Politically Active

This is the letter I sent to my Representative regarding SB 263:


Ryan:

I don’t get wrapped up too much in political wrangling but when this issue came up and I realized I actually know my representative I had to contact you. I am a Registered Nurse. I work at McKay Dee Hospital in the Emergency and Acute Psychiatric departments. I have a Bachelors Degree in Nursing, minor in Philosophy (WSU) and am better than half way through a Doctorate in Nursing Practice at the University of Utah. I tell you this so you know that I am coming to the issue of nursing education with quite a bit of experience on the subject. If you aren’t familiar with this bill, SB263 seeks to modify the Utah Nurse Practice Act specifically Part 6: 58-31b-601. At present this allows DOPL and the Board of Nursing to dictate the requirements of nursing education programs by division rule making.

I don’t know the exact motivation that Mr. Davis and Mr. Newbold have in mind when bringing this forward but it seeks to amend provisions within the practice act as to who can accredit and approve nursing education programs. I have no general objection to amending the Nurse Practice Act with regard to specifying accreditation and approval and I can even understand why there are some schools that are nervous about being restricted by rules rather than specific legislation. However, none of the schools currently operating as accredited in Utah are affected by the current rules. They appear to be promoting this legislation to preempt rules they are concerned might be offered in the future. There is no urgency in addressing the issue of accreditation and therefore we have all the more reason to ensure that the legislation be carefully and properly crafted.

That said I do have a concern with the way in which the current version is offered. As drafted it effectively cuts out DOPL and creates a gap in oversight of nursing programs. Currently Utah operates under the same model of accreditation approval as every other state. By changing the accreditation process in this way Utah will be be utilizing a completely different model of monitoring than any other state. The Utah Nurses Association and the State Board of Nursing are unclear as to how this proposed change might affect the schools currently operating in the state. Nursing is a highly technical, highly skilled, pivotal position within our healthcare system. We cannot afford to have nurses entering the workforce who have recieved inadequate schooling and training. This does a disservice to not only the student but places a burden on our healthcare facilities as they try to re-train new nurses and a burden of risk on our community members who are recieving medical care at the hands of nurses.

With all of this in mind SB 263 falls short of an appropriate piece of legislation – one that is well understood, well thought out and maintains or improves the integrity of the program it is designed to govern. SB 263 is none of these things. I encourage you to vote No on SB 263.

If you have any questions or concerns please feel free to contact me.

Sincerely,

Jeremy Norton BSN, RN

If you feel like jumping on the Bandwagon you can find talking points from the UNA here and you can find out who your representative is here.

New Things - Module 6

Hard to believe that 12 weeks and 6 modules are done.

*(Please note that the previous statement is merely commentary and should not be construed as a pining for the semester to continue.)

It is also hard to come up with only one thing  that I learned in this module. If I had to pick, I think that I would emphasize the realization that I had as to how powerful and ultimately necessary information technologies are, especially when we talk about healthcare reform, controlling healthcare costs and the role of support systems. I think I expected this to be a course more about charting and documentation storage systems (which would have been really boring) but instead the totality of informatics is much broader and more integral to healthcare than I anticipated it would be. I admit, I'm not going to run out and add an informatics degree to my education plan, my plate is full enough. But the role that informatics plays and the ways  that I can be involved with it as a provider were very pertinent to my future plans.

Now.... what to do with this blog?... I think it needs another re-purposing.

Module 5 - Decision Making

I consider myself good at making important decisions. The irony in this is that I'm actually pretty lousy at making small decisions. Important decisions usually have some amount of data or information associated with them that allows for comparison. When you are making the comparison you can give weight or credence to one aspect over another. A system of analysis can be put into place that ranks the data on importance and pertinence leading you to eliminate some choices and promote others as you ultimately make a final decision.

