At the start of this school year, I am contemplating the DNP Essentials. As a DNP, how are you using the knowledge and skills acquired through your DNP coursework to impact healthcare outcomes? When was the last time you read the DNP Essentials and thought about how the DNP Essentials can provide a framework for your professional growth and development?
I am working with a number of students this fall who are in the final year of their DNP program and are working on their DNP projects. (Note: We need a different word for this, but "project" it is for now.) These projects will directly impact the health of the patients, improve outcomes and create another service our free clinic is able to provide to improve access to care for some of the most vulnerable in our community. As faculty or as preceptors, we all have the ability to help guide our DNP students and new graduates into roles and jobs that use all of the DNP Essentials.
In my free clinic, we recently acquired Telehealth through a grant project. We will use this technology not only to connect our patients with specialty providers to improve access to care, but we will also use it as a way to connect our patients to primary care. One of the ways to reduce healthcare costs is prevention and expert management of chronic diseases through new models of care. Utilizing Telehealth to "hot spot" patients who are potentially high utilizers of expensive services, such as the ED, directly improves the health of the patient and family and keeps healthcare costs down. It is more cost-effective to send a nurse (or DNP student) into a patient's home with a Telehealth enabled tablet (HIPAA compliant and encrypted) to facilitate a Telehealth visit than it is for this patient to miss multiple appointments because of lack of transportation or other barrier and then end up in the ED.
By developing a new model of care for this specific patient population, the students are learning to use the knowledge and skills they have acquired through competency in the DNP Essentials. These scientific underpinnings for practice (DNP Essential I), organizational and systems thinking (DNP Essential II), information systems/technology (DNP Essential IV), interprofessional collaboration to improve healthcare outcomes (DNP Essential VI), clinical prevention and population health (DNP Essential VII), and advanced nursing practice (DNP Essential VIII) all focus on the patient and improving outcomes. One of my students will be working on this project. Data, analysis and dissemination of findings will address clinical scholarship for EBP (DNP Essential III) and health policy (DNP Essential V).
As you contemplate your reasons for starting your DNP journey or for completing your DNP degree, I urge you to return to the DNP Essentials as your guiding framework. As a DNP graduate, I have moved into roles I never dreamed of years ago. I recently looked at an assignment I completed for school a few years ago. It was one of those "Where do you see yourself in 10 years?" type assignments. My thesis was "I will change the world." Using the knowledge, skills and abilities I gained through completion of my DNP degree, I am changing to world. Will you join me?
How much do you know about full practice authority (FPA)? As NPs, we have state and federal laws and regulations that govern our practice. As we prepare for fall elections and legislative sessions in the new year, we all need to consider our ability to practice to the full extent of our education and training.
I live in Virginia. If you look at the AANP State Practice Environment map (AANP, 2016), Virginia is a red state, meaning we have restricted practice. Twenty-one states and DC have granted NPs FPA. There are only 12 states that are red. In Virginia, NP practice is regulated by the joint boards of the Board of Medicine and the Board of Nursing. We must practice under a written collaborative agreement with a physician that acknowledges the physician is the lead of any patient care team: "‘[C]ollaboration' and supervision requirements establish physicians as gatekeepers who control APRNs' independent access to the market," (FTC, 2014, p. 29). There is no other profession that is regulated by another profession. Further, we have a joint board. FPA means we should be regulated and licensed under the exclusive authority of the Board of Nursing.
As we work on grassroots advocacy, we need to ensure a consistent message to our legislators, patients and colleagues. We need to gather momentum from grassroots NP support as well as legislative support before proposing additional legislation. If we take the time to develop a solid base of support, our legislative efforts will be more rewarding. A consistent message signifies unity within our profession and clarifies our argument.
Here is my proposed elevator speech about FPA:
"As an NP, I am a board certified healthcare provider. FPA means I am allowed to practice to the full extent of my education and training under the exclusive licensure authority of the Board of Nursing."
Do you know what color your state is? How does restricted practice affect your ability to care for patients? Are you involved in your professional organization and advocating for FPA?
