, not "taking over." I've said time and time again in this blog, let the patients decide if they want care from an NP. If not, we would surely have little to argue against. However, if patients want to choose care from an NP, they should be able to without prejudice or barrier.

I continue to have tremendous respect for my physician colleagues. I appreciate their time commitment to the education/training process and vast knowledge base. I cannot perform surgery or many other procedures nor would ever want to. But I am confident in identifying when a patient does need surgery for example. I just don't necessarily think that physicians can be the only providers and captains of health care. I don't buy into the argument that we don't know what we don't know. We all collaborate and refer to colleagues when something falls outside of our comfort zone or specialty. The one who thinks they know it all and can cure all is the one I would be especially leery of.

Momentum

2010-04-15T08:16:00.003-04:00

U.S. World News & Reports' Dr. Bernadine Healy gets it. She serves as their health editor and her latest column, The New Doctors in the House, is one of the most objectively and frankly written that I've seen that describes NPs filling the gaping holes in primary care.

Check it out and tell me what you think.

The Interwebs are Abuzz

2010-04-13T22:51:00.004-04:00

The interwebs are abuzz with the latest AP article, Doc deficit? Nurses' role may may grow in 28 states. The article is pretty well balanced and has views from patients, nurse practitioners and our physician colleagues. There is a sense and some from the medical community imply that NPs are trying to expand scope of practice. I think that is a fairly short-sided and inaccurate view of what is going on at the state level. Most of the collaboration and supervisory regulations were written when the profession was brand new, is not based on any evidence, and does nothing to improve the quality of care as they are retrospective in nature. Removing statutory collaboration or supervision would not change how NPs are educated or trained. It would however, increase access to more providers.

Each day I see how breakdowns in communication and how ill-planned initiatives negatively impact patient care. This has little to do with the knowledge base of the providers rather than not knowing how to work together and ensure everyone is on the same page. It is so cliche but what we often have is a failure to communicate.

Nurse Practitioner Recognition in New York

2010-04-07T08:20:00.004-04:00

Here in New York, the month of April is proclaimed by the governor as Nurse Practitioner Month. This is a noble attempt to recognize the work and care that the 13,000 or so Nurse Practitioners do every day in New York.

I'm curious if other states have such proclamations or if anything is done on the state level to recognize NPs. Please post any information relevant to your state and I'd be happy to list the data in a table.

And to my fellow New York Nurse Practitioners (and NPs all over), Happy Nurse Practitioner Month!

More Bloggers

2010-04-05T10:42:00.005-04:00

There have been quite a few new NP student/NP blogs that have recently sprung up and I highly recommend that you check them out. Over the last few years, there has been a lack of NP representation in the blogosphere (other than a handful of NP authored blogs). There are plenty of well written physician and RN blogs in existence so it is nice to hear the stories, messages and advice from the NP perspective. I try to keep my blogroll on the right hand side of this page updated with new and timely blogs. Here are just a few to check out:

Laura blogs over at Ask the Nurse Practitioner, http://askthenp.blogspot.com/, and gives patient-centric answers to some common questions and sets the record straight on some myths health myths.
Jeff blogs at NP Health Care - Nurse Practitioner Owned and Operated Practice, http://nphealthcare.blogspot.com/, and shares his (seemingly frustrating) instances of owning his own NP practice in Texas.
FNP Student blogs at Triumphs and Tribulations of a Student Nurse Practitioner,http://fnp2011.wordpress.com/, and shares her experiences on her road to becoming an NP.
Michael is a Physician Assistant and blogs over at Are you a Doctor?, http://physasst.blogspot.com/and offers his views on timely health topics from the PA perspective.

I encourage anyone with a story to start a blog. There are many untold experiences out there and blogging helps to get the message out and can even be therapeutic in a way. Be sure that patients can not be identified and update often!

(I've also connected with some awesome people on Twitter and have found additional blogs and stories to share. Follow me on Twitter @StephenNP).

A Changing Landscape

2010-03-30T13:13:00.005-04:00

With the passing of the recent historic health insurance reform, the focus has turned (see here and here and here) to how will the system deal with the influx of approximately 31 million newly insured seeking access to care. All of these articles address the current shortage of primary care physicians in some way and creates a sense of urgency for patients to try and secure one before access becomes crippled (as it has in Massachusetts).

What these articles fail to address is the true potential that NPs and PAs have to pick up this slack. There is this incorrect assumption that NPs, facing the same barriers in primary care, are flocking to lucrative specialties. Fortunately for patients, this is not the case. A recent survey by Advance for Nurse Practitioners, reveals that most of the NPs polled work in predominantly primary care or primary care-type settings. Also a very informal survey of the NPs that I know has a similar result.