Small decisions on the other hand are problematic. I can almost never make up my mind (for example) on which restaurant  I ought to eat at without resorting to something like a coin toss. (By the way, if you grab what you think is a penny it behooves you to verify that it actually has a 'heads' and a 'tails' otherwise, as it turns out, you haven't made any real progress). I think this is because everything is weighted fairly equally in small decisions where bigger decisions actually have parts with some weight behind them. Equally weighted 'big' decisions are the stuff moral dilemmas are made up of.

From a clinical standpoint I realized that I have no significant objection to 'cookbook' medicine as the use of algorithms and decision systems is sometimes called. I think the competent, confident clinician can use their clinical judgement and be guided rather than threatened by the additional support provided by these systems. It was however, a bit of a wakeup call for me reading about Heuristics and Biases because I tend to be a very intuitive person when I have to make rapid decisions and according to our reading the majority of individuals don't actually 'get it right' when they rely on  these decision makine shortcuts; makes me want to brush up on my formal logic and be a little more careful in my critical thinking. This is not to say that all decsions should only be made in a logical fashion, but when it comes to important snap decisions I could probably be a little more prepared.

Unit 4 (and four weeks to go but whose counting?...)

There is a certain amount of symmetry that I felt just had to be acknowledged in the timing of this particular blog post. Really the fact that there is only 4 weeks and 3 days, 2 modules and 1... (well I'm sure there is one of something left this semester related to this class) also had to be pointed out. There. Pointed.

This weeks topic is two-fold. We want to have a short dialogue about the role of teaching in our profession and we also want some input on mobile devices (read: smart phones). Apparently I have Algernon in my pocket tonight, I can't think of any other reason why I'm speaking in the plural here... So, on to teaching.

My current professional role is as a team-lead on an inpatient psychiatry unit, and as a staff nurse in an ED. As a team lead I have been assigned to mentor 5 of the staff nurses so I assist them with their goals and encourage them to improve their clinical knowledge etc. This involves some teaching as does the primary role of a team-lead on any unit - putting out fires. This requires the ability to educate patients, family members and nursing staff as the primary strategy for defusing a situation. In the ED I get to provide ongoing education to my patients: the reason for a particular therapy, the interpretation (read: plain language) of their diagnostics, appropriate follow up, medications, etc. The truth is there isn't any nursing role that I can think of that doesn't require some teaching in some fashion even the occasional  nurse in the middle of nowhere who gets elected to be the County Coroner probably has some obligation to public health teaching (although technically you don't need any medical background to be a Coroner so technically it wouldn't be a nursing job, even if you were a nurse... Moving on...)

And on that note... on to 'mobile devices'. Just a quick reminder for anyone who needs it (or if you just need a good laugh) this is my phone. I'm baby-stepping into the 21st century and just added texting to my plan. I'm steeling myself for a data-plan addition this fall and then will embrace assimilation by the Borg having the internet in my pocket.

My informatics class has a 'Mobile Device' wiki. Right now it looks like a large directory of sites without much text, but they look worth using for some research.

Check out my poll on the right side of this page and help a guy out by giving me some input. If you select Droid and have a model I should seriously consider leave me a comment with your suggestion. If you select 'or...' please let me know what I'm missing out on by not considering it. If your name is CeCe please only vote for the IPhone once. I promise to count it as 10 votes if you leave me a comment (or at least leave me a comment saying how many times you voted eh?).

Anticipatory...