I challenge each of you to use the DNP essentials (organization/systems leadership, healthcare policy for advocacy, information systems/technology to improve and transform healthcare, and clinical scholarship and analytical methods for EBP [AACN, 2006]) as an advocate for FPA to be a leader in improving healthcare outcomes.
American Association of Nurse Practitioners (AANP). (2016). State practice environment. Retrieved from https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment
American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/dnpessentials.pdf Federal Trade Commission. (2014). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf
Have you thought about how you're using your DNP in your practice? As I write this, a small group of us from my DNP graduating class are finalizing our first state DNP conference. We recognized that we have a national organization, Doctors of Nursing Practice, but our state had no such networking organization. Over the past year, we have created an association and planned our first conference, which will focus on health policy, leadership and disruptive innovations. We have speakers who are leaders in all of these areas who will share their knowledge and experience. The plan is to have special interest groups (SIGs) develop from these focus areas so we can continue exploring how DNPs influence healthcare in our state and our nation.
This planning committee includes two faculty members from our program (who were the visionaries), as well as nurse executives and CRNA, NP and CNS practitioners. By utilizing our various professional networks and knowledge, we believe this DNP association has the power to stimulate and support all DNPs to actively engage all of the AACN DNP Essentials in our practice areas.
As an FNP, learning from other DNPs who have created new models of care, utilize disruptive technologies and improve population health through scholarship, systems leadership, health policy advocacy and interprofessional collaboration has greatly enhanced my practice. Continuing to explore innovative care delivery models to improve outcomes for the uninsured and poor in my free clinics enables me to provide high-quality, cost-effective interventions that directly improve the health of my patients and their families.
The rising cost of healthcare is unsustainable. Individuals are facing higher deductibles in their insurance plans and often avoid accessing healthcare services, even when insured, because of these deductibles. I challenge each of us to re-examine the DNP Essentials to reach out to other DNPs and colleagues in order to explore new models of care delivery providing more access to services with lower cost and improved outcomes.
As nurses, we have the power, knowledge and experience to change healthcare. What will be your role in healthcare reform in your workplace, community, state and country?
As I reflect over the past legislative session and more recently over my past week as I met with each of my bosses and collaborators as well as legislators and other elected officials, I thought I would share a helpful communication tool I learned while completing my DNP.
As we learned about organizational development and self-reflection on our behavioral tendencies, we also learned strategies for communication, especially where there is a conflict or hot button issue.
One of my jobs is in a Free Clinic. This is not a Federally Qualified Healthcare Center, but it is a safety net clinic. We only see people who have no health insurance and live <200% FPL. We have a single major donor and a few very small additional donors.
During the week, I am the only provider and I have an office manager. Between the two of us, we complete eligibility screening, provide primary care services for patients, order medications, write referrals, reach out to community partners, look for other funding sources such as grants, provide patient navigation, and respond to our patients' questions and concerns.
I have been using the Awareness Wheel as a way to help articulate my concerns and requests in a non-judgmental manner to facilitate true communication rather than conflict. If you are not familiar with this tool, there are many variations. I prefer the, ‘Facts,' ‘I Feel,' ‘I Imagine,' and ‘I Request' model. Below, I will demonstrate how it may be used.
Facts: The Free Clinic is a safety net clinic providing coordinated healthcare services, through a network of community partners, to those who have no other access to healthcare. Currently, our network is very small and we are unable to meet many of the needs of the patients we serve. Everyday, the office manager and I work hard to care for patients with our very limited resources.
I Imagine: I imagine that the Board of Directors and the Clinical Operations Committee shares the clinic vision and want to do everything possible to fulfill this vision and beyond.
I Feel: I feel that my ideas for creating a sustainable comprehensive network of community partners and reaching out to the wider community in which the clinic is located are not clearly heard.
I Want: I want to be a part of building the foundation of the Free Clinic to create sustainable partnerships throughout northern Virginia. I want all of us to diligently reach out to all community partners who would help us to provide comprehensive healthcare services for our patients. I want to develop partnerships with Universities and larger healthcare organizations to be able to create new models of healthcare that keep the patient at the center of everything we do at the Free Clinic.
