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.

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.

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.

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.

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!

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.

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.