In general, the nursing faculty shortage has been well documented. The shortage has a profound effect on the entire nursing workforce. Many even point to the nursing faculty shortage as a major cause of the nursing shortage. Undergraduate programs are turning down qualified applicants since there is such a limited number of eligible slots in nursing programs.

Three of the contributing factors in the shortage are:

1. increasing faculty age;
2. much lower salaries than these nurses direct clinical counterparts;
3. the cost of graduate education.

Fortunately, a number of steps have been taken in both the public and private sectors to address these issues and provide incentives to nurses to pursue faculty positions. For example, the Johnson & Johnson/AACN Minority Nurse Faculty Scholar program provides financial support ($18,000 to five winners from minority backgrounds) to teach in a school of nursing after education. In addition, federal legislation was enacted forming the Nursing Education Loan Repayment Program (NELRP). New in 2012, nurse faculty with greatest financial need working at schools of nursing with at least 50 percent enrollment of students from disadvantaged backgrounds will receive funding preference. Note that the 2012 application is closed but check the above link for information for 2013 application information.

The requirements for nurse practitioner clinical faculty are a minimum of a Master’s degree and several years of clinical practice. A good way to start teaching nurse practitioners is by becoming adjunct faculty with a nursing school. Adjunct clinical faculty will often serve as school’s representative for the nurse practitioner at their clinical site. The clinical faculty will ensure that the student is receiving the proper exposure to the clinical outline, perform site visits and grade clinical assignments. Oftentimes, nurse practitioner faculty will maintain some sort of other clinical practice as well. I believe it is important for seasoned clinicians to take these roles as clinical faculty to help educate the clinicians of tomorrow.

Adjunct faculty can also find themselves in the classroom teaching classes such as advanced clinical assessment, billing and coding basics, and even chronic disease management.

Some of the benefits of adjunct faculty are: being associated with an educational institution, shaping future clinicians, access to the university library, various faculty discounts, and supplemental income.

Once you have a few years of clinical practice under your belt, consider becoming adjunct clinical faculty. The nurse practitioner students and future NPs will surely appreciate current and new faculty.

Also check out the National Organization of Nurse Practitioner Faculties (NONPF) for more information.

One of the unique aspects of being a nurse practitioner is that we are nurses first. All of the experience and skills that we attained as nurses are used for advanced nursing practice. Obviously, I am biased but believe this makes nurse practitioners an ideal provider of care. That is, having a very strong patient advocacy and patient educational component as well as the ability to manage and treat chronic conditions while promoting wellness and proactive care.

Many institutions are recognizing their nursing staff in different ways. For example, it is common for large hospitals to host a breakfast/lunch, offer 5 minute massages, raffles for prizes and giveaways. This is certainly commendable and a very nice gesture. I am sure that most nurses are appreciative of these events. I am also sure that nurses would be even more grateful if they were treated professionally and with respect every day.

And now I’d like to end this post with a pledge that was written in 1893 by Mrs. Lystra E. Gretter to honor Florence Nightingale and nurses everywhere. This is known as the Florence Nightingale Pledge:

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.

Happy Nurses Week 2012!

As of March 2012, 5152 of 13,202 eligible Nurse Practitioners have been paid a total of $109,218,169 dollars for adopting electronic health records and meeting the Stage I Meaningful Use requirements. Please note that NPs are only allowed to apply for the funds for their patients with Medicaid. Under the program, nurse practitioner were unfortunately omitted from eligibility requirements for Medicare patients.

What is the Medicaid EHR Incentive Program?

The Medicaid EHR Incentive Program will provide incentive payments to eligible professionals, eligible hospitals, and CAHs as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years.

• The Medicaid EHR Incentive Program is voluntarily offered by individual states and territories and may begin as early as 2011, depending on the state. Check with your State Medicaid Agency for more information.
• Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program.
• Eligible hospital incentive payments may begin as early as 2011, depending on when the state begins its program. The last year a Medicaid eligible hospital may begin the program is 2016. Hospital payments are based on a number of factors, beginning with a $2 million base payment.
• There are no payment adjustments under the Medicaid EHR Incentive Program.