The emphasis from this weeks readings and assignments in N6004 - Intro to Information Technology center on the use of technology to access and manage information resources especially those related to the development of evidenced based practice.
The assignment for this weeks blog is to discuss how I anticipate this information will help me in my graduate coursework. I jumped right into the readings before I looked at the assignments so I've already developed a pretty good idea, based on prior experience and the course reading how information management and storage systems are going to benefit me throughout my coursework.
1) Efficient storage and retrieval systems are essential to manage the massive amount of data and information available to us via the electronic databases currently available. Learning the specific tools and rules of operation that each database employs means I will be able to spend less time digging and more time synthesizing information. Getting back 25 hits on a search topic rather than 2500 makes all the difference in the world.
2) Personal use reference management software such as EndNote, Biblioscape or Qiqqa  makes the writing, citation and referencing process smoother. There is a learning curve but I can see the benefit of a good program that applies the right citation and reference format as I type, leaving me free to focus on the analysis of information rather than what APA 6th edition says about the third citation in the same paragraph of an article written by 12 authors and 1 organization published on a website that no longer exists. Ok, probably even EndNote couldn't handle that scenario but you get the idea. I've tried two different strategies for hand insertion of references, the 'type citations as I go and edit later' option; as well as the 'go back and figure out the citations later' method. They are both tedious, produce iffy results and don't quite get to what the APA had in mind with regard to consistency in citation, at least, not without a lot of work.
With these ideas in place and anticipating the benefit that comes from understanding information management I am going to take the opportunity to explore some of the reference management software out there. I was required to use EndNote two semesters ago and was only moderately impressed with the user interface. It seemed like a powerful platform in desperate need of an update. I hope to take the time to look at a couple of the different software options although, truth be told I probably will stick with EndNote, at least for now as my schedule doesn't really accommodate learning curves very well right now.

Getting Involved - Module 2

The question posed at the close of this weeks module is What is one way you could become involved in designing, selecting, evaluating, or implementing an information system in your workplace?

I have known two people who have been actively involved in the design/selection/evaluation of an information system:

The first was a nurse that I worked with for maybe a month when I was a brand-new LPN. I have no idea how he was selected, all I know is he left for what he described as a cush corporate level job that would last at least 5 years. During that time he planned on pursuing a degree in informatics and leveraging the degree along with the hands-on experience of five years into a string of cushy system design/implementation jobs. At least, that was the plan. I guess I just answered at least part of the question. as to how he was selected - expressed interest in informatics. I'm pretty sure not very many of the nurses he worked with even really know what that was. I know that my brand new, temporary DOPL licensed LPN self had no idea what he was talking about at first.

The second individual is my wife who is on a CPOE committee for Intermountain Healthcare. Despite being a very part-time employee her attention to detail and follow through came to the attention of the director during the most recent round of Joint Commission preparations and it just so happened he had been requested by the corporation to furnish one Radiologic Technologist to the committee. Viola - my wife the CPOE committee member.

Since all my managers know about my current battle with the space-time continuum It is unlikely that I will be selected in this sort of fashion...Wait, wrong battle - this is the one... (Well actually, side by side these aren't that different are they?)

The truth is, almost every nurse practicing is going to be or already is involved in implementing information systems. The complex and intense process of getting these systems up and running necessitates (in most instances) a gradual role out or integration with the systems already in place. In the Emergency department that I work in we have reveled in the simplicity of paper based charting by exception for far too long. Over the last year we have been slowly incorporating more and more aspects of an electronic charting system with an announcement that this fall we will complete our transition and begin bedside computerized charting in the ED.

A few years ago we switched over to a barcode scanning system. I vaguely remember the days of having only a med cup in the one hand, the patient's wristband in the other and the five rights on the tip of my tongue (my LPN clinical instructor was famous for bedside pop-quizzes). No juggling the med cup, and wrist band with the addition of a (set your phaser to 'wristband') scanner in hand. Anyone who has been through this kind of transition and says that they weren't intimately involved with the integration process should have their narcotic wastes triple checked. The bedside nurse is the key player in the final product rolling out and actually making a difference in the clinical setting. In the end we all get to be involved.

Why Informatics

This semester is chock-full of classes that I thought were going to be pretty irrelevant in the grand scheme of things. Just more hoops to jump through. However, after getting into the assigned readings this reasonably tech-savvy guy felt like it might be a miracle that I've been able to function in our society and an even bigger miracle that I've been able to function as a nurse. Ok, I might be indulging in hyperbole here - but if you took the course pre-test/questionnaire for N6006 at the University of Utah you know exactly what I'm talking about. Turns out that you can function in our information tech world in one of two ways (at least there are two that I have employed) and fake it present as reasonably competent.

