Friday, November 25, 2011

Time flies and change is inevitable.

Why are my posts so often about time or the lack thereof? Are you ever amazed at how fast time really does fly? I know it is early for a “year-end wrap-up,” but I just seem to be in the mood for reflection on this gloomy day after Thanksgiving.

There is enough research out there about adjustment after a move (and even more about how long it takes to feel “normal” after a divorce) that I shouldn’t be surprised at how much difference a year makes. Most experts agree that it takes a year to feel settled after a move, to see the “new” place as your place and for that feeling of being a stranger to go away. And the good news is, it has!

I no longer say things at work such as “You guys do things strange here,” and I have accepted many of the quirks as normal. I have also taken a more active role in bringing about change for the better and not just to make things more like where I came from. I do, however, continue to fight silliness and am the first to speak up when wacky decisions are made that don’t really seem to be for the good of the group.

One battle I recently lost was a decision to rearrange our primary-care teams. It seems my MD “partner” and I are too efficient and need to be split up to balance another team. We have access within a few days. In fact, I saw people last week for follow-up the day after an emergency room visit, something unheard of at many military clinics. We even have days where we have appointments that go unbooked, and we receive very few patient complaints.

How do you reward that kind of access? You split us up, of course! So, as of the first of the year, I will be switched to a different MD partner, one who is very meticulous, kind and thorough, but tends to have less convenient access. I fear that, for me, it will translate to more crossbooking and more difficulty for my enrollees to get in to see me as easily as they do now. Only time will tell! The good news? I’m able to keep working with the same technician. She does a great job of keeping me on schedule and has taken over some of the paperwork the nurse used to do.

A battle still to be waged is improving communication between public health and primary care with respect to deploying members, something that is a bit convoluted right now. We will also be moving our whole clinic this winter, which will tax the patience of staff members and patients alike. The move also puts us back on the list for a visit from the national accreditation agency, which always creates extra “spin” in an organization. It’s all part of the life lesson that life never settles down and change is inevitable!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Thursday, October 20, 2011

Follow the red tape to New Beginning!

I work for one of the largest bureaucracies in the world and have for 18 years. So, when confronted by red tape, I am not surprised and usually find a way to cut through it rather than work around it. It drives my dad crazy. As a retiree from a large corporation, he knows red tape and tries to redirect my efforts to working within the system, rather than fighting it. I figure it is a little bit of the rebel in me that wants to set things “right,” to have things “make sense,” that drives me in moments like this.

My nursing license was due for renewal at the end of October. Normally, it’s not a big deal. I log onto my computer, answer some questions about whether I’ve been arrested or had action taken against my license—I responded “no” to both, in case you’re wondering—and enter my credit card information. Before long, I’m notified that my status has been updated and am informed of my next license expiration date, two years hence. My chosen state of licensure doesn’t issue a special practitioner license, but I do declare myself as an advanced practice nurse on the renewal form. The Air Force then logs onto the online verification system and—surprise—I am current for another two years.

Not so this year! It seems the Air Force has issued new guidelines (obviously written by someone not familiar with all state licensing requirements) that require APNs to have a nursing license that identifies them, in some way, as an APN. (If memory of my first year of graduate school is correct, I don’t always need a license as an APN, just a registered nurse license and APN certification.) When I pointed this out at the local level, I was told, “But that isn’t what the regulation says.” At the consultant level, I was told: “Don’t worry about it. Have your local level call other bases. It’s fine!”

So, in an effort to do this “the easy way,” I called my state of licensure (it’s a large midwestern state spelled with more than four letters) to request a letter that simply states they are aware of my APN status but do not issue an additional license for this higher level of practice. They agreed this is true, but said: “We are a state; the federal government can’t require us to do anything. If we write you a letter, everyone will want one!” Really? How many APNs, do you think, carry a license in your state? And, if you keep that letter on file, just change the names!

I finally got though to an assistant director, who agreed to discuss my situation with the director of the board, who has never e-mailed me back or returned phone messages. So, I guess this is the way this state wants to “support the troops,” which is what frustrates me more than anything. They request my military stories to share for Nurses Week or 9-11 anniversaries, but when I need something, it boils down to red tape and closed doors.

So, where does this leave me, besides disappointed, frustrated and out the money I paid to renew my license in the state where I have been an active RN for almost 20 years?

I will now have to research the law for the state in which I currently reside and pay the several hundred dollars required to get a license here. (It is the state where APNs started, and where we are so respected, we can open a private practice.) I will need a license here eventually, anyway, as I plan to stay in the area once I retire. (That’s also my dad’s rationale; just get one here rather than argue the issue.)

So, I will spend a vacation day this week doing the research and finding all the necessary paperwork. And, I will cease my relationship with that old state and, here in our new home state, call it a New Beginning!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Sunday, October 9, 2011

Juggling glass balls

Have you heard the story of the many balls we juggle? Some balls are made of rubber and bounce, while others are made of glass and will shatter, if dropped. Each of us determines the balls we juggle and some of them change, depending on a day’s priorities. Often, when I walk in the door of my clinic, my “family” ball changes from glass to rubber, because my kids are well cared for and safe for the day at school, but my “work” ball suddenly becomes glass. Some days, that glass ball stays in the air with what seems like little effort. Other days, I feel as though I should be wearing protective gear as I dive repeatedly to the floor in an attempt to catch my ball before it shatters.