I hope you find this tool useful as you communicate with your colleagues, collaborators, partners and legislators. It has worked well for me!
In Virginia, our Legislative session ended two weeks ago. We have made some subtle progress in our move to full practice authority, but we still have many challenges. Our task is now to regroup and to plan a path forward in preparation for the next legislative session.
Nurses at all levels should be prepared to engage in healthcare policy and advocacy.1 However, nursing is under-represented in our political landscape. There are currently only six nurses elected to Congress,2 but 20 physicians currently serve in Congress.3 There are more than 2.7 million registered nurses working in the United States4 and 894,000 physicians.5
With the advent of the Affordable Care Act in 2010, 16 million Americans have gained healthcare coverage.6 This has created a greater need for healthcare leaders with the knowledge, skills and abilities to not only provide healthcare for additional individuals, but to ensure that healthcare policies address the population health needs and cost as well as the patient experience. DNPs are perfectly poised to be health policy leaders. But how is that achieved?
First, we must all be familiar with the basic political structure. Remember the Executive, Judicial and Legislative Branches of government you probably first learned in elementary school? We will focus on the Legislative Branch for this discussion. Recognizing your elected officials and having a basic understanding of the legislative process is the first step in understanding health policy and being an effective advocate. Each state has a website dedicated to the legislative branch where you can look up your legislators if you do not know their names or contact information. For our Congress, simply go to: House.gov and Senate.gov. Each has a link to find your Representative or Senator.
Second, the DNP needs to be able to identify opportunities to assess, design, evaluate and implement health policy based on the current healthcare and legislative landscape. Effective and politically competent advocacy efforts will result in the greatest improvement in healthcare delivery and nursing's role in healthcare redesign. Grassroots advocacy can be a very effective way to identify and create a politically active base that has the power to inform and influence health policy.
Finally, identifying experiential learning opportunities for the nurse to actively engage in healthcare policy, politics and advocacy is essential to position the nurses as leaders in healthcare reform and improved patient outcomes. As DNPs, we can be leaders in completing Health Policy Fellowships, actively seeking opportunities to gain a seat at the table through appointments to Governor's task forces and coalitions, and continuing to be politically aware through participation in advocacy efforts in our state and national organizations. Mentoring nurses new to advocacy can be another easy way to gather a small group of people to work together for a common goal.
Nurses are in every healthcare setting and are integral to healthcare delivery and outcomes. Empowering the nurse advocate to assess, plan, implement and evaluate healthcare policy will improve the Triple Aim7 and improve access to care to reduce health disparities. All nurses should be ready "to participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy."1
1. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf
2. American Nurses Association. Nurses Currently Serving in Congress. http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Federal/Nurses-in-Congress
3. American Medical Association. Advocacy with Congress. http://www.ama-assn.org/ama/pub/advocacy/federal/advocacy-with-congress.page?
4. Kaiser Family Foundation. Total Number of Professionally Active Nurses. http://kff.org/other/state-indicator/total-registered-nurses/
5. Kaiser Family Foundation. Total Professionally Active Physicians. http://kff.org/other/state-indicator/total-active-physicians/
6. The White House. At a Glance. https://www.whitehouse.gov/healthreform
7. Institute for Healthcare Improvement. IHI Triple Aim Initiative. http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx
Have you ever wanted to be part of something bigger than yourself? Have you ever dreamed of changing the world? Advocating for health policy that directly affects the health of individuals and communities as well as our profession is one of the easiest and most important ways to do this.
Earlier this week, I spent a day advocating on Capitol Hill. I met with the staff of my senators and representative in Congress with the United Nations Foundation initiative called Shot@Life. Through this initiative, over 150 individuals from more than 30 states advocated for continued funding from the U.S. government to support immunization efforts throughout the world. Over the past five years, Shot@Life has advocated for government funding and President Obama has pledged one billion dollars for these efforts. This is less than 1% of our total Federal budget; our total military budget is $585 Billion. Global health and immunizations in particular, are not only a matter of "doing the right thing." Global health support helps to protect our nation.