1) Avoid tech you don't understand, just don't use it.

This works pretty well at least until you are confronted with a mandatory use scenario. Like when our unit implemented a mass text message policy to communicate shift needs. I found myself - a very accomplished text-avoider (this is my phone, check out that display) responsible for sending out 70 some odd text messages via the text groups function on the Charge Nurse cell phone. It only took me 45 minutes the first time. Clearly I can't thoroughly endorse coping mechanism number 1 whole-heartedly.

2) Use you intuition (and only your intuition).

This works if you have a basic idea of how computer systems and tech gadgets work, what they are intended for and can be kind of creative with setting expectations for your usage of those software/computer/gadget packages. It goes something like this: I want to chart a treatment team meeting in our computerized charting software. No one has ever charted treatment team meeting on the computer before, so we don't even know if there is a spot for it. But I think there should be a spot for it. And then I go looking, find a place under 'problem/event - new problem - Conference - Interdisciplinary conference'. Well there you go; what is treatment team if it isn't an interdisciplinary conference? This is the same approach I have take toward word processing programs, presentation programs, even this blog when I first started it.

The down-side to this is that functionality and use is limited to your imagination and expectations. And, lets be honest, anymore most programs and gadgets are way more complex and featured than we can imagine which means we are leaving a lot of untapped potential on the table using this approach.

With all this in mind it stands to reason that taking the time to learn about why systems were built and a little about how, you can tap into the imagination and expectations that the creators had for their systems; and now we're on track to really use a program/system/gadget to its full potential. This continuum contains learning and acknowledging the difference between the internet and the World Wide Web (never thought about that one before) at one end to exploring the world of electronic patient identifiers, E-prescribing and Computerized Physician Order Entry (CPOE). Just this week my wife came home from work and revealed that she is going to be working on Intermountain Healthcare's CPOE committee as a voice for General Radiology as they begin to incorporate imaging order sets later this year. Looks like I get a front-row seat to this.

As a major stake-holder in the future of health care it looks like this course is just in time to save me from my ineffective technology coping. It also means maybe I will eventually embrace texting as a legitimate form of communication...

A Repurposing

In the spring of 2010 I was accepted into the D.N.P. program for Family Nurse Practitioner at the University of Utah in Salt Lake City, Utah. Now in my third semester, with two years left, I find myself taking an informatics course with a requirement to blog some specific exercises throughout the semester.
I must admit to being excited pleased with the idea that I can resurrect this project blog and give it a little face-lift.(Ok, I'm excited, I just didn't want to seem like too much of geek)

Robert Wilensky's qoute at the top of this page summed up how I felt about the information I found regarding graduate school for nurses. Now, I find it equally apropos as I stumble my way through course syllabi, new platforms for education delivery and the general madness that is graduate school. I am also happy to find that the title I created for this blog 2+ years ago might still apply to the current use.

Welcome {back} to a window on Graduate Nursing.

Why This Site

Despite going into nursing with the express goal of pursuing licensure in Advanced Practice I find myself weeks from graduation with very little understanding of the options ahead. Early on I made the concious decision not to look at, read about or research graduate school as I realized it could be a huge distraction. Truth is if you flunk out of Pharm I then there isn't much point in dreaming about grad school. Unfortunately it would appear that I took this too far. Penance for my sin of ommision has been a flurry of networking, research, emails and phone calls to try and sort out the basics of what I actually need to be doing to make the culmination of my efforts feasable and not slip through my fingers. On this site is a series of posts that will outline key areas of confusion that I have attempted to tame. Most of the information is focused on clinical degrees rather than education or leadership, although much of the information is universal to all graduate school modalities.

Scroll down or follow the links in the right hand column of this page under 'Blog Archive' to access a basic primer on graduate school for nurses. Blue text is hyper-linked.