There are many ways the Air Force is ahead of the times (or at least keeping pace). We utilize “mid-levels” to the fullest extent of their education; we embraced the electronic medical record long before our civilian peers; and we are constantly evolving in practice theory with a mindset of patients first.

Where do we fail? In managing our people and, often, the day-to-day running of our clinics. We put nurses or providers into mid-level management roles, and the position of “Group Practice Manager” is handed off like a hot potato to the most junior administrative lieutenant. The result? Often a poorly managed clinic, with constant errors in schedule templates and lots of scrambling to keep up to date on performance reports and award packages.

Have I seen it work? Yes, there are nurses or providers out there who are excellent managers, whose calling is more toward leading people, who display great juggling talent as they keep those glass balls in the air with apparent ease (or they just work 60-hour work weeks to make it all “look easy”). And I have seen group practice managers, with prior experience in running large civilian clinics, calm the chaos and facilitate better provider efficiency.

Why this discussion today? I spent the last week filling in for the nurse who normally performs our middle-management role, while I continued to see a clinic full of patients every day. I have said all along that both are full-time jobs and, when trying to do both, neither is done well. This week proved it. (As glass shattered all around me, I definitely needed protective gear!) 

I was consistently a few patients behind and frequently had a line of people out my door who wanted to update me on personnel issues or get paperwork signed. I missed my usual lunch catch-up time, spending it instead in meetings where my attendance was required but my input not needed. The saving grace? I was not on call, so I didn’t have that added stress.

The lesson I learned? I am a provider, and pretty good at it, but middle management is not where I want to spend my time! I am so thankful for those who do enjoy that role. It allows me to stay where I thrive, immersed in patient care and, most days, easily keeping the balls in the air and not surrounded by shattered glass!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Monday, September 12, 2011

National day of remembrance

Like so many Americans, it is hard for me to believe it has been 10 years since the day that so changed all our lives.

Every U.S. generation has “that moment”—the one that forever defines for members of that generation where they were when “it” happened. For some, it is the beginning or end of a war, for others the day President Kennedy was shot. For younger generations, it seems there are several moments: The day President Reagan was shot and the two times we lost a space shuttle certainly qualify, but the biggest one was the attacks of 9-11.

Where were you on September 11, 2001? What is your story? How has your life changed?

For me, I was sitting in my favorite chair, nursing my now 10-year-old and enjoying a rare solo visit from my father. My mom was in North Carolina, awaiting the arrival of my sister’s third child. We were living in Las Vegas and had turned on the TV to check the weather for our planned outing to Mt. Charleston, for a day of hiking and a picnic. At first, as the weather report filled most of the screen, a list of airport closings and shutdowns scrolled across the bottom. It didn’t make sense. When we changed channels and saw pictures of what was happening in New York, Washington, D.C. and Pennsylvania, the situation came into focus—at least as much as anything could come into focus that day. It took awhile for the shock and reality to sink in.

We called Mom and then pressed on with our plans to spend the day on Mt. Charleston. There was nothing we could do, and our need to escape and try to be as normal as possible was strong. But as we hiked, we were a little on edge, wondering if anything else was happening or what surprises awaited us when we returned to town and the constant media coverage.

Has life changed? Sure, especially when it comes to travel and security. As a military member, I have deployed in support of the global war on terror. My kids now live with the knowledge that our borders are not as safe and secure as we believed them to be when we were young. But our lives have also changed in positive ways. There seems to be more support of those who spend their days protecting America: policemen, firemen, soldiers, sailors and airmen. Ordinary citizens seem to better grasp the service-before-self concept that these people display every day they’re on duty. The stories of public servants entering the doomed twin towers, or the daily scenes played out at airports all over the country as military members deploy or return in support of the mission, remind Americans everywhere of those who serve.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

Tuesday, September 6, 2011

“The physician will ...”

People who know me well will not be surprised that I was recently pretty fired up by some otherwise benign statements. I tend to be a little sensitive when it comes to physician-centric verbiage. I have a healthy respect for my MD counterparts, and it frustrates me to be sidelined or to feel our role as NPs is not being supported. (I also tend to shudder at the terms “mid-level” or “physician extender.”)

So what set off my tirade a few days ago? I read the Accreditation Association for Ambulatory Health Care (AAAHC) standards for Patient Center Medical Home (PMCH). Have you read them? If you work in a PMCH or Family Health Initiative (FHI) clinic, you should. You might be surprised at what we NPs no longer need to do as, apparently, “the physician will” do everything!