Eligible Professionals (EPs) must meet the following criteria for Stage I Meaningful Use:

• 15 core objectives (An example of a Core Objective is utilizing an electronic prescription (eRx) interface withing the electronic health record.)
• 5 objectives out of 10 from menu set (A Menu Set Objective would be sending reminders to patients per patient preference for preventative/follow-up care).
• 6 total Clinical Quality Measures – 3 core or alternate core, and 3 out of 38 from alternate set. (A core clinical quality measure would be to keep the Hemoglobin A1c of patient with diabetes less than 8.0).

The sooner that one attests for the meaningful use guidelines, the more incentive money one can get. The Medicaid Incentive program is set to expire in 2021.

Of course, you first must choose an EHR that is capable of meeting these objectives. You can check out the CMS website to start the attestation process and for a handy checklists to help ensure that you have everything needed to get started.

Next up is Stage 2 of Meaningful Use which has been pushed to 2014. Stage 2 builds upon the Stage I objectives and really pushes interoperability among the various clinical information systems.

It is a very busy time in Health Information Technology and using it to enhance clinical outcomes. Therefore, it is so important to stay abreast of these important updates.

As I enter the last few weeks of the DNP program and what will likely be the last time that I can call myself a “student,” I reflect on this experience. I assuredly have many of the typical feelings that many graduate students encounter at the conclusion of their studies. These include the joy of completion, the exhaustion of a grueling program, and the fear of the unknown in the future. However, there is a difference. Unlike completing the FNP program where role clarity was defined, I believe there is a greater amount of uncertainty with the DNP. For instance, there are no job postings looking for a “doctor of nursing practice,” at least not yet. The interesting piece is that I don’t believe that is necessarily a negative.

I believe DNP graduates will be defining our own roles rather than someone else doing it for us. When we review all of our coursework including: teaching/mentoring, health economics, evidenced-based practice, ethics, policy, and health information technology, we were given the tools to find our own niche in the complex health care landscape. It is therefore imperative to position ourselves and partner with organizations that are anything but status quo. In actuality, organizations cannot afford to maintain the status quo for they will surely be left behind on the health care reform train. This translates into excellent timing for DNP graduates.

One of my proudest achievements throughout the program is the approval of our systematic review and meta-analysis by the Joanna Briggs Institute. I don’t recall ever committing so much time and energy to any one project before. There were certainly some challenges along the way. I recall countless statistics discussions and whether we would be able to do a meta-analysis, difficulties with the JBI software, and determining inclusion criteria. Then there were the articles – over 2000 whittled down to just 15. In the end, I absolutely feel that our meta-analysis on group medical visits adds to the evidence in support of group medical visits to lower hemoglobin A1c for patients with type II diabetes. I find this not only significant for the knowledge base but this is something that is patient-centered. This is the essence of the DNP for me. That is, translating evidence into the real world where it is about patient care.

I believe this is congruent with my philosophy of practice – establishing strong partnerships with our patients, other members of the health care team and stakeholders. In the end, it should always revolve around our patients. Sadly, this is often not the case as special and personal interests take precedence. Another important consideration for us to remember is that just because the evidence may suggest a particular treatment, the patient has the ultimate choice in deciding their course of action.

I have already started to incorporate the knowledge gleaned from the program into my daily practice. For example, I often look for systematic reviews/meta-analyses for answers to common issues encountered. I’ve realized two things: 1. I can now understand the terms, rationale and outcomes in a clearer way and 2. there aren’t many systematic reviews out there that pertain to the clinical question that I may have. While this can be somewhat frustrating, it presents an opportunity to conduct my own research to answer the question. It is important to note that the last thing I want to do right now is perform another systematic review! However, I now hold the tools and knowledge if I chose to do so.