Click on the player at the bottom of the page to enjoy a little soundtrack to your life for just a few minutes.

An outline

I met briefly last week with one of the Nursing Faculty to express my frustration. Summed up this is what I don't get:

• There is no support for nursing graduate school plans at the campus I attend unless you are interested in their graduate program.
• The pre-med program (not an actual degree - therfore not an actual deparment) has a 'graduate school' advisor.
• There is no consistent database to find schools. Word of mouth seems to be the way people decide on nursing graduate school programs. Currently students in my BSN classes are fairly consistently aware of the following programs with a clinical emphasis: University of Utah, Westminster College (both northern Utah universities so that makes sense), Oregon Health Science University (about a days drive away - they have a fairly aggresive marketing campaign), and Southern Alabama University... Southern Alabama? how did that make it into the mix?

She agreed completely and said she faced the same thing when she was working on her MSN and is dealing with it herself again as she looks at schools to pursue a PhD. I asked her if she had any advice on how one goes about this process. She had the following three points that she felt were the important decision makers:

• Decide what kind of a degree you want (clinical vs. adminstration/leadership vs. education)
• Decide if there are any geographic areas that appeal (or don't appeal) to you
• Are there any schools you have a personal preferance for (or against)?

With these things in mind the following posts will explore various areas that I wish I'd had at my disposal earlier on. Namely:

• School Databases
• Accreditation
• Funding for Grad School
• Modality Options
• Practice Acts

Oh yes, and before I forget. Start studying for the GRE now. I mean it... now. If you are like me the only math you have done in the last 3+ years is med calculations (want-over-have times whatever...) Not all schools require this but in the survey of schools that I have done in my dazed confusion it seems like about half do. The school I obtained my BSN from has a GRE prep course. There are of course self study guides and other pograms. Also, know that if you take it early and don't do well some schools average your test scores if you repeat it hoping to get higher. So seriously start studying now...

Finding a School

There is no all-inclusive database for nursing school graduate programs. This is the honest truth. However, the following sites appear to provide a fairly comprehensive list of graduate schools and avoid the hassle of using a search engine to try and find a school.

The NLNAC site: only lists those schools credentialed by them

The AACN: You can't search by program type but they do provide a link to the school website.

All Nursing Schools: This site used to be a comprehensive list including obscure programs in tiny states like New Hampshire. Then you needed to use a backdoor link to get anything besides 'featured' schools and now it would appear that they are 'All Nursing Schools Who Pay Us a Subscription Fee To Be Listed.com'. Still, they do have a lot of schools and you can search by specialty.

Accreditation

We nurses sure love our acronyms. RN, BSN, FNP, ANP, PMHNP-BC. You get the drift. These are three that are important with regard to schools.

CCNE: This is the Commission on Collegiate Nursing Education. It is adminstered by the American Association of Colleges of Nursing. It is "an autonomous accrediting agency contributing to the improvement of the public's health. CCNE ensures the quality and integrity of baccalaureate and graduate education programs preparing effective nurses."

NLNAC: This is the National League for Nursing Accrediting Commission. It is "nationally recognized by the U.S. Department of Education as the accrediting agency for postsecondary and higher degree nursing programs."

ANCC: This is the American Nurses Credentialing Center. It is a subdivision of the American Nurses Association. They are "the world's largest and most prestigious nurse credentialing organization." They do institution accreditation and individual nurse credentialing.

You will note that each claims to be the premier credentialer of nursing programs. As you can imagine there is of course debate on the point of which is a better one to have certify the school you attend...

Funding

Information about funding graduate school is definitely something to look at and be aware of but to arrange more specifically once you have been accepted into a program. Obviously there are military contract programs through each of the branches of service especially if you come to them already having earned a BSN. Aside from that, and scholarships which are either school specific or require outside research and application, the U.S. Government is your best bet for funding programs.