So what does all this mean? The good news is that potential solutions already exist to help with this dilemma. I believe that primary care physicians in the trenches largely recognize this and together we are trying to innovate the system and provide high-quality care with the limited resources we have. We are examining new models of delivery and determining how technology can work to our advantage and improve communications among patients and enhance the continuity of care. The bad news of course is that the aforementioned is easier said than done. Opposition to NP directed care and turf concerns are abundant. State laws and regulations regarding NP practice are out-dated, not evidence based and vary from state to state leaving a patchwork of rules and regulations further impeding access.

I remain hopeful that we will slowly improve the system so that these newly insured as well as already insured will have access to high-quality whole-istic care, will take a meaningful and responsible role in their care, thus producing better outcomes than ever before. It will not be easy and it will be with on-going debate but the landscape of health care will be different in the near future than it is today. It has to be.

What Impact Will Reform Have On Nurse Practitioner's?

2010-03-23T11:06:00.005-04:00

There are so many unknowns regarding both patients and providers with the passing of the recent monumental health care legislation. Thanks to a recent post on AJN's Off the Charts blog, they posted a link to a handy ANA chart comparing both versions of the legislation and what it means for nurses and nurse practitioners.

Of course, this is subject to change somewhat based on the revisions that still need passing however, I would imagine that it will remain pretty close to this.

It appears the biggest factor for NPs is the ability to lead the team of providers in Patient Centered Medical Home demonstration projects.

Stay tuned for more on this white hot topic of reform......

New Nurse Workforce Data

2010-03-18T15:04:00.004-04:00

The US Department of Health and Human Services just released "Initial Findings from the 2008 National Sample Survey of Registered Nurses." There is some valuable and interesting information in the latest report (the last one was done in 2004).

Of note:

There were an estimated 3,063,163 living in the US as of March 2008 (of these, 2,596,599 were employed in nursing positions).
The average age for all licensed nurses rose from 46.8 to 47 years and employed nurses rose from 45.4 to 45.5.
There are 158, 348 identified NPs
The number of NPs grew 12.1% over the last 4 years
There were an estimated 28,369 RNs with a doctoral degree in 2008. This is an increase of 64.4% since 2000.
The workforce is becoming more diverse. 6.6% of nurses are male (a small jump from 5.8%) but a higher percentage of recent graduates were male from previous (4.1 % prior to 1990 vs. 9.6% since 1990).
Hispanics are the most rapidly growing group of registered nurses.

These are just a few highlights from the report. I highly recommend that you review the report to review the data. It is important to recognize and understand the composition of the largest collective group of health care providers in the U.S. After all, these individuals will be among those caring for America.

I Took the Bait

2010-03-11T20:57:00.007-05:00

I have tried to refrain from taking the bait from some recent negative opinions regarding nurse practitioner delivered care. Quite frankly, the arguments are old and tired. My goal as a clinician is to deliver the highest quality, evidence-based, and culturally competent care that I am capable of. I refuse to pit NPs versus other professions. We all have our own slightly varied philosophies and approaches to delivering care. Some may prefer the approach of a DO while some choose to see a NP or PA or MD. I believe patients have that right. However, I cannot believe the nonsense and out of context rubbish posted on the AMA's "Virtual Mentor" in a column entitled, "The Primary Care Shortage, Nurse Practitioners, and the Patient-Centered Medical Home." Oh, where to begin!

The opinion piece begins with the patronizing idea that NPs are part of the solution but not THE solution to the primary care crisis in this country. Funny, but I couldn't find a single reference that states NPs want to solely take over primary care. It goes on to give a functional definition of primary care and states:

Primary care serves four important functions in the delivery of health care: (1) first contact access for each new medical need, (2) long-term, person-focused (not disease-focused) care, (3) comprehensive care for the majority of a person’s health related needs, and (4) coordination of care when it must be sought elsewhere.

Wow, that sounds an awful like what NP philosophy is grounded in:

NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices. They are truly your Partners in Health. In addition to being top-notch healthcare providers, NPs deliver a unique blend of nursing and medical care. They provide comprehensive, personalized health education and counseling. NPs assist patients in making better lifestyle and health decisions.

The next statement in the piece is truly baffling:

Primary care physicians are the only medical professionals who provide patient-centered, integrated, accessible health care that addresses the large majority of patients’ needs in the context of a sustained partnership with the patient and the community [2].

Huh?!? Is that your opinion or is that paraphrased? That reference comes from Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.

I could not find any mention of that within the reference. Unfortunately, there is no page number to cite it from. In fact, reading through this very reference, I found:

...[the] definition of primary care...is presented in terms of the function of primary care, not solely in terms of who provides it" (p. 2).

These authors go on to say that critical elements of primary care include: "services provided by primary care clinicians - generally considered to be physicians, nurse practitioners, physician assistants - but involving a broader array of individuals in a primary care team..." (p.2).