Looking toward the future, my ideal role would be one that allows me to maintain some aspect of clinical practice while incorporating the pillars of the DNP program into my organization with an emphasis on health information technology. I have thoughts of partnering with some of my DNP colleagues and perhaps providing consultative services to organizations looking to implement evidence based practice into their culture.

In conclusion, I reflect on the last 3 years of the DNP program and am certain that my decision to pursue this degree is validated. I’ve been exposed to a wonderful mixture of faculty and classmates. I knew doctoral work was not going to be easy and I would venture to say that it’s been the most challenging work that I’ve professionally completed to date. I firmly believe that I’m transformed and uniquely positioned to tackle the complexities of the health care system as well as digging deeper into patient care.

It seems these days, anyone and everyone is willing to share their thoughts and opinions about the Doctor of Nursing Practice (DNP) degree. These include non-nurses and nurses alike. Well, I thought I’d take a stab at it as well since I am now 2/3 through my pursuit of the DNP. If you were to strictly listen to some of those opinions, you would have a very poor view of just what exactly this academic degree is and what it can (and can’t) do. Perhaps I can dispel or at least clarify some of these points, at least from my view.

• First, no one is “forcing” anyone to go back to school to get this degree. The 140,000+ already practicing NPs will continue to practice without the need to return for formal academic education. However, starting in 2015, it is presumed that MS programs will transition to the DNP.

• Second, there is some variation in the DNP program types. This is incredibly frustrating to me since not all programs are created equal. The DNP is not synonymous with nurse practitioner only practice, creating further confusion. For some great fact gathering, look at the AACN – Doctor of Nursing Practice section. One must thoroughly research the program and decide if it is congruent with their own practice philosophy, learning & lifestyle.

• Third are the financials – it does indeed cost a significant amount of money for doctoral education. However, there are loans and grants available for those willing to search them out. In keeping in line with the financial aspect, no one really knows what the additional education will translate into when it comes to salaries. I’d say, if that is your main motivating factor, the DNP probably isn’t for you. (As an aside, I’ve started reading the book, “Drive” by Dan Pink and he asserts that autonomy, mastery and purpose are the real long-term successful motivating factors rather than financial incentives when it comes to non-task oriented work). I don’t think I know one NP who became one for the money (because the reality is, some RNs are making significantly more than NPs). Of course, one would want to know what their return on investment would be but it just isn’t that simple. I believe that it is safe to assume that somewhere & sometime, a doctorally prepared clinician can make more than one who is not and will have a number of new opportunities at their door.

So, why did I decide to return to school for a DNP? Here is a little background: I have been an FNP for 10 years and have held a variety of positions in correctional health, college health, men’s health, retail health and occupational health. I’ve seen many patients in many different settings and I’ve been able to build upon each experience. However, I was growing increasingly frustrated with conflicting published data, major dysfunction of the health care and system and at the end of the day, wanted to be able to provide the absolute best care for the patients I served. I vehemently refused any additional “residency” type of education. In fact, I had very mixed feelings when I first heard about the creation of the DNP. Not to be coy, but I already had the education and training to take traditional care of my patients in the family practice setting. I could manage my patients with asthma, diabetes, and hypertension just fine. However, I felt that I was not using the latest proven evidence in my care. The research classes I took as a student were generally dry and seemed to have little applicability to direct practice. For me, it was critical to take my practice to a new dimension. This is the essence of the DNP for me and I was fortunate to find a program that I believed would take me where I needed to go.

The last two years of doctoral education has been both grueling and exhilarating. I am viewing my patients, their health concerns and the health system through different lenses. Didactic coursework included health policy, informatics, economics, legal/ethical, and teaching/learning/mentoring. One may look at this sampling and say that it isn’t very “practice” based. I’d say that is quite a naive view of health care today. It would be easy to “just” take care of patients’ health issues and ignore the rest since patients are multi-dimensional and never just present as an illness or disease. In addition to subtle differences in pathophysiology, patients bring their own cultural, societal, and beliefs to each and every encounter with a provider. The key is being able to navigate these complex intertwined systems and team together to best care for the patient for that time and place.