A little background is needed, I suppose. All U.S. Air Force (USAF) facilities, as well as most other armed-services facilities, are in the process of changing their clinical operating model from one where the goal is to see your Primary Care Manager (PCM) to one where you are able to see only your PCM or his or her team partner (a team typically made up of an MD and a “mid-level” NP or PA). Under the new system, providers were rumored to have more control over their schedules, creative templating was encouraged and we were no longer restricted to the traditional, clinic-wide template of 20 or 30-minute appointments. A minimum number of per-week appointments was established, and we were given the flexibility needed to ensure that each of our populations was taken care of. We were allowed to do this as uniquely as we chose.

All USAF facilities are inspected by the AAAHC, and careers can be made or ended by inspection results. As an additional duty—yes, as in “in addition to doing all the patient-related care”—I review the inspection criteria and, through a series of self-inspections, make recommendations to the senior management team regarding our adherence to the standards on which we will be inspected.

So, on a rare day when no patients were scheduled—we were waiting for a planned base “incident” to happen, so we could prove our ability to care for a mass influx of “patients”—I took the opportunity to review the new PCMH standards from AAAHC. I was shocked to see how prejudiced the verbiage was and how it completely sidelined the role that NPs (and PAs, for that matter) play in today’s health care arena. The standards were completely based in physician-centric terms and gave the impression that physicians are the only deliverers of health care.

Get with the times, AAAHC! In some states, we can practice independently, hanging out a shingle and seeing patients without the oversight of a physician. If we seek accreditation in that instance, will we fail because there is no physician guiding the patient-care decisions?

It frustrates me that this national organization, one from which facilities seek accreditation, can be so close-minded about what is needed for health care to survive. Do we as NPs recognize the training and schooling that our MD counterparts must endure to practice? Yes! And we know our role in health care. and that most of us do not need a physician to direct that role. We are counterparts, members of a team, who work together to provide the services our patients need most. Does a team need a leader? Yes, sometimes it does, but in health care, that leader is often the most experienced member, not just the one with the MD behind his or her name.

I don’t know that this physician-centric rhetoric will ever change. A friend of mine (gasp–an MD even!) thinks that, as the “silverbacks” who currently head up these types of organizations move on and a generation that has trained alongside NPs comes to “power,” things will be different. I hope so. Only time will tell.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Monday, August 22, 2011

'Forever friends'

Do you have “forever friends”? You know the ones—people who have known you since high school or even elementary school, people who know you better than your spouse does, the people you reach for in those life moments when you need to cry or celebrate. Not that, when you first meet someone, you actually define them as a “friend for now” or a “friend forever,” but you often know pretty quickly if this is someone who will fade away when the circumstance that brought you together is history.

I recently saw on Facebook a post that occasionally circulates, the one about people who touch your life and either stay or move on. Many posts also comment on military friends, those people who are brought into your world because of an assignment or deployment and become a forever friend. Whether it is a circumstance or common culture, shared events or true connection, these people are the ones you invite to your promotion or retirement, the ones you travel cross-country to visit, or celebrate with when your paths cross again, perhaps to spend another assignment or tour together.

We have had a busy summer, and I was lucky enough to spend a few days connecting with a few of my forever friends. There are five of us from college who still keep in close touch, who shift schedules and move mountains to spend a short weekend together every year. Some years, the mountains won’t move and someone has to miss—in my case, “Uncle Sam” sometimes has a different plan—but we continue to make the effort.

This year, I was the lucky host and the girls spent a short 48 hours in my new house, sharing stories of kids and significant others, tears over the same and sightseeing around these beautiful mountains. We decided two days is not nearly enough; that once we get the youngest off to college, we will spend an entire week together, soaking our toes in the sand somewhere. And we were reminded that, although 363 days may pass before we get together again, because life is full and we rarely have time to connect, there will always be those two days when time stands still and we can surround ourselves with those who know us best.

Thank you to all my forever friends!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

Friday, July 22, 2011

Checking out the "real" NP world

I have to admit, as a military FNP, I am a little sheltered from the “real world” of NPs. In our community, FNPs usually work in primary care and, occasionally, pediatrics. We don’t typically specialize in areas such as surgery or dermatology. There are programs in the military for our PA counterparts to branch into specialty practice—most common is surgery or orthopedics—but they are not available to us. Why this is, I cannot answer. I would think it has much to do with the current shortage of primary care providers, but if that is the case, why do PAs occasionally specialize?

Over the last few months, I have met more and more civilian FNPs and am frequently surprised by their ability to specialize. One works in general surgery at the Veterans Administration (VA) facility in town, and prefers to specialize in breast surgery. I was thrilled to hear this because, historically, the VA has been a “man’s world” where there were few services tailored to the female veteran. Another friend works in oncology, both inpatient and outpatient. She talks about how removed she feels from “regular” medicine, and my head spins thinking of all the complicated medication regimens she prescribes.

The one that surprised me the most? A friend who is a women’s health NP recently interviewed for a job in pain management. My first question was, “Can you really do that? Take care of men, too?” And, apparently, she can!