The next few paragraphs suggest that primary care by primary care physicians is *better* than care delivered by anyone else. Of course, these studies aren't even looking at physician-directed care - they just underscore the need for primary care.

Here is another great quote:

Policy discussions about ways to increase the primary care physician workforce have considered utilizing nurse practitioners to address the shortage of primary care physicians. Nurse practitioners are part of the answer, but they are not the solution. Although nurse practitioners provide some types of care that primary care physicians do, their training is very different. There are limits to a nurse practitioner’s ability to deliver the full-service, comprehensive care delivered by primary care physicians.

The limits to a NPs ability to deliver this care has nothing to do with education but oftentimes is restricted by antiquated statutory regulations. Requiring a collaborative agreement costs practices time and money requiring physicians to co-sign charts, which is not a good use of anyone's time, is retrospective, and has no evidence to support enhanced quality in any way.

Next the author mentions the 2004 Cochrane systematic review, "Substitution of doctors by nurses in primary care." A systematic review attempts to use a non-biased systematic approach to review the available evidence from previously completed studies. I am certain that this author did not even read the full review since their criteria was looking for data from the period of 1966-2002 (he sites the lack of "recent" data) and in total only 16 studies were used for inclusion methods (he makes it seem as if the evidence was robust). Incidentally, the review didn't just examine NP care - it also looked at registered nurses trained in primary care and clinical nurse specialists). Incidentally, the reference list in this study has the authors names misspelled. I am also perplexed by this statement:

By comparison, the studies cited above on outcomes in primary care have demonstrated improved patient outcomes with an increased primary care physician workforce [4, 6].

Now maybe its my little NP incapable brain that cannot comprehend all of this data but the aforementioned studies DID NOT EVEN MAKE THIS COMPARISON as he purports! Again, I checked those references and could find no such information.

Next, the author refers to some fuzzy calculations that NPs going into primary care is declining. While this may be true, it is because the NP profession has had explosive growth over the last 10 years and there is no way that it could be sustained. It has also been traditionally difficult to gather accurate data on NPs in the workforce. So, yes, the numbers are declining but not because we are choosing not to go into primary care. In fact, one estimation states there are collectively more NPs and PAs providing primary care than they are family physicians (Green LA, Dodoo MS, Ruddy G, Fryer GE, Phillips RL, McCann JL, et al. The physician workforce of the United States: a family medicine perspective. Washington, D.C.: Robert Graham Center, 2004.)

Finally, the author uses the current buzz-term, the patient-centered medical home, to suggest a physician-centric approach utilizing NPs as "vital team members" will somehow meet the demands of the primary care crisis. This statement is patronizing, is simply misaligned with the definition of primary care and is anything but "patient-centered." If it's truly patient centered, I say let the patient have a say in the provision of care.

To sum, I am woefully disappointed that such a crudely researched article with out of context facts is allowed to be published on a professional organization's website. The Virtual Mentor (VM) "explores the ethical issues and challenges that students, residents, and other physicians are likely to confront in their training and daily practice." This type of rhetoric only begets further silos among disciplines and misrepresents the nurse practitioner profession where ultimately coordination of care and communication is compromised. Shame on them.

I just had to get that off my chest.

Evidence in Labeling

2010-03-04T08:46:00.003-05:00

The NY Times reports that the F.D.A. is cracking down on food manufacturer's health claims on their package labels. I have somewhat mixed feelings on this. On the one hand, if a purported health claim is enough to convince someone to make wiser eating habits, then that has to be a benefit (albeit to the financial advantage of the manufacturer). However, as we strive to incorporate scientific evidence into these health claims, they need to be accurate and actually based on good data. A lot of supplements and vitamins now shy away from clear health claims for fear of the same F.D.A.-type crackdown (though is simply adding the word, "may" to the claim enough? As in "Vitamin C may contribute to increased immunity," etc.)

It seems as if the F.D.A. is willing to work with the manufacturers to convey accurate and scientific information that should satisfy the manufacturers while protecting and correctly informing consumers and this should be lauded.

Wonderful Resource: How Healthy is your County?

2010-02-17T12:35:00.005-05:00

Today, the University of Wisconsin and Robert Wood Johnson Foundation launched www.countyhealthrankings.org, a website that examines the health of each county in the United States and ranks them accordingly. This is a wonderful resource for both patients and health providers that examines health at the local community level.

Health disparities exist here in our own country. This new comprehensive database is an evidence based perspective so we can begin to address these issues.

All key stakeholders must be engaged if we are going to make a difference. Where does your county rank and how will you address these disparities?