As our society becomes more transient and global with world wide travel becoming more common, affordable, and easy, disease transmission can be just a plane ride away. I live in the DC Metro area where we have some of the busiest airports in the country. This threat directly affects my family, community, and patient population. When the Ebola outbreak happened in Nigeria, community health stations that were created for immunization and other public health efforts were able to be efficiently converted to centers to evaluate and treat individuals who may have been exposed to Ebola. This helped to prevent a serious epidemic in Nigeria.
As a primary care provider, I recognize that immunizations are one of the most important public health interventions of the past century. Diseases such as polio, that are endemic in only two countries right now (Pakistan and Afghanistan) could make a resurgence, if immunization efforts are not supported. Despite the 99.9% decrease in polio cases in the past 30 years, polio continues to be a threat to the entire world. Imagine living in a world that is free of polio. Complications from diarrheal disease kill more children under the age of five worldwide than any other disease. We have a safe vaccine to combat rotavirus, but it is only effective if it can get to the children who need it most; those living in developing countries who often lack the benefit of adequate medical care. Four hundred children die each day from measles, a disease the U.S. had eradicated from our borders by the year 2000. However, in the past two years, with a measles outbreak in an Amish community in Ohio and at a California theme park, we once again have active measles cases within our boarders.
This issue happens to be one of my passions. What is your passion? I challenge you to find one issue and advocate for it. How will you be an advocate for your family, your patients, your community and your profession?
As we move through the legislative session in Virginia, I am reminded that there are multiple sides to each issue. As an APRN, I have worked in "green" states with full practice authority (FPA) and "red" states with restrictive practice regulations. The uphill battle to gain FPA in Virginia is constantly blocked by the Medical Society of Virginia and other groups who perceive the push for FPA as a threat to their income and turf.
As NPs and DNPs in particular, we need to understand and help our colleagues and supporters to understand the legislative language. Current bills under consideration in our General Assembly address NPs practicing outside of a physician-led patient care team in specific settings. These settings include medically underserved areas or locations that suffer from 1.5 times the state unemployment rate. However, after subcommittee discussion, some of these bills received "substitutes" that removed the original language and substituted completely different language.
Amazingly, the same arguments that have been circulated for years by APRN opposition groups, have been re-circulated again this year: education is not as rigorous as physician education, NPs will not move to practice in rural and underserved areas if practicing in a FPA state, NPs are unsafe practitioners, NPs have worse outcomes, etc. Each of these claims has been debunked through rigorous research and decades of practice data and outcomes.
Interestingly, in December 2015 and January 2016, there were two new studies published by Montana State University. One specifically addresses NP cost for caring for Medicare patients versus physician cost. The second specifically addresses NPs moving to rural practice in states with full practice authority. As DNPs, we need to help lead the movement to move all states into FPA by continuing to review the literature for additional supporting evidence and to counteract the loud voice of our opposition.
As DNPs, we need to be well versed in the arguments against FPA for APRNs and against the IOM recommendation to allow all nurses to practice to the full extent of their education and training. These restrictive practice environments are not only found in Federal and State regulations, but in our hospital and outpatient practices as well. In order to be an effective advocate for ourselves, our patients, and our profession, we need to be aware of and understand both sides of the argument.
I challenge you to become an advocate. Learn the legislative process and take an active role in health policy.
Happy New Year! This morning, I completed a 10K. I am a runner and always start the New Year with a race. There is something about a group of people set on the same goal that encourages the best in everyone. Although I race throughout the year, this first race of the year sets the tone for the rest of my year and makes me feel that I have been part of something amazing from day one. This year, the race I ran was the "Resolution Race" with the proceeds benefitting local charities. Running on the first day of the year also gives me time to think about my other resolutions for the New Year.
Fundamentally, a resolution is an expression of the will, resolve, or determination of an individual or legislative body. As we start this New Year, my professional resolve is to continue advocating for full practice authority in the Commonwealth.