I am now onto the practicum portion of the program and am excited to take all of this new knowledge and integrate it into a patient care initiative. For the summer, I am part of a group that will be conducting a systematic review of the current evidence (related to diabetes care) utilizing the Joanna Briggs Institute method of systematic review. We have met and will continue to meet with the practice locations’ key stakeholders (including patients) to implement an evidence based, culturally congruent practice improvement plan that will be assessed and reassessed. We are hoping to uncover some great evidence and have it affect our patients in a positive way. I am also hoping for a few publications from this process as well!

To sum, the DNP will make me a more adaptive clinician. I will still see the same patients that I’ve already been seeing and will still collaborate in a multidisciplinary environment. What has changed is a truly evidence-based, patient-centered approach. Pink’s concepts of autonomy, mastery and purpose resonate with me and are in alignment with my philosophy. At the end of the day, I want to be able to care for patients in the way that they should be cared for. I believe I am on the right track.

My first year in the Doctor of Nursing Practice program has been an exciting and challenging one. My practice has been enlightened in many different ways, especially concerning culture competence and evidence-based practice. These aspects seem so intuitive once one is aware of them yet we constantly see practices that are not evidence-based or culturally competent. The program has forced me to re-examine direct primary care issues and the larger health care system issues as well.

I consider this first year one of transformation. Doctoral studies are much unlike any other course work I’ve taken before. For me, I can take the time to understand the concepts and am encouraged to formulate my own. Since we are already family nurse practitioners and don’t need to worry about passing a certification exam, I believe I can better focus on interpreting the content rather than having to memorize and regurgitate. For example, there really are no “correct” answers when dealing with policy and ethics-type issues. I am forced to think about these topics and will not find an answer in a text.

The method of learning and the format of the program allows for flexibility yet definitely takes some getting used to. This is the first time that I have participated in a mostly on-line forum and while I do enjoy the postings, I look forward to the monthly on-campus sessions. The sessions usually present an explosion of ideas from the cohort and faculty alike. I find these sessions very valuable and always look forward to the next on-campus session. I feel that the weekly on-line sessions sometimes don’t allow for enough time to read the content, synthesize the information and formulate my thoughts. In addition, this is often reliant upon the others in the cohort doing the exact same thing yet differing schedules can make this difficult at times. Effective time management skills are essential for this program.

I have a much better understanding of evidence-based practice. This is the evolution from nursing research, which is what it was referred to nearly 10 years ago in my master’s studies. I am comfortable recognizing the different levels of evidence and have the knowledge base to read and perform a systematic review of the literature. One of the more exciting concepts is integrating cultural competence into evidence-based practice. I think this is mostly uncharted territory as there is not much in the literature about the melding of these two concepts. I look forward to learning more about this process and building upon it to actually implement an evidence-based practice improvement initiative. I believe we’ve only skimmed the surface on these topics and am looking forward to more cultural competence content since I don’t feel terribly strong in this category. Yet, I am now much more aware of it and cognizant of its impact on patient care.

In conclusion, I am becoming more comfortable utilizing the tools that will help me bring evidence-based practice and culturally competent care to my practice. I am looking forward to continuing this journey and building upon this knowledge base to enhance the care I provide to my patients and in my community.

So cerumen is actually the body’s way of protecting the ear canal. Some people naturally produce more cerumen than others and may end up needing to have this ear wax removed by a clinician. Certain skin conditions such as eczema can cause increased cerumen production or debris inside the ear canal.

Cotton swabs (Q-Tips) and in the ear “ear bud” type headphones are two of the major culprits for causing cerumen issues (and potential hearing loss). Since a cotton swab is blunt, it merely pushes ear wax further into the canal. This can cause extreme discomfort as the cerumen presses against the tympanic membrane (ear drum) and can even cause the tympanic membrane to rupture. Cotton swabs do not clean ears. Patients have told me that they don’t feel “clean” if they don’t swab their ears. I ask them to only use the swab on the external ear and to use a warm washcloth on the inner part of the ear.