(image borrowed from:http://www.msnbc.msn.com/id/35439793/)

Let's Move! & Serving Size

2010-02-09T10:22:00.006-05:00

Today, Michelle Obama launched the Let's Move! campaign to tackle childhood obesity. The goal of the program is: "to solve the epidemic of childhood obesity within a generation." We are right there with you to tackle this challenge!

Speaking of obesity.....

William Neuman of the New York Times takes on our antiquated and hard to interpret food labels in terms of serving sizes. Its a great video and shows what a serving size should be according to the label. Now, the FDA is considering changing the standard serving sizes and encouraging manufacturers to list calorie counts on the front of packages.

It is truly mind boggling to try and interpret portion sizes and nutrition information on today's foods. Most of us under-estimate the amount of food we eat. Healthy living begins with our diet and if we cannot adequately determine the nutritional value of what we are consuming, it becomes impossible.

This also ties into the recent study that showed calorie counts are frequently less than what they actually are. If we are going to make any progress in the fight against obesity, we need to have the correct information from the outset.

Enjoy the video....

Removing Barriers

2010-01-27T22:09:00.005-05:00

Thank you to New York Senator Montgomery of Kings County for introducing legislation that will allow nurse practitioners to sign death certificates (S.2969). The bill passed the NY State Senate with strong bi-partisan support, 58-3. It must next pass the Assembly and then on to the Governor's desk for approval to become law.

Here is some additional information on the bill and its rationale.

iPad and Health

2010-01-27T15:03:00.007-05:00

I am a techno geek. I love my iPhone and BlackBerry. I have a laptop, a netbook and a couple of desktop computers. I am currently piloting a Kindle DX, which is pretty cool.

Today, Apple introduced the iPad, their hotly anticipated tablet computer. It is a beautiful device, about the same size as the Kindle DX, though basically a blown up iTouch. While I can't wait to get my hands on one (it's not available for another 60 days or so), I wonder what apps will be developed to enhance the flow of information in health care. There are already a number of EHRs that run on mobile platforms and since this basically uses the iPhone operating system, it would appear that this is tailor made for health applications - both on the patient side and on the clinician side.

This device may aid in the modernization of health records. The flow and integration of data can and should be so much better. I believe this is a game changer and we will see a further explosion of health related apps and uses.

And it can be yours starting at $499. Very cool.

Show me the Love

2010-01-20T11:31:00.007-05:00

I came across this wonderful post on Dr. Edwin Leap's blog, "Attention Doctors: People may not like you." It is relevant for all clinicians and talks about the interactions between patients and providers, patient expectations, and the handling of these expectations.

The important thing to remember is that we are providing a service to our patients. Patients come to us for our advice, opinion and to make them feel better. Some may not agree with our plan and will seek further opinion - and sometimes they certainly should. Patient's should be empowered to be actively involved in the decision making process. But oftentimes silos are created, further fragmenting care and communication. That's why I believe firmly that comprehensive care is best delivered in teams - where team members share the same focus and are aware of each other's strengths and weaknesses. There are so many patient variables to consider: culture, socio-economic status, gender, past medical history, genetics, etc. The list can go on and on. Surely, some providers are more apt to care for certain conditions given the complexity of the individual than others (and I'm not necessarily referring to traditional specialists per se). In addition, there are the many treatment modalities to consider. Is that treatment modality proven? Does the evidence support it? Will this treatment work for this specific patient?

I'm not sure what that model of health care truly looks like or if it even exists today. I don't think we need to get too complicated and assemble "true" teams complete with uniforms, logos, statistics, coaches, general managers, free agency, arbitration, and a trading deadline. Or should we? One of the main problems is that the health care "system" isn't coordinated by anyone or anything. Could this be the opportunity for the "medical home" concept to flourish?

The bottom-line is that we are judged by our actions and interactions with patients. We must constantly remind ourselves of this. Most of them will be favorable (hopefully) and some won't. Clinicians need to perform a delicate balance of providing evidence-based and compassionate care, being an effective communicator, yielding high-quality results while doing all of this cost efficiently. The question becomes, How can patients objectively evaluate this information? Does anyone have any suggestions???

Health "Advice"

2010-01-13T14:29:00.004-05:00

An article appears in Health Magazine advising its readers "when its OK to skip the Doc." But of course in doing so, nurse practitioners get slapped. You see, the article refers to convenient care clinics - a continually hot topic - and how their nurse practitioner staffed model makes it OK for them to treat minor boo-boos but aren't capable of treating more serious maladies.

Now in all fairness, most clinics aren't currently designed to treat conditions beyond episodic-type care and health screenings though there are reports that say this trend may be slowly changing to include other conditions. I just don't understand why the inference is always that the NPs staffing them are limited to treating just those conditions as well. I know plenty of instances where NPs referred patients to other providers based on subtle signs picked up during a convenient care visit which might've otherwise gone unnoticed. Further, patients in these settings were easily able to access a clinician and ask for advice and direction. I'd much rather have that be the case than a patient ignore their signs and symptoms due to lack of access.