As my time to leave the military slowly approaches—I have just three years left!—it is a little overwhelming to think I will have to go looking for a “real job” and that there are more options than family medicine. I still don’t know that I would choose something else. I enjoy the variety of what I do. But, you never know what door might open when the time comes!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Tuesday, July 5, 2011

Buckle up!

To quote the much-missed Jerry Garcia, “What a long, strange trip it’s been!”

The roller coaster that I call life is still going full speed, with the occasional quick turn and corkscrew thrown in (just to keep me on my toes, I think). In the last month, we moved into our new place, Mom arrived for the summer and I spent a week at the American Academy of Nurse Practitioners (AANP) conference in Vegas. Throw in the last weeks of school and all the programs, typical summer turnover and staffing woes and the day-to-day of sporting events, and I sometimes forget to breathe!

First, the house. It is fantastic! The choice was the right one. The size is great, things are fitting into their places and the cul-de-sac is fantastic! Great neighbors and other kids, as good or better than I had hoped for. The landscaping is moving along, and we should have a back yard within the week. I spent lots of spare time looking for plants to create the low maintenance but enjoyable backyard space it needs to be, and I think we have achieved that.

Now, Mom. What would I do without such great parents?! Both my folks arrived shortly after school ended, then dad returned home after a week. He left mom and her car here to get me though the summer, which is so fantastic! The kids can hang out with friends, go to the pool, attend Vacation Bible School and sports camps, and just relax without going to all-day care, while I rush off to work. And Mom gets to beat the Arizona heat for the summer, which I think she enjoys as well. The three of us as so happy to have her here!

Now, the conference. What a great week! I saw some old friends, both Air Force contacts and friends from graduate school. The lectures were interesting, the Venetian Resort was HUGE—anyone else still getting lost the last day?—and the evenings entertaining. There were some drawbacks to such a large attendance and some things missing I had enjoyed in years past but, all in all, I gleaned some new concepts and ideas to implement in practice.

Since returning to the clinic this last week, there were several times I had to stop and think about lectures I had attended and how to use that new information in practice. I took in the four-hour ECG lecture and, when I did a 12-lead this week, was able to quickly assess for axis deviation and bundle branch blocks. Yes, prior to this I considered them but, after the lecture, they actually made sense!

I have also been working harder to match depression symptoms to medications, considering more dopamine stimulation for those who need it. What I wish I knew more about are herbals, supplements and vitamins. I heard a bit about this, but there does seem to be a connection between some deficiencies and depression, headaches and many other things. It would be nice to be able to support this as an early or additional option for patients. Maybe, a good idea for my next conference choice?

So, summer is off to a roaring start. I am looking forward to some afternoons at the pool, a vacation in August and maybe getting the pictures hung. Oh, and soccer camp, sleepovers, baseball games and can’t forget work. There goes the roller coaster again. Guess I better strap in for the ride!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Monday, June 6, 2011

Helicopter parent

I just recently learned the term “helicopter parent” and (small gasp!) think I might on occasion—maybe—hover too much. Take a recent example from my busy week.

It was my girl’s first experience with trying out for a competitive soccer team. She has played for five years or so, thus far on recreational teams that sometimes rock—GO TWISTERS!—and sometimes don’t. In Texas, we were lucky that the team she started with pretty much stayed together, and those girls are still together, still rocking the league. Since arriving in Colorado last year, however, things haven’t been as great.

The team was full of wonderful girls and nice families (which is actually more important than winning) but only a couple girls stayed through two seasons, and the coach basically had to start all over, which led to a pretty dismal record. Since my daughter is now eligible for the U11 age bracket, the start of the competitive track in many clubs, the decision was made to change clubs and actually try out. She was a little nervous, but apparently did one of her signature moves. (Using her backside to block her opponent, she stole the ball and then ran it down the field.) She was quickly moved to a more advanced group of girls. Parents were informed that, if a coach saw something that he or she liked, a phone call would be made if your girl were chosen for a team. No phone call? Come back Thursday, and try again. So we waited, but no phone call came and, on Thursday, off we went to try again.

Now, knowing that my girl is awesome, I was a) a little disappointed we were not called and b) a little frustrated by her performance on Night Two. She seemed more content to visit with the other girls and stand around playing with her “penny” than chasing down balls. It took all my limited restraint to not pull her off to the side when she was rotated out and explain that she needed to go to the ball and visit with the girls later. (So, maybe I’m not a helicopter parent, after all?! I did restrain myself!)

Long story somewhat short. The coach apparently was excited when she learned my girl’s name, as they had tried to call but, somehow, the number didn’t work (maybe confused by the out-of-state cell?) and, now, two coaches wanted her for their teams! I could have done a cartwheel, I was so proud of my girl! Yes, I am sure there will be some complaining as this gets underway, as this is a year-round commitment, will cost more than the furniture I am currently coveting for my new kitchen and will involve travel to distant towns. (Grand Junction is a possibility. I hope that trip comes before the snow starts in the fall!) But it is a great opportunity for her to get some quality coaching and flesh out her skills a little more.