Currently, only 21 states plus D.C. allow NPs to practice to the full extent of their education and training. Some of the barriers to full practice in states like mine are regulations requiring a physician to be the leader of a patient care team, joint boards of nursing and medicine, required collaborating agreement with a physician, and lack of legislative advocacy by all nurses to ensure we retain control over our professions.
We should all be familiar by now with the numerous studies documenting the safety, cost-effective care, equal or improved patient outcomes, and patient satisfaction when a nurse practitioner rather than a physician provides care. This is not meant to endorse an opposition to physicians, but rather to highlight that nursing is a separate profession from medicine.
As part of the nursing profession, we are also the most trusted profession in the United States! With all of this supporting evidence, how do we justify allowing others to control our profession? I firmly believe that teaching advocacy needs to start with the first nursing courses.
As nurses, we are excellent patient advocates. As NPs, we need to be knowledgeable, confident, and passionate advocates for our profession. This means being able to articulate what an NP does, be knowledgeable about the scope of practice of the NP and be able to utilize various tools to communicate effectively with the public and elected officials. My second professional resolution this year is to work on improving education of nursing students at all levels in health policy advocacy.
Just as curricula are changing to reflect the increasing numbers of community based nurses rather than acute care, curricula need to include health policy advocacy. This will ensure our newest nursing graduates at all levels have a basic understanding of health policy and understand the importance of advocating for full practice authority legislation that reflects our scope of practice and the full extent of our education and training.
I hope part of your New Year's resolution includes taking a more active role in your profession. Together, we can all improve healthcare by harnessing the power of all nurses to advocate. I challenge you to become more active in advocacy efforts in your workplace, community, state and at the national level. Be Well!
The DNP has the power to change healthcare. We have an obligation, as nurses and as patient advocates, to use our knowledge, skills and abilities to gain a seat at the table.
As the largest healthcare workforce, with over 3.1 million registered nurses, we should be the go-to profession for issues about healthcare. However, we still lag far behind our physician colleagues in positions as elected officials, at national healthcare conferences and in the boardroom.
As a nurse practitioner, individuals in my profession are still frequently referred to as mid-level providers. As the saying goes, "if I am a mid-level, who is the low-level?" I believe our collective lack of advocacy for our profession of nursing over many generations has kept us beholden to others' direction and vision for healthcare.
As a recent DNP graduate (May 2015, Old Dominion University), I try to embrace as many of the DNP Essentials1 as I can every day. I have the skills and confidence to be a healthcare leader, a patient/profession/healthcare advocate, a scholar, an organizational innovator and a more effective advanced practice nurse.
I have learned to integrate new technologies into my patient care to improve outcomes and into my organizations to improve efficiency and delivery of care and education. Over all of these essentials, I have realized the importance of interprofessional collaboration as we all seek to improve patient outcomes. As an NP, I am educated and trained to provide high-quality, cost-effective healthcare resulting in improved patient outcomes. As a DNP, I can be a leader in interprofessional collaboration by gathering together those who seek to improve patient outcomes through cost-effective innovation.
As an experienced RN and FNP, I have been a preceptor for students from many different universities over the years. I have realized many of these students do not recognize the power of advocacy. They shy away from anything that has the work "policy" or "lobbying." Thinking about my education as a nurse, my only health policy in my BSN program was the nurses' legislative day at the capitol. In my MSN/Educator program, we had a few more health policy interaction requirements, but still no dedicated course for health policy.
Yet the American Association of Colleges of Nursing has included Health Policy as an Essential component of the BSN, MSN and DNP education.2 During my DNP program, I had an entire semester course in health policy and completed a health policy Fellowship. These experiences have committed me to being more involved in health policy in my state as well as at the federal level.