NPs can be found in all settings: from hospitals to private practice to school-based clinics and beyond. The "advice" in these types of health publications minimize the role we play and cause confusion to the public.

I'm sure that clinicians in retail eye care, urgent care centers and the infamous doc-in-a-box delivery models faced the same type of issues. We realize today that the status quo is no longer acceptable and we must have delivery models adapt to where patients the patients are.

The most ironic thing about this article is a link to a related article entitled, "Danger at Your Doctor's Office" and uses an unfortunate missed diagnosis by a physician resulting in an advanced terminal cancer in one of their patients.

The reality is clinicians make mistakes. Critical lab results get missed and reports get misfiled. This is the case across all disciplines. Hopefully, this will be less common with a move towards more streamlined electronic records. However, publications should be giving its readers evidence-based information to promote empowerment and advocacy to patients such as getting a copy of your lab tests and progress notes for your own file. And keeping detailed records of signs and symptoms, etc. This is the type of advice that patients should be given.

Tis the season...

2009-12-23T19:49:00.004-05:00

Just when you think you might've seen it all, some companies are rolling out medical gift cards. There is perhaps nothing more complicated as a health care consumer attempting to navigate the health care system and trying to figure out costs. I can see it now: bewildered looks from health office personnel trying to decode what the card even is in the first place; "should we apply this towards your deductible, or maybe the lab fees" etc. Of course, the problem is most of the time folks have no idea what they are paying for health care services and providers don't know what they are getting reimbursed.

Here is just another poor attempt at trying to solve the mess of the health care system we have today. At least with a Health Savings Account (HSA) you get a break with it being tax-exempt. I'm not sure what benefit these medical gift cards offer. Maybe since costs are so out of control, people would rather not carry around the wads of cash to pay for services?

So if you are in a bind this holiday season and are in need of a last minute holiday gift, run to your local pharmacy and buy your loved ones a medical gift card. Who knows, maybe they already asked jolly old Saint Nick for that appendectomy or knee replacement they are hoping will be left under the tree.

(image borrowed from https://bcspinball.com/images/giftcard.jpg)

Its been awhile...

2009-12-21T10:37:00.005-05:00

Hi All,

It has been awhile since I've last had a thoughtful blog post (a hectic personal life has a way of re-prioritizing things!)

Though there's been no shortage of topics to write about. The heath care reform bill has gained momentum, mammogram screening guidelines were revised, and H1N1 vaccine and cases continue to make headlines.

This is certainly an interesting time to be in health care. I look forward to seeing what the future brings and plan to be part of these discussions (or at least have something to say about them here on my blog).

Till then......

Happy NP Week

2009-11-10T21:14:00.002-05:00

Happy NP Week to all of my NP colleagues out there!

If you are a patient of an NP or work with one, be sure to recognize the fine work they do every day.

Here is the press release from the American Academy of Nurse Practitioners and the theme this year is 125,000 Solutions to the Primary Care Shortage.

(I'm a bit late, but also Happy PA Week to all of my physician assistant colleagues).

AHRQ Ad Campaign: Questions are the Answer

2009-11-07T09:09:00.004-05:00

I came across this well thought out commercial that has appeared on TV from the U.S. Department of Human Health & Services' Agency for Healthcare Research & Quality (AHRQ). Their website has a few other public service announcement-type of ads. With their, "Questions are the Answer" campaign, they are encouraging patients to ask questions about their care and to take an active role in the provision of their care. Hopefully, patients and providers alike will embrace this idea so that there are more answers than questions.

Any questions?

H1N What?

2009-10-13T19:15:00.004-04:00

With all the talk about H1N1 influenza, I think it;s important for folks to understand where the H1 and N1 come from.

The "H" comes from the substance hemagglutinin and the "N" comes from neuraminidase. There have been identified influenza strains of the H and N types and this is how some influenza viruses are classified. The particular "swine" flu that has garnered so much attention is of the H1N1 type. A few years ago, the fear was of the avian type, H5N1.

This past Spring, the Wall Street Journal Health Blog did a good job explaining some of the background regarding the naming of this particular strain of influenza.

This may help us all understand the nomenclature and rationale behind what has become household names.

Provider Ratings

2009-09-28T10:38:00.003-04:00

I recently decided to obtain auto insurance quotes from most of the major insurance companies websites. The quote process is generally very simple: enter your information and you get an instant on-line quote. As I feel it necessary to perform some due diligence and not just go with the least expensive quote, I Googled "auto insurance ratings." Well, what a frustrating experience. I wouldn't say that I am now more confused - only that it wasn't at all helpful. The Web is filled with a smattering of reviews and many of the negative ones seem that there is more to the story than what is written. In addition, we mostly know that an unsatisfied customer is much more likely to take their story to the Internet and post it as opposed to a satisfied customer with no issues.