Then, it hit me. Are we nurses more prone to being helicopter parents? Is this a new term for micromanaging? In a conversation I had recently with a colleague, we discussed that, as nurses, we tend to lean toward micromanagement. We are taught from Day One to “micromanage” the care of our sick patients, who are hooked to complicated machines that, if left to others, could result in negative outcomes. It is so ingrained in us to maintain control that many of us have a hard time letting go of things we feel are our. We are also taught to manage the minutiae because, if we stay on top of the little things, we prevent the big things.

I try to remember this when I feel squeezed at work. When I feel like a playing card in someone’s obscure game that doesn’t make sense to me, or when my schedule is scrutinized down to the second, I have to remember some are more prone to being helicopters than others!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Tuesday, May 17, 2011

A REAL doctor!

I had one of those experiences last week that I know is not specific to military medicine. I am sure it happens to our civilian counterparts, to other NPs and PAs. And I know it happens on a near daily basis at military treatment facilities worldwide. As I walked into the exam room and introduced myself as a nurse practitioner, the patient announced she was “forced” to come to our clinic and “wasn't allowed to see a real doctor” downtown. I was slightly taken aback. Here I was, running on time, in a pretty good mood and ready to assess and treat to the best of my abilities, and then WHAM. I took a deep breath and realized she wasn’t slamming NPs; she had a grudge against military providers, regardless of education background.

Some people think we are on active duty because we can’t cut it in the “real world,” that we are somehow subpar when compared to our civilian peers. And, people do sense a lack of control, since they have to enroll with a provider at a military clinic, requirements put in place by TRICARE (basically, our military HMO/PPO/insurance provider, depending on current terminology). In reality, we are all credentialed and/or certified in our specialty and really have two specialties to maintain, our civilian requirements and our military ones. I honestly believe military medicine should be it’s own specialty, since we have to know how various military-specific careers affect disease processes. And don’t even get me started on deployment medicine—who needs malaria prophylaxis, who is more resilient and able to tolerate the stress of deployment, etc. I could go on and on!

So, what did I say to that patient that day? Basically, a toned-down version of the above. That she is actually lucky, that we are a unified practice of providers all credentialed in our fields, who “get” the difficulties of being a military family. Then I asked, “What can I do for you today?” and we progressed on with the visit. I hope it was a positive experience for her and she won’t be so opposed to military providers in the future. Time will tell.

As NPs, that is all we can do; try to show the world—a patient at a time—what we bring to the table and what we have to offer. And, to hope that, over time, the response won’t be, “I wasn’t able to see a real doctor” but that patients become more accepting and some will even prefer to see us for what we have to offer!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Wednesday, May 11, 2011

Patient Centered Medical Home

If you stick around the military long enough, you will experience change, which may come as a surprise to people, since we are known as one of the biggest bureaucracies in the world! Since I have been on active duty, we have changed the names of our units (remember Strategic Air Command?), added new units (Space Command is a great example) and closed multiple bases. In the medical service, we have tried multiple ways to provide consistent, quality care to our patients (Primary Care Optimization and Primary Care Management, to name two) and now, we are changing again.

A few years ago, we started hearing more about something termed Family Health Initiative (FHI), and most of us feared it was just another attempt at putting a shine on what was quickly becoming a failing mission. We were undermanned, overdeployed and, in many cases, overenrolled. A case in point, before leaving Texas for Afghanistan, I was assigned more than 2,000 patients, well over the suggested cap of 1,500. But, we had a couple unfilled provider positions, and the patients needed a provider, so we muddled through as best we could. And, when I deployed, the sole primary-care physician who remained carried a load two to three times that until replacements arrived.

With that kind of workload, we had very little control over schedules, and a frequent complaint was the feeling of “running on a hamster wheel,” as we tried to meet the rising demands. I don’t think this was an issue specific to our little corner of the world; it was a frustration voiced by providers at many military treatment facilities and likely echoed the struggles of our civilian counterparts, who experience their own provider shortages.

So, we spent a few days last week learning more about FHI (now renamed Patient Centered Medical Home) and making plans for implementing this philosophy over the next few months. This is not a military-specific patient care theory, but a model being executed in the civilian community in an effort to maximize available providers and contain health care costs. For us, it will involve a change in staffing ratios and a decrease in maximum enrollment numbers. We will be shifted into teams of eight, composed of a physician, a mid-level (a term I still don’t love), a nurse and five medical technicians. (That’s the ideal composition. When we continue to deploy and our staffing is already below expectations, we will aim for three technicians per team.) We will be responsible for 2,500 patients (1,250 per provider) and be given more freedom to creatively meet patient demand through improved template management.

I honestly can’t yet say that I am 100 percent on board with the change. Part of me still sees it as a name change with lots of empty promises. One concern: Even though there is a strict cap placed on enrollment, as well as “cross booking” between providers, there are still requirements to see patients who are promised care and, after dividing those between our available providers, we are again back to 1,500 patients each. Also, there is an expectation to meet the needs of our patients on a daily basis. So, if there is a spike in viral illness and a need for more acute or walk-in visits, we are expected to do it. This can wreak havoc when my leaving work on time is necessary to make our usually maxed-out, kid-centered evenings work as planned! Between homework and sports, there is little room for overtime at work!