I believe we all have an obligation as members of the largest health profession in country to be advocates for our patients, professions and practice. We need to ensure the knowledge, skills and abilities are integrated throughout the nursing curriculum beginning at the BSN level and continuing through the doctoral level. How else can nurses truly be able to "practice to the fullest extent of their education and training" as advocated by the Institute of Medicine?3
1. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf
2. American Association of Colleges of Nursing. Essentials series. http://www.aacn.nche.edu/education-resources/essential-series
3. Institute of Medicine. The future of nursing: Leading change, advancing health. http://iom.nationalacademies.org/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf
I have been enjoying going to work these days. That's a feeling I haven't felt in a while. Training these last 4 months was even more amusing than my last job. I had begun to think the only thing I was ever going to treat was URIs, back pain, and diabetes. Don't get me wrong, treating these ailments is important, but they don't excite me and I think I lost interest in primary care some time ago, I just don't know when.
Interest in your work is important. If you have no interest in what you do it will lead to dissatisfaction that spreads to all facets of your life. It can also make you less motivated to participate in other things that may interest you. I am interested in entrepreneurship, scholarship, policy, and clinical practice, and where I was working was not inspiring me to push myself towards pursuing those professional aspirations. I want to feel inspired and motivated by my work and those I am surrounded by. I didn't just want to just go to work every day- I wanted to love it. You should love what you do. That's where I am right now. All of my previous positions have made me feel like just another number, just another provider. All I was needed for was to see patients and go home. Never asking me for my input or including me in decisions, never allowing me to feed my hunger to be more involved in the company I worked for. There is no chance for vertical mobility in organizations where there is already a hierarchy in place and if there ever was a chance, I never felt that way.
I don't feel like that anymore, and it's weird because I don't know that I actually have any of these freedoms that I discussed but I feel that I do. I am able to be more mobile since I now see patients in long-term care settings, which I love because I am not constrained to an office with no windows and preset lunch breaks. I am not pressured to see patients in 15 minute increments. Patients are no longer double and triple booked. I can take my time and enjoy my job. I can take my lunch breaks when I want, and I am able to freely go and come as I please-because the work environment and the position allow that. I am in charge of ME- and I like that. I set my own schedule and I leave for work when I want and I go home and finish my work day when I want.
I guess all I ever really wanted was freedom, freedom from a constrictive work environment, freedom to relax and have balance with work and home. I have all of those things now and could not imagine life how it used to be.
Dermatology has offered me a fresh breath, a new start.
Morrison and Furlong (2013) identify the four major ethical theories - nonmaleficence, beneficence, autonomy and justice - and apply them to healthcare. It is the ethical responsibility of the provider to ensure that these principles are upheld, regardless of the work load or stresses of the office practice.
Nonmaleficence: The first thought in any provider's mind has to be to prevent further harm to the patient. Even in a busy practice, the APN must take the time to listen to the patient, review the history, and make a diagnosis. Hurrying through any of these steps can result in misdiagnosis, missed drug allergies or interactions, and potential harm to the patient. It is important that the APN remains in control of the patient schedule and to never allow the schedule to build to the point that the patient is placed in jeopardy.
Beneficence: The concept of beneficence goes beyond prescribing the appropriate treatment. The APN must also narrow the studies and treatment to only those things that will aid in the diagnosis or treatment of the condition. In a healthcare environment where the emphasis is on maximum billing, the provider must be mindful of the orders that are written and the services that are being billed. If, for example, MRIs are being ordered because the office manager thinks that the office owned MRI is being underutilized, then the patient's best interests are not being met.
Autonomy: As Morrison and Furlong (2013) point out, the ethics of healthcare go beyond doing good and not doing harm. As the provider considers the treatment options, it is imperative that the competent patient (or the surrogate for a patient unable to make decisions) is a working member of the decision making team. The APN must be careful to make sure that the patient is properly informed and that they understand that information. The good intentions of nonmaleficence and beneficence mean very little if the provider acts against the patient's wishes.