What's my point to this post? I have come across various articles and websites that give patients the opportunity to rate their health care provider. In fact, here is an example of such a site. One can even go to Yelp to get provider-specific ratings from their patients. I have some concerns over what impact these ratings may have on providers and patients. Clearly, objective data cannot be disputed such as the education, training and the certification of providers. However, how much emphasis can we place on subjective data? Does this truly help us when choosing a provider? The patient who claims to be "mis-diagnosed" is much more likely to post this experience than someone who is truly satisfied and happy with their care.

I would much rather see some sort of qualitative data (i.e. percentage of patients with diabetic complications, number of hospitalizations, etc) when choosing a provider. Unfortunately, much of that data is nearly impossible to aggregate with the archaic paper and pen records system of most practices. So, we are largely left with subjective data to guide our decision when choosing a provider (this also assumes that we actually have a choice when it comes to choosing providers - I'm not sure most of the un or underinsured are taking to the Internet to research this kind of data).

What do you think? Are these rating sites helpful? After all, nearly every other industry uses customer ratings on their websites (think eBay and Amazon). Should health care also follow suit? Could this create a new independent agency whose purpose is to perform these ratings (such as a J.D. Power & Associates)?

Now I must go back to making that auto insurance decision!

Mandatory Flu Shots

2009-09-26T10:12:00.003-04:00

The New York State Department of Health recently passed emergency regulations requiring all healthcare personnel working in hospital and nursing homes to receive mandatory influenza vaccinations or face termination of employment.

I am a vaccine advocate and believe that vaccinations have decreased and in some cases eradicated some infectious illnesses. I do, however, worry about the mandate aspect of this law and how it will be truly be enforced.

What do you think? Good idea? Cutting-edge? Violation of privacy? I'd love to hear your thoughts.

You Can Count On Us

2009-08-31T23:28:00.005-04:00

Pennsylvania Governor Ed Rendell, a longtime champion of NP practice writes a column in today's USA Today, "Health reform can count on nurses." I am encouraged by this support and recognition for the thousands upon thousands of NPs, Nurse Midwives, Nurse Anesthetists, and Physician Assistants practicing and caring for patients in community, hospital and out-patient settings every day. We are not a new concept nor fad. Our practice is centered on our patients.

I invite everyone to read the blogs on my NP Blogroll. You will find examples of the extreme care and commitment we give to our patients. It certainly seems as if Governor Rendell is reading. Its exciting to ponder who else may be reading as well.......

Forms, Forms and more Forms

2009-08-27T09:38:00.004-04:00

It's back to school time and that means droves of physical forms flowing into offices as a requirement for school. Each form is different in its length, complexity and readability. Some practices have refused to complete forms and will attach a copy of their own. Some practices charge an additional fee to have the forms completed.

Why can't we ascribe to a standardized school form that everyone can use? I have seen some forms ask only for height, weight blood pressure and immunization history while others require a complete review of systems, physical exam, diagnosis, and dietary restrictions.

What do you think? Should we have a standardized physical form? Do you charge extra for completing patient's forms? If you are a parent or a patient, what do you think of this superfluous and redundant paperwork?

I'd love to hear your thoughts.

Evidence-Based Prevention

2009-08-11T12:54:00.003-04:00

Here is an article from the U.S. Preventative Services Task Force and is a resource for NPs to implement evidenced-based preventative practice.

When the buzz today is about health care reform, here is a good place for us all to start - talking about a preventative proactive evidenced-base approach rather than the opposite of that (which is what we largely have now!)

For the Record

2009-08-02T20:21:00.006-04:00

Here is a very informative interview about current NP practice and health reform from nurse practitioner, Dr. Thad Wilson, president of the American College of Nurse Practitioners (ACNP). Dr. Wilson eloquently provides clarification of the NP role and how our health system will be a better place when full inclusion and barrier-free practice is consistent along state lines.

Thanks, Dr. Wilson.

There is a post on the same site from a third year medical student about health reform and refers to chatter about nurse practitioners supplanting primary care physicians on a particular board. The posts on that board are certainly entertaining and show how turf wars are alive and kicking.

I hope that folks will read Dr. Wilson's interview to get an alternative perspective and realize that we need to work together to ensure that our families and our communities will be taken care of in the health care system of tomorrow.

Flaming

2009-07-27T19:04:00.003-04:00

Here is a rather short and short-sided article written by CNN Money about an "endangered breed" of "family doctors."

Interestingly, it ends with asking the question:

Should specialists, nurse practitioners and physician assistants be encouraged to fill in the gap left by shortage of primary care doctors? We want to hear about your experiences.

