From practitioner to parent of a patient

Seems I always start a post with a statement of how long it has been since I have managed to write or how busy life tends to become. It seems I blink, and time just flies past—between school projects, spring sports, a big inspection at work and training for a half marathon, there is barely time to breathe some days.

But summer is just around the corner and, thanks to a fluke episode, my boy is ensuring that we will slow down over the school break. He just turned 9 and is an active, typical little boy—playing baseball and riding his bike over any jump he can find. A few weeks ago, he had what appeared to be a minor viral illness but then suffered what is now being termed a fainting episode. Because it mimicked seizure activity, off to the ER we went.

A routine ECG turned up some thickening of the right side of his heart, so we saw a cardiologist a few days later. A long afternoon spent in the cardiologist’s office ended up in a surprise diagnosis of two congenital heart defects that could result in significant damage if we don’t repair them. Needless to say, I was in shock and still am two weeks later. My healthy, typically wild but extremely kind-hearted boy is shunting oxygenated blood back into his right heart with every beat!

Yes, we are getting a second opinion in a week but, because I have confidence in the diagnosis, the surgery is scheduled for the middle of June—a week after school ends. He will spend the summer being spoiled rotten, and the goal is to be back in school when it starts in mid-August. The cardiologist even said we could sign up for fall baseball. I think he is as optimistic as I am about all this, something I really appreciate.

In the meantime, my son has no activity restrictions, so we are pressing on with life. We fill our free time with baseball and soccer, bike rides and yard work, Cub Scouts and Girl Scouts. We have tickets to see the Rapids and the Rockies and hope to throw a big presurgery party in June. I firmly believe attitude can affect outcome, and we will enter this with the best attitudes we can muster! I will do my best to keep this site updated with our progress on this new adventure in life and know we are wrapped in prayer every day by so many people, something I am very thankful for and believe is contributing to my calm emotions.

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

Inevitable change ... continued

Why is it I seem to find time to blog only when the clouds roll in and gloominess invades? Maybe because on the sunny, blue-sky days we are on the go—skiing, hiking, exploring!

What a whirlwind December it was! Between school and scout programs, church activities and ski lessons, our evenings and weekends have been packed. The kids took a series of skiing and ski boarding lessons that really paid off. In the last week, we managed to have some days on the mountain together and they were racing down the hill with me, hitting little trails through the trees. We even ventured into the terrain park for one run!

My boy is a daredevil on his board, and he was thrilled to tackle a small table/jump. He almost landed it! The down slope on the landing surprised him a little; he’ll get it next time. My girl switched to skis this year and is very happy with the change. She is flying past her brother, leading the way through the trees. It’s a big change from last year, when she boarded well but was a little fearful.

Work is ... work! The only constant is that change continues to occur and should just be accepted as fact. We continue to plan for our big move to our new space, but that appears to have been pushed back a few weeks or months. The space isn’t finished yet. One concern is that it was developed three or four years ago when we were much smaller. With the current floor plan, we will be short on exam rooms, so are attempting to creatively plan for this challenge. The space also appears to limit efficiency with provider offices segregated from the exam rooms. Technology may save us on this. There’s talk of tablets and more mobile computing.

I am sure more change will happen with the new year. It’s inevitable and, if you know me well, you know that change is something I don’t enjoy. My personal goal for the coming year is to embrace change better for the opportunity it provides. We will see how that works out!

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

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.

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.