I would love to become a convert to anything that will provide consistent care to our patients. I know they are tired of seeing a new provider every visit and “starting over” every time. Rumor has it that, after the first few months of working out the kinks, most providers really enjoy the new model. I’ll keep you posted on the transition.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Wednesday, May 4, 2011

Some nurses still eating their young

First of all, somehow, in just two months, I’ve managed to precept an adult health NP student for more than 135 hours! It was her first semester, and it reminded me so much of how things were five years ago when I did my first adult health rotation!

I attended graduate school at Uniformed Services University of the Health Sciences (USU). The military’s own graduate-level university, USU has both medical and nursing programs. USU Graduate School of Nursing offers a doctoral program as well as master’s degrees for family nurse practitioner, anesthesia and perioperative clinical nurse specialist.

Within the first few days, six of us gravitated toward each other and we were just as tight when we graduated two years later. We studied together, laughed together—sometimes cried together—and, in our free time, got our families together. We were an incredible support group for each other, and we all stay in contact today. Four of us are still on active duty, one has left the Air Force to start medical school and one, fulfilling a lifelong dream, is is providing health care in India.

I remember those first few days, thinking I knew so much, then walking into clinical, terrified, trying to just remember my own name. Now, five years later, it was a great experience to support another NP through those first scary patient interactions. First, we would talk about the questions to ask and the assessment to do, and then I would turn her loose. She quickly took to the whole process and I watched her confidence grow as she formulated her own style in the exam room. Simply talking through disease processes and looking up current research has done much to reinvigorate my own practice. I look forward to spending more time together over the next year as she works through her program.

Contrast that with another experience I’ve had recently. I conducted a medical legal review for a pending case against another practitioner. I won’t go into details, but it was interesting to read the case files and to read the detailed notes made by the specialist reviewer. She even went so far as to conduct a literature review of the standard of care that was in evidence 10 years ago when the initial incident occurred! My frustration? Another NP reviwer, in seeking to build a case against the person in question, used research that wasn’t even published 10 years ago. It frustrated me that, as nurses, we sometimes still have the “eat our young” mentality.

I wonder if there is any way to remove that from our collective culture. Maybe in precepting a new generation of practitioners, we can take away this outdated belief that we have to step on each other to get ahead. I think there are enough opportunities in this world for all of us to succeed without using our peers as stepping stones!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Monday, April 4, 2011

I love vacation

I love vacation, even the vacations when I never leave town. I think it
has more to do with not having to work than visions of exotic locales.
I do like my job but, some days, the demands pile up and my patience
falls desperately short of the expectations. So, after a week of
feeling like the bug who loses to the windshield, we headed off to
sunny Arizona and Southern California for a week of being spoiled by my parents and time for the kids with their cousins.

We took in a spring training game. The Reds won.

We played at the beach.


And stayed to see the sun set.

We even visited Knott's Berry Farm, where my mom had been more than 50 years ago! We kept asking her if it looked familiar!
The time was much needed for all of us, and my previous stressful week was quickly forgotten (at least until I returned to work today). Time with family just makes it all worth it!

Monday, March 28, 2011

The speed bump that became a high spot

Friday was one of those days that will linger in my mind for quite awhile.

It was the end of a long week. Sick children, life stressors, work demands—all the typical things that pile up in the face of an approaching weeklong vacation. I thought I had the week pretty well planned in advance—a few days of “sick call” and a wide-open Friday afternoon to ensure a few quiet, patient-free hours to tie up loose ends before leaving the nurse in charge. (I hate leaving too much for my covering physician to deal with. He has his own daily demands and, as we all know, covering for another provider can destroy your week.)

Then, as only the military can do, a huge speed bump was put in the middle of my well-planned road! In response to the events occurring in Japan—the earthquake, the tsunami and, now, a nuclear threat—the military was offering voluntary evacuations to family members located in that country. The evacuees—mainly women and children—were being routed through various cities, and our location was chosen to support this mission. The request was for a provider to be on site at all times to provide acute care and address any medical concerns that might arise as the families were routed to final destinations elsewhere in the United States.

I scrambled to find someone to come to the house in the early morning hours and get the kids off to school. A few good friends have made the offer to “call anytime,” so I took one up on it, and he was quick to say yes. (Proof that the week wasn’t all that bad is that it reminded me of the wonderful friends I have made here in a short six months!)

When I arrived at the site, I was pleasantly surprised to see how organized the event was. The USO and Red Cross were there with food, hygiene items and a bank of computers and phones for the evacuees to utilize. The support staff had established play areas for the various aged children (everything from playpens to a bounce house to Wii) and staff to supervise them. They even had military members in place to walk the animals that were accompanying the families.