Now, the article mentions nothing about NPs or PAs yet asks for reader experiences. Fair enough. However, the barrage of degrading and insulting comments from self-identified physicians and others in healthcare are downright angry. I wonder what impact this has on their patient care.

Get it Right

2009-07-24T11:37:00.004-04:00

The media has picked up a story of a tragic alcohol-related death of a 16 year old male. His autopsy reportedly revealed a relatively low blood alcohol level but high levels of papaverine, a drug sometimes used to treat erectile dysfunction in men. What do the headlines read?

Erectile drug mystery in teen's death at party

Traces of erectile drug found in dead teen

The problem here is that papaverine needs to be INJECTED into the penis to work for erectile dysfunction. Oral forms of papavarine are not routinely used and will do nothing for erectile issues. The headlines can cause people to panic because the complete medical information is not presented in the articles. This boy suffocated on his own vomit when he was unconscious due to a combination of alcohol and this medication found in his bloodstream. Questions surround why this medication was found in his bloodstream and perhaps these articles were crafted to bring increased attention to the case as his family were growing frustrated with the investigation (Orinda mother calls death investigation 'shockingly passive').

Nonetheless, a tragedy such as this should highlight the need for teen education when we are talking about toxic drinking. A new program has begun at Stonybrook University in Long Island, New York called the Red Watch Band that specifically covers this topic. This project was started after a Stonybrook faculty member lost her own son, a college freshman while away at another college, to an alcohol overdose.

When used properly with consultation from your health care provider, there is little need to worry about the FDA oral prescription medication (Viagra, Cialis and Levitra) or injectable medications (Edex, papavarine) used to treat erectile dysfunction although reading only these headlines may cause you to think otherwise.

WOW - Obama on Nurses

2009-07-15T23:33:00.003-04:00

Here is some validation for the work that we do as recognized by our Commander in Chief. Thank you, Mr. President. Now its time to "Buck up!"

Succinct

2009-07-15T23:12:00.004-04:00

Here is a great initiative that the Institute of Medicine and the Robert Wood Johnson Foundation has launched on the Future of Nursing in America.

This gives a wonderful depiction on how nurses and nurse practitioners will be part of providing the solution to health care reform. As we have sensational portrayals of nurses in such recent series as Nurse Jackie and HawthoRNe, it is refreshing to have a vivid description of the impact nurses have in health care in America. This goes beyond the petty back and forth between other health care providers that is good for TV and some blogs and puts us on the high road - that is, taking better care of our patients, their families and our communities. And quite frankly, that to me is what it's all about.

Experts

2009-07-10T20:11:00.004-04:00

A friend of mine was recently browsing McNeill's Monistat website and noted that their "Ask the Expert" section is authored by a team of Nurse Practitioners. Kudos to McNeill for utilizing NPs as experts in women's health.

Rx for America

2009-06-25T20:27:00.005-04:00

ABC News recently sat down with President Obama for their "Prescription for America" forum. You can read the transcript here. It is a wonderfully transparent and thorough conversation on the major issues of health reform today. They address the primary care and nursing shortages, comparative effectiveness, putting an emphasis on prevention/wellness and even discuss nurse practitioners and physician assistants as being part of the solution.

I truly believe we will see steady, incremental progress regarding health reform because all of the stakeholders are/will be part of the process. This has started with a dialogue where respect for each other is paramount. We all know that it is rare for everyone to agree and that's ok. But if we can respect one another's views and roles we are well on our way to addressing this ailing system.

This is a prescription that must be 'dispensed as written.'

Primary Health Care Defined

2009-06-23T20:30:00.005-04:00

Once again, a debate is reignited about physicians versus nurse practitioners over at A Happy Hospitalist's blog. I'm not getting into a contest of who is smarter than who. I have always acknowledged that a physician's education is longer than that of a nurse practitioner's. My education and training has prepared me for a career in primary health care - a field that I am passionate about, am constantly trying to increase access to and one that I'm good at. Primary care is part of that vision of primary health care. There are many definitions of what "primary health care" is and the one that I use is not made up by me in my fairy tale world - it is the one that the World Health Organization defines as:

reducing exclusion and social disparities in health (universal coverage reforms)
organizing health services around people's needs and expectations (service delivery reforms)
integrating health into all sectors (public policy reforms)
pursuing collaborative models of policy dialogue (leadership reforms); and
increasing stakeholder participation

I believe in treating people equally and fairly. I don't treat them as disease, illness, number or an inconvenience in my day. I provide culturally competent and evidence-based practice. I recognize that an individuals culture may have an impact on a prescribed treatment or intervention.