Justice: Finally, the busy provider must be careful to deliver the same quality of care to every patient. Every provider encounters patients who try their patience or who do not fit the provider's concepts of responsible behavior. Despite their internal conflict with the individual's personality or lifestyle, the APN must focus on the presenting problem and treat that problem as they would with any other patient. There are times when the treatment options are narrowed by the insurance coverage or the patient's ability to pay. It is the provider's responsibility to explore every option to find affordable options or to help the patient find ways to finance the care they need. It is not enough to simply write a prescription when the patient does not have the resources to fill it.
For many providers, the ethical concepts relayed by Morrison and Furlong (2013) are the tenets by which they practice. While they may not use the same words to describe what they do, the basic philosophies are the same.
Morrison, E.E., & Furlong, B. (2013). Health care ethics: Critical issues for the 21st century (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.
Transitioning into specialty practice has been rewarding. The passion for what I do feels like it has been rejuvenated, especially in the clinical setting in which I am working in. What I still find most challenging is the battle between being seen as a specialist and having the confidence of one given my minimal experience in dermatology. I mean I took care of patients with dermatologic needs as a primary care provider, but that was not my sole responsibility. I had to juggle the other chronic diseases and often times the dermatologic issues, if not pressing or of a concern to the patient, were not always addressed by me. Often times, I would refer patients out to dermatology (because I did not have the time to focus on these problems, and often times because I did not feel comfortable addressing these issues). I am finding now in my new role that I possessed the skill all along to be able to manage and diagnose these diseases if I just had the time to focus on them.
The last three months has been eye opening (and I mean that literally!). Since dermatology is such a unique specialty you must have a good eye to detect subtle differences in the skin. I mostly practice this by taking pictures of what I see and reviewing them again later. I am still surprised at the difference in what I see at the bedside and what I am able to detect in a picture! I have a long way to go, but I am feeling more comfortable with what I am looking at and how to describe it (the pictures help me with this). It's hard to imagine, but three months ago I had difficulty doing this and now it comes with some ease.
As a DNP, especially a DNP in a specialty like dermatology, I have learned that no matter how uncomfortable I may feel, projecting a certain level of confidence when interacting with patients, nurses, and other providers is imperative. It is important because everyone is counting on you and whether you think so or not, those three initials after your name (DNP) are symbolic and they not only represent your level of preparedness, but also a level of expectation. You must demonstrate that you can walk the walk and talk the talk. It is a burden that you must bear, but it is one that you should take on without hesitation because it just might be this burden that helps to advance the NP profession.
I do this by studying and reading all the time as well as conducting biopsies on everything I can, reviewing pathology reports and staying grounded in the most current evidence. Additionally, I take on the burdens and expectations while showing poise.
It is a day to day battle, but I cannot express to you how much this will help you along the way, in any specialty you choose.
Never let them see you sweat.
With the push for doctoral-level nurse practitioners, one of the major questions has been should NPs have to take an extended certification exam in order to be recognized as a Doctor of Nursing. This topic is highly controversial because most practice-based professions that have a doctoral degree do not required an extended certification in order to practice (i.e. physical therapists, pharmacists, etc.) Unfortunately though NPs are faced with physician counterparts arguing that although doctoral-level NPs have extended education, they do not have extended certification by a certifying body and therefore no difference should be made in the clinical arena between a nurse practitioner and a doctor of nursing practice. Many have argued that DNP graduates should the Comprehensive Care Certification (CCC) yet many NP organizations are saying no to such an exam.
So should we have to take an extra certification upon completion of our DNP education? I personally have not decided one way or another. In support of certification, I feel it does provide us with further leverage in both the clinical arena as well as in legislative issues. Certification would also provide a standard of accreditation for DNPs rather than simply going to school and coming out with a DNP especially due to the vast difference in some DNP educations. On the other side, I feel that the DNP education certainly does not support a further certification necessity. The focus of my DNP education was on leadership, evidence-based practice, and transformational care rather than on increased clinical knowledge like pathophysiology etc. So could this education and expanded knowledge actually be tested?? The debate certainly continues and I hope to hear some of your thoughts on whether or not DNP graduates should have to face certification exams.