As the evacuees arrived, it was awesome to watch young soldiers, sailors and airmen assist the travel-weary women by carrying their baggage, pushing strollers and cleaning up after pets. The women were free to complete all the necessary paperwork and arrange their follow-on travel, knowing that everything else was covered, and the kids—and pets—were able to spend all their stored-up energy in a safe environment.

Except for treating some nausea and hypertension and handing out lots of Band-Aids, I provided very little patient care. In the course of the day, eight to 10 new moms and their babies came through—one just 6 days old—and I touched base with most of them to ensure they were doing OK and didn't need additional support. In general, I just watched and was so proud to be a part of this organization that sometimes can frustrate me to no end but, at the end of the day, can put together an operation to support our own that is second to none.

Although the evacuation initially added stress to an already stressful week, I am so glad I had the opportunity to assist in this massive undertaking, talk to these people, hear their stories and provide what little relief I could. It may have started as a road bump in my busy life, but it ended up being one of those experiences that will stick with me as a highlight of my time in the military.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Thursday, March 17, 2011

The search continues

I am still looking for our “forever” house. My military friends will understand this.

We live in many places while serving our country. Most members of the military move every 3 to 4 years. We adapt to new communities, new cultures, new norms. Our kids adjust to new schools, new friends, new sports teams. And, through it all, we live in dorms or base housing, apartments or rental homes, and we occasionally purchase homes, usually knowing it is only for the duration of our relatively short stay in that community.

When we buy we look for something that will “do” for those few years, with a relatively short commute, safe in case we have to leave our spouse and children there alone during a deployment, something in which we can acquire some sweat equity, something with good resale potential.

Now, with a relatively short time remaining for me in the Air Force, I am considering the option of staying put in this community, allowing my hoodlums to finish high school with friends with whom they attend elementary school. The decision is tough but, when my retirement rolls around, they will be in middle school, a tough time in any child’s life and a tough time to start over.

So, we spend our weekends looking for “the one,” the house that won't just “do” for the duration of the assignment but maybe “forever” (or at least until the boy child finishes high school). We have found a few that are OK, that meet our basic needs. But we haven’t found anything yet that is on a quiet street, has enough beds and bathrooms to accommodate my parents’ frequent visits, has a backyard big enough for impromptu soccer games but not too much for me to keep mowed and a reasonable price that enables me to keep the kids in their current elementary school! Do you think I am asking too much?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Monday, March 7, 2011

Simple pleasures

Today is one of those days I initially railed against when the school calendar was released. It’s a “non-contact” day, as they call it in this district, a day set aside for conferences but not a federal holiday. Thus, it’s a day I am forced to either take leave from work or enroll the kids in all-day care at the school. I chose this school for its quality before-and-after school care program as well as the all-day care it makes available on breaks. They do a ton of activities, and the kids have grown very attached to the staff members, but I feel that, if my children have a day off from school, they should get a day of freedom—a day to sleep in, watch bad TV before breakfast and maybe hit the skate park when the “big kids” are still in school.

So, I was frustrated that I would have to “burn” a day of leave to stay home with the kids. Now that the day has rolled around, I’m loving my break from clinic. I had a long day Monday, saw 25 patients in 3.5 hours of sick call, followed by my first experience of precepting an NP student.

So, today, I slept in and got in a workout before the kids woke up. Then, the best part of the day so far, my girl child delivered one of those notes we parents are so familiar with: “Dear Mom: Come downstairs and take a seat.” I honestly had no idea what to expect. A story request, maybe a “show” she had choreographed, a made-up play? What I found was a clean room with the bed made and her table pulled into the middle, all set for tea! We enjoyed a rare chance to just sit together and visit. We talked about her artwork that she has displayed in her room and about the colors she would like to paint her room, once we find that house.

So many days are spent running from activity to activity, task to task. We go to school and work, come home and complete homework, cook diner, and then hurry through showers so we have time to read before bed. This morning provided that rare opportunity to just sit and enjoy my girl’s company without worries about the day. So, my thanks to the school district for this wonderful opportunity to enjoy an unstructured day with my babies! And tomorrow? I have another of these “forced” days off, a day we’re looking forward to spending on the slopes with friends!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Thursday, February 17, 2011

Shopping blues

I, like many women out there, like to shop. I also like a bargain and rarely buy unless I think I have gotten a “deal,” so shopping has been difficult lately. It might be what I’m shopping for—a house, some furniture—or simply my perception of a deal!

The area where I am house hunting has weathered the financial storm pretty well, looking at it from my side of the fence. I hear stories from people who live here that most home prices have fallen more than a hundred thousand dollars, but they still seem pretty pricey to me!

The issue is the elementary school. It’s rated at the top in the state and I firmly believe it has helped maintain property values, because people want to start their children off here. I refuse to move my kids from this school, as they have settled in nicely, love their teachers and are thriving in the before- and after-school care program. And what a program! They’re taking TaeKwon-Do, participating in science clubs and my girl has attended two sessions of cooking classes—all this in addition to homework assistance (run by the teachers) and an excellent staff! Needless to say, we are not changing schools, so the search continues. So far, I have seen several homes I like, but none I love and, since this is, potentially, a home we will live in for several years, I want to love it!

