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.

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.

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. 

“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.

'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. 

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.

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.