When cerumen occludes the ear canal and cause symptoms such as discomfort, hearing loss, tinnitus (ringing in the ears) and ear fullness, it should be removed by an experienced clinician. Patients having cerumen that is difficult to remove or with a history of cholesteatoma should be sent to an otolaryngologist for removal.

For the primary care provider, I suggest a few very helpful products that make cerumen removal much easier. Removal can be done by irrigation, manual removal, and cerumenolytics.

Irrigation: Many may recall using the old metal syringe filled with tap water. This simply doesn’t do the job as it doesn’t hold enough water to properly irrigate the ear canal. One product that has worked extremely well is the Elephant Ear Wash System. This is an ingenious system of utilizing a spray bottle with a specialized extended rubber nozzle with single use tips. I am able to get an adequate stream and have plenty of water to use without having to constantly refill. Only lukewarm tap water is required though sometimes I mix 5-10 cc of hydrogen peroxide to the water for thicker cerumen (note: the manufacturer advises against this as it can degrade the rubber hose).  This system has been very helpful and successful for me. Anyone with a suspected tympanic membrane rupture should NOT have their ears irrigated.

Manual Removal: Extreme caution must be used when attempting to manually remove ear wax. It is essential to had good lighting and the best visualization possible whenever sticking anything in the ears. Many tympanic membrane ruptures happen this way. The instruments and expertise of an otolaryngologist should be utilized when cerumen removal upon irrigation is unsuccessful.

However, when I can visualize the cerumen as it is at the outer third of the ear canal, a plastic curette works great. Another option is the Lighted Ear Curette that magnifies and lights up the area suprisingly well. Again, I only use this when I can see what I am doing in the ear canal.

Cerumenolytics: These are drops designed to break up the cerumen. One of the most popular cerumenolytic is carbamide peroxide (Debrox). Cerumen is much easier to remove if a patient uses this for 3-5 days prior to irrigation. Hydrogen peroxide also works well but also must be followed up with irrigation since it will only soften the wax. I often instruct patients to allow copious amounts of water to stream into the ear during the shower following a few days of hydrogen peroxide. This may help them keep their canals free from obstruction and save them a visit.

Finally, instruct patients that nothing small should ever be put into the ear canal. I have heard of patients using pen caps and paperclips in their ears to scratch them or try to remove the wax themselves.

(Please note that I receive no compensation whatsoever from any of the products mentioned here. This is simply my experience of what has worked best for me in my practice).   

This initiative is a natural fit since nurses and nurse practitioners care for our military servicemen/women and their families across the health care spectrum – from VA hospitals to the private and public sectors.

The criteria of support per the American Nurses Association is as follows:

• Educating America’s future nurses to care for our nation’s veterans, service members, and their families facing post-traumatic stress disorder, traumatic brain injury, depression, and other clinical issues;
• Enriching nursing education to ensure that current and future nurses are educated and trained in the unique clinical challenges and best practices associated with caring for military service members, veterans, and their families;
• Disseminating the most up-to-date information as it relates to traumatic brain injury (TBI) and psychological health conditions, such as post-traumatic stress disorder (PTSD);
• Growing the body of knowledge leading to improvements in health care and wellness for our military service members, veterans, and their families; and
• Leading and advancing the supportive community of nurses, institutions, and health care providers dedicated to improving the health of military service members, veterans, and their families.

By Joining Forces, the profession of nursing will inspire and prepare each nurse to recognize the unique health and wellness concerns of this population, and thereby improve the lives of those who have sacrificed in the service of our country.

Individual nurses and nurse practitioners can also sign the pledge by visiting the ANAs website.

One of the resources that clinicians should employ with their military patients is the PTSD Checklist/PCL (Weathers, 1993). As per the US Department of Veteran Affairs:

The PCL is a 17-item self-report measure of the 17 DSM-IV symptoms of PTSD. The PCL has a variety of purposes, including:

• Screening individuals for PTSD
• Diagnosing PTSD
• Monitoring symptom change during and after treatment

A score of greater than or equal to 50 suggests the possibility of post-traumatic stress disorder and appropriate clinical follow-up.