One thing I did manage to buy yesterday—a new car! I had been driving a 2001 Suburban, which I loved and hated to give up. It was comfortable, old enough that I had ceased caring about the kids eating in it, and I knew how it responded in most conditions. It responded poorly. It was not a four-wheel drive, and it had a tendency to slip-slide on almost anything. Having been built in 2001, it lacked any significant safety equipment for the rear seat, where my most important riders sit.

All of these drawbacks led to some pretty white-knuckled drives down from the mountains. Many days, I was thankful for the heavy traffic, because it kept speeds down and I could drive slow, not feeling pressured to push the limits of my aging ’burb! So, last night the kids and I headed off to see our friendly Ford dealer and we are now the proud owners of a new 2010 Explorer—old body style, truck frame, all the bells and whistles for safety and heated seats! We are pretty darn excited!

But—out of the mouths of babes—my boy just told me, “Mom, you should have bought the more expensive thing first; the house, then the car.” Thanks, son. Maybe you will stay home today while I go out and test our new toy, driving to the mountains! We will table the home search for a few weeks; we have nothing but time!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Wednesday, February 9, 2011

Keepin' on bloggin'

Maintaining this blog often competes with other priorities—cleaning house and grocery-shopping, to name two. I am so thankful to Sigma Theta Tau International for providing this forum and for Jim Mattson, editor of Reflections on Nursing Leadership (RNL), who ensures that what I say makes sense and helps keep me on track. A couple times, he has sent an e-mail asking if I plan to continue posting, a very polite way of encouraging me to get typing!

So, recently, in the midst of a rare Saturday morning without my children, I managed to write three posts and even looked over the blog design and statistics. I had no idea there was a way to see how many people had accessed the site and where they were from. I was pleasantly surprised to see there have been more than a thousand hits since my blog was created almost two years ago. Now, I realize that really isn't much when compared to many others out there, but it gave me a little lift to think of all those people reading what I write.

What was fascinating to me was all the foreign countries where people access my blog: Malta, South Africa, China. What do those people think when they look at what I write? Why did they land on this page? Are they nurses? Are they looking for information on Afghanistan? Are they Americans living abroad or are they native to those places?

I also took time to update the “blogs I am following” link (click on "Lori" under "Contributors" in the right-hand column) and was a little sad to see that some people had stopped posting blog entries. One of the soldiers on the team we replaced had stopped updating his blog when he returned home from Afghanistan, in the summer of 2009. I enjoyed his writing and hope he has returned to the “peace-loving lifestyle” he was so looking forward to.

I also added a favorite website—“
The Pioneer Woman.” If you’ve never visited the site, I encourage you to check it out. Several months had passed since I had last viewed it but, after receiving her cookbook for Christmas, I plan to become a regular again. Her humorous reflections on farm living always lift my spirits. I also—finally—updated the link to Meg’s blog, “Soup is not a finger food.” Meg is an old friend who frequently has a sassy way to state the obvious. Reading her posts brings a smile to my face, as I remember the days I spent hanging out in the ’hood.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Friday, February 4, 2011

Greener pastures

Many of us who spend the majority of our time in military medicine see private practice as so much better. No inspector general visits, no “working for the man” and no threat of deployment. We often feel as though, with meeting access demands, completing medical evaluation boards and fulfilling all the required military training (frequently on our own time because of patient care demands) with no end in sight, we are on a hamster wheel.. But, as two of my good friends have discovered, the grass is not always greener!

One of my friends, a physician, left the military to join a large group practice connected to a large hospital. He enjoys the time off, choosing his own hours, and the increased time he haswith his family, but he is considering rejoining the Air Force, because he senses something is missing. There is no camaraderie within the practice, and he misses feeling that he is serving a greater purpose. He still has pressure to see patients and sees changes to insurance reimbursement limits as potentially detrimental to private practice. He also realizes the impact of walking away from the retirement money. As he puts it, “I still work for the man; it is just a different man and I get to choose the clothes I wear to work!”

Another friend left the military just a few years short of retirement. She was dissatisfied with future assignment opportunities and wanted her spouse to have stability in his non-military career. After a recent move, she struggled to find a job. Medical-provider positions are not typically listed in a newspaper and she almost resorted to going door-to-door or hiring a headhunter. Now, working in a practice she enjoys, she can still tell stories that would make most of us military medical members’ toes curl! She discovered the medical assistant wasn’t wiping her exam tables after every patient, and my friend recently returned to work after a vacation to discover she was double booked and, because a colleague unexpectedly needed time off, had been volunteered to take on that provider’s schedule.

So, on those days when I feel like the hamster wheel is more challenging than usual, I remind myself that the grass is not always greener. When it comes to medicine, you can change the clothes you wear to work or the “man” you work for, but that elusive “perfect” job or practice may not exist. Sometimes, you have to find the “perfect” where you are and focus on that; and hope you don't fall off the wheel!


For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International (STTI).