Since changing from primary care to dermatology I have noticed there are a lot of basic skin issues that primary care providers overlook, and cannot correctly diagnose or properly manage in practice. Some examples are stasis dermatitis, psoriasis, tinea and candida infections, and actinic keratosis. Did you know stasis dermatitis is a result of uncontrolled edema? Or that treating psoriasis with oral prednisone can actually make psoriasis worse? Did you know that nystatin will not treat a tinea infection? Can you identify an actinic keratosis (which is a cancerous precursor)?
Let me give you an example. Recently in clinic I saw a patient with generalized pruritus and a papular rash. This particular patient has been biopsied and treated several times for this rash but it waxes and wanes. The primary care provider placed the patient on oral fluconazole for two weeks for what he diagnosed was a "generalized tinea corporis." First-the primary diagnosis is not correct so therefore the patient is receiving the wrong treatment. Tinea infections are typically not papular and are usually associated with some level of scale. Second-fluconazole does not treat tinea it is treatment for candidiasis. This patient was suspected to have a contact dermatitis from the laundry soap used in the nursing home based on the history of the rash and its primary morphology. In addition, the rash was previously confirmed by biopsy that it was not fungal.
I am bringing this matter to your attention because it is clear that the PCP could not distinguish a tinea infection from a contact dermatitis, and even worse did not know the appropriate therapy for tinea versus a candida infection. If the PCP was uncertain of the diagnosis he/she could've referred, re-biopsied the skin, or chosen a broader spectrum antifungal like econazole (if he/she was debating tinea vs. candida as this med treats both).
The skin is the most easily accessible organ of the body and so biopsy should always be the default (when in doubt) and can be done safely and routinely in the primary care setting. In this instance, lucky for the patient we caught this PCP's mistake during our follow up visit before the patient was treated with any more doses of an unnecessary anti-fungal for a contact dermatitis.
Please, as DNPs and providers I encourage everyone to go the extra mile and put in the effort required to familiarize yourself with skin conditions you are likely to encounter through additional formal clinical training i.e., post-masters certification or CME (NADNP conference each May).
Over the last 2 months, I have done several full body skin examinations, and you would be surprised by how many skin cancers and rashes are found on these patients with no complaints! It just goes to show you that just because the patient doesn't complain of a rash or a skin problem does not mean they don't have any!
By including a full body examination with each and every annual physical you will ensure your patient's dermatologic needs are met.
This will show your patients that their skin is just as important to you as it is to them.
Last weekend I went to a fantastic pediatric conference and one of the talks was on preceptoring and how to be successful as a preceptor. During this talk they also gave a plethora of encouragement for NPs to become preceptors and asked those that had been preceptors to raise their hand...only about a quarter of the room raised their hand. This lecture together with the experience of working with a local NP organization chapter and struggling to find preceptors for our student members, I really got to thinking...why is it such a struggle to find preceptors for our future NPs?
I certainly struggled with this as a student, and, like so many others, whipped out a list from the internet and began cold calling, ultimately to be left with many MD preceptors that practice on a very different model than NPs. Unfortunately, I have heard so much about the problems with nurses eating their young and horizontal bullying among nursing staff, but I would say the same is true with the gap in students being able to find preceptors. As we try to rise our profession up, it seems as though there is a missing link happening among seasoned NPs supporting NP students.
As a DNP graduate, I feel even more empowered to be a preceptor and lead the way for our future NPs through education, preceptorship, and involvement with students at the bottom level. For some reason, though, this does not seem to be a common theme among many NPs in practice... Whether it be because of barriers in their workplace, inability to take the time to teach due to busy schedules, or simply the reluctance to work with the less experienced NPs. Yet working with students has so much to bring to the practice of those who precept from updated knowledge on evidence-based practices to keeping the preceptor on their toes with being as informed as possible.
It is for this reason that I call on NPs to pay it forward and precept our up and coming NPs. Preceptors are as important of an influence on the new NPs education as the university they went. In a healthcare environment where the number of NPs continues to rise, so too does the dire need for preceptors to come forward in assisting students in their clinical education. So stop eating our young and start teaching our young about the amazing profession we have chosen!