Pell grants, Stafford Loans, Perkins Loans and PLUS loans are all available to graduate students with the appropriate demonstration of financial need. The application is a one stop shopping place for almost all government administered financial aid programs. The benefit to this is that you only fill out one application. You are automatically offered any program for which you are eligible.

Most schools like to have the results from this application by february or march for academic years starting in the fall. Also remember that your school may have a school specific application that you should fill out also.

The National Health Service Corp is a program seperate from the other federal financial aid packages. There are two tracks, a Scholarship track and a Loan Repayment track.

• Scholarship is a funding program that pays up front for tuition, books, equipment, supplies and a monthly stipend. After graduation you are contracted for one year for each year that you recieved assistance with a two year minimum. The contract requires that you obtain employment in a designated underserved area. Clinics and healthcare institutions apply for this status through the NHSC.
• Loan Repayment is applied for after graduation and provides up to $25,000/year of loan repayment for the first two years and $35,000/year for each additional year of work.

To view areas that are currently considered underserved, look here I recommend leaving the projected hire date blank so you can see all opportunities. Obviously the jobs you see now may or may not qualify as NHSC sites by the time you have graduated, but it gives you an idea of how broad the kinds of areas serviced are.

Applications are accepted each year until July.

Fellowships, sponsorships, etc. are another thing that may be difficult to find but well worth it if you do find one. Check with your school and local healthcare agencies/institutions. Networking is the best way to sniff these out. Here's an example of one: Intermountain Healthcare Urban North Region is looking to hire ten Pscyh Nurse Practitioners in the next five years. They are offering a tuition/book reimbursement program for individuals that are interested in this modality. The program also includes a stipend opportunity that pays the difference between full time and part-time wage so that you can work part-time while in school. The contract for this program is a 1:1 years in school to years of full-time work post graduation.

Modality Options

Nursing is incredibly diverse. For me it was almost overwhelming when I realized how many choices a bachelors degree in nursing opens up for you. Advanced practice isn't any different in this respect. However, in choosing a modality it is important to realize that the wide expanse of options begins to taper as you move forward with further education. This is particularly true with clinical degrees. Each degree with it's specialization area has an associated scope of practice. The ANCC certifies several different levels such as Nursing Specialties, Clinical Nurse Specialists, and Nurse Practitioners.
The following nurse practitioner modalities are recognized by the ANCC:

• Acute Care NP
• Adult NP
• Adult Psychiatric and Mental Health NP
• Diabetes Advanced
• Family NP
• Family Psych and Mental Health NP
• Gerontological NP
• Pediatric NP
• School NP

The American Association of Nurse Anesthetists (AANA) has their own board certification for

• Certified Registered Nurse Anesthetist

The American College of Nurse Midwives has their own board certification for

• Certified Nurse Midwife

Each of these lend themselves to a particular patient set that can be further specialized. Many Family NPs find that they particularly prefer pediatrics, some pediatric NPs go into oncology. However, it is important to understand the scope of practice of your chosen modality. As a general rule for example it would be poor form to be prescribing for a pediatric patient if your license says you are a Gerontologic NP. It is also important to remember that NP doesn't automatically mean prescriptive practice. This varies by modality and by state. In Utah for example a Family NP has prescriptive license, as does a Psych Mental Health NP, but not nurse anesthetists.

Going away for school

Each state has a Practice Act that outlines the rules and laws that govern nursing in that state. It outlines some areas of scope of practice, licensure and certification requirements, disciplinary issues, etc.. Although nursing is generally the same country wide it is important to recognize that practice can vary state to state. This becomes important if you are planning on leaving the state that you earned your RN license in to go away to graduate school. Some states require additional certification/course work beyond the standard ADN/BSN course work such as HIV/AIDS awareness, and IV certification. Also note that only 21 states are part of the Interstate Compact.

Nurse practice acts, how they are written, and where they are put into state law is about as varied as the acts themselves are. TheTravelNurse.com has a nice database of practice acts for all 50 states and some other areas such as Samoa and Guam; here.