I don't pass myself off as a physician. New York State says that I have showed competency as a nurse practitioner in Family Health, have thus received certification with prescriptive privileges and ultimately national board certification. I'm not making it up as I go along. I don't know it all and am honest and open about that. But I'd be damned if I send a patient back out there without a plan or without collaborating with other members of the health care team. Maybe the word "independent" is the issue. I say, anyone who thinks they practice anything independently will not get very far. The health care system is just that - a system. A system that relies on one another, of different disciplines in the common interest of patients. No one discipline "owns" health care. Would that word "autonomous" be less threatening? I'd be happy to use that describing my practice if we can ultimately work together and make a damn difference in the work that we do.

My education, that is on-going and what I consider life-long, hasn't prepared me to be a physician. As an NP, my education and practice is blended of both nursing and medicine. If/when I am sick, I seek care from a team of providers that is best prepared to assess and treat me in a partnership at that particular time and place.

Maybe I am still too idealistic after 10 years of NP practice. But you know what, that's the stance that I'd rather take than complaining about patients, the staff that I work with and our payment structure (not that some of those issues aren't worth complaining about).

So for now, I choose to focus my energies on trying to improve this health care system and finding ways to ensure health for all.

Smoke 'em if you got 'em

2009-06-12T21:58:00.004-04:00

Today, legislation has passed Congress and is on its way to President Obama that will allow the F.D.A. for the first time to regulate tobacco products. This truly is a huge step. As a health care provider, I see the harmful effects of cigarette smoke, not only on my patients, but on their families and on unsuspecting members of the community. Just recently I spoke with a patient that at one point in his life was smoking 4 packs a day. He now enjoys regular trips to his pulmonologist and annual arterial blood gas draws from his wrist - not fun nor painless. (If you ever thought having blood drawn from a vein is uncomfortable, as is the case with most labwork, drawing blood from an artery is a completely different ballgame).

Unfortunately in this legislation, nicotine (the highly addictive "feel good" substance found in cigarettes) isn't banned altogether but some chemicals in tobacco products are and there are restrictions put on advertising.

It still amazes me whenever I fly and see the no-smoking light above my seat that at one time smoking was allowed on airplanes. Talk about second hand smoke in a closed vessel! You can make a similar argument when it comes to restaurants and bars where in most places it is now banned.

Of course, we still have a long way to go when it comes to incorporating healthier evidenced based practices in our lives. Smoking causes cancer and other chronic respiratory problems. This legislation, once signed by President Obama, will be a major step in the right direction.

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2011 Reflections

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Nurse Practitioner Evidence

Guest Post: Keeping Your Brain Fit After 65: 5 Important Memory-Boosting Ingredients Found in Common Foods

Potpourri & an Election

Instant Lab Results

Brief Update

Additional Nurse Practitioner Blog

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Preventative Health: Is it Really Preventative?

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Calling All Shoppers - Redux Again!

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DNP Series: Published!

Poll Results on the NP Modernization Act in New York

National Health Service Corps

Guest Post: 10 Free Online Tools for Nurse Practitioners

DNP Series: Down the Stretch

Target

NP Ranked in Top 5 of "America's Most Loved" Health Care Provider

Snow Day

Private Practice

2010 End of Year Reflections & A Look Ahead

NP Residency

Guest Post: North Carolina Nurse Practitioner Fights for Change

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

Social Media

Guest Post: The Pros and Cons of Legal Nurse Consulting

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

DNP Series: Onward and Upward

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

The IOM Report: The Future of Nursing

Funny and Sad

Precepting Students

The ER Study

Egg Safety and the Egg Recall

More on Patient Centered Care & Homes

Team Work

Top Posts

Dysfunction

DNP Series: The Search

Passé or is it?

Guest Post: How Hospitals Can Better Retain Their Nurses

Let Down

Happy Father's Day - Get a Prostate Exam

Obama: "America's Nurses are the Beating Heart of our Medical System."

NY Newsday Article on NP Practice

Guest Post: Nurse Walkout Highlights Conflict With Hospitals and Health Insurance Plans

Guest Post: Ageism in nursing, oh my.

The DNP for Me

A Lesson

Proceed with Caution

Guest Post: The Future is Bright for Careers in Nursing

Thank You!

Guest Post: Nurse Practitioners

Submit a Guest Post

Bring It

Another Media Piece

Susan Apold, PhD, ANP on Fox and Friends Debating NP Role

Great Read

Reflections

Momentum

The Interwebs are Abuzz

Nurse Practitioner Recognition in New York

More Bloggers

A Changing Landscape

What Impact Will Reform Have On Nurse Practitioner's?

New Nurse Workforce Data

I Took the Bait

Evidence in Labeling

Wonderful Resource: How Healthy is your County?

Let's Move! & Serving Size

Removing Barriers

iPad and Health