There are many resources and screening tools available for clinicians at the US Department of Veteran Affairs National Center for PTSD which includes downloadable material.

Please consider supporting this important initiative and incorporating these materials in your daily practice.

A thought that crossed my mind is that from kindergarten through high school, gym is a requirement for virtually every child. The importance of physical activity is instilled at a very early age and is built right into the student’s weekly schedule. However, once we get into the “real world” there is no time allotted for exercise. Of course some jobs are physical in nature so this doesn’t necessarily apply. Though a large proportion of jobs are mostly sedentary.

Something must be done. Fortunately, many employers are recognizing these trends and are addressing it. Thus, we are seeing the advent of workplace wellness programs. For employers offering health insurance, their incentive is to reduce and prevent disease which will keep their healthcare costs at bay.

In my institution, a variety of methods are being employed in the name of workplace wellness. The hospital system that I work for is very large and has many resources though there are alternatives to these that don’t require as much intensity.

Our workplace wellness consists of:

• Occupational/Employee Health to perform required annual assessments plus offer episodic visits for acute illnesses.
• The availability of a registered dietitian to work with employees on healthy food choices and diets.
• Instructional cooking classes for employees.
• An on-site Farmers Market emphasizing fruits and vegetables.
• A smoke-free workplace.
• Smoking cessation program via occupational health services.
• Zumba classes after work.
• Weight Watchers “at work” program.
• A customized WebMD portal.

Who better to run workplace wellness programs than nurse practitioners? Nurse practitioners are well-positioned to administer such programs based on the health promotion and wellness model that is at the core of NP practice.

On-site clinics that perform physical exams, treatment of acute and chronic conditions are also emerging as options for employers to reduce sick days and control healthcare costs through wellness.

Social networking and workplace wellness are also finding their way in the healthcare landscape. An innovative company, ShapeUp, is using social networking to improve health and wellness. The idea is that your colleagues will help motivate you by posting their exercise accomplishments and goals. It creates a culture of wellness.

We will continue to the expansion and proliferation of worksite wellness programs as long as they prove to keep costs down and improve health. In the future we may very well pack those gym shorts for a mid-day workout at the office!

In all probability, most of the groundwork has already been established and it may not be so apparent. Connections have been established in clinicals and networking has taken place with your state/national nurse practitioner association. Certainly, now is the time to test the job market waters and make those connections pay off.

In my 10 plus years as a nurse practitioner, there has never been more opportunities that exist than do today. However, this does not mean that employers will be knocking down your door with job offers. It is important to get a very good understanding of the potential employer and their needs to see if it is consistent with your own. I hear of many nurse practitioners taking the first job they are offered and end up being miserable because of the unreasonable demands placed on their work loads.

Some things to consider for your first NP role are:

• Is there an orientation and who will be overseeing the process?
• Is the orientation formalized with concrete objectives or are they winging it?
• Is this a brand new NP position where no one has previously worked in the role? (Be especially wary of this as the employer may not have reasonable expectations of the role and the new NP is busy enough becoming acclimated to practice as a novice clinician).
• How will collaboration occur? Are there other clinicians on-site and if not, how will that work?
• How much time will be allotted for episodic visits/physicals/new patients, etc?
• Benefits – will health insurance, malpractice insurance, reimbursement of professional dues and conference fees be offered? How much vacation/sick time is given?
• Are there any on-call requirements and if so, how is it reimbursed?
• Will you be expected to sign a contract and a non-compete clause?

The process of interviewing can easily take 3-4 weeks depending on scheduling and the number of interviews the employer wants. Therefore, it really is not too early to start looking. Finally, if the employer identifies you as an ideal candidiate and vice versa, they will likely be willing to wait a few weeks extra while you formally get your license and certification.

So take a deep breath in anticipation of the next few weeks of school while formally starting your job search.