DNP Essential I: Scientific Underpinnings for Practice
This essential was met by rigorous hard science courses spread out through the first year of the DNP program. Classes in Gross Anatomy, Physiology, Pharmacology and Pathophysiology helped build the basic foundation to further explore disease processes in classes that followed, such as Adult and Pediatric Health, OB/GYN, and Geriatrics. The Infertility Management paper was the first major writing assignment, and it challenged me to put my new knowledge to work in the role of primary care provider to a young couple seeking care for infertility. This meant diving into the literature and searching-out all possible anatomical and physiological reasons that might be creating this medical issue so that I might guide the couple through a difficult time in their lives.
The Osteoporosis PowerPoint was a joint effort with other FNP students to create and teach a presentation to my colleagues on the nuances of the disease. The challenge was analyzing all of the medical and nursing science, and then creating a single, easy to follow guideline a provider could use in future practice to help diagnose and treat patients. The strong background in science I received at USUHS serves me well in clinical practice, as I continually return to my science textbooks to assist me as I search evidence-based literature to keep up-to-date on any latest changes in health care.
DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking
DNP-trained FNPs are more than just primary care providers. We are expected to be organizational and systems leaders in the healthcare setting, and the courses we received in leadership and economics helped prepare me for this role. Leadership and Advanced Practice Nursing was a course introduced early in the curriculum, and my assignment on Strategic Organizational Change was my first challenge in understanding healthcare management. The assignment was to review a business/leadership book that was not directly related to healthcare, and then create a paper and presentation revealing how this information might be used by a DNP working as a clinic manager. This assignment showed me that though I am in the business of healthcare, healthcare must still be run as a business, and that means knowing as a DNP how to lead as both a provider and a manager.
The Business Case with Operational Budget assignment tested me in a realm I have always been uncomfortable with: economics. Though I am well versed in financial-planning for running a household, creating a business case and budget to meet the goal of providing top-notched patient care while simultaneously maximizing profits was quite a challenge. I was required to step out of my comfort zone and spend some time in a realm I had always hoped to avoid. But, the assignment gave me a new perspective into the challenges clinic managers face, and the Health Economics and Advanced Practice course prepared me to be able to understand the financial basics I will need to know in my new role as a DNP-FNP.
DNP Essential III
The term evidenced-based practice has become a cornerstone of my education at USUHS. It was introduced during the first week of classes and it is what guides not only our classroom assignments, but also my own daily clinical experience. A week does not pass that I do not find myself searching a research database or reading medical email updates regarding a newly changed clinical practice guideline. I have spent time setting up numerous computer folders to organize all of the research articles I download and make sure my iPad has the most relevant material to refer to whenever it is needed.
Looking back through the assignments, I found just how each class has been building the concept of evidence-based practice and moving me towards becoming proficient in the ability to apply new knowledge to any clinical question I might have. Both of the papers I have provided as examples were written in the final year of my instruction, as they make full use of everything I have been taught. My paper on probiotics was prompted by the number of patients I see monthly who complain about gastrointestinal issues that arise from numerous issues, including antibiotic associated diarrhea (AAD). When I began searching the literature, I was surprised to find that I was not the only person who wondered if probiotics could help combat AAD. There is an abundance of new literature on the topic, so I was able to pull enough information together to find an answer to my clinical question.
The paper on fibromyalgia was a project I collaborated on long-distance with another classmate, and it was made easier because of the didactic instruction we had received together. I mention this because I am amazed when I find colleagues in my clinic who are still using medical therapies to treat disease that have been outdated for many years, and who I would not be able to complete such an evidenced-based project with because they do not have the knowledge of how to search and evaluate literature. Though I thought during my first semester that evaluating literature was a tedious task I was learning only for school, I have found how beneficial it has become and know it will always remain as the initial building block for finding answers to my medical questions.
DNP Essential IV: Information Systems / Technology and Patient Care Technology for the Improvement and Transformation of Health Care
One night while working the night shift as a new nurse, a young medic said to me, “Sir, you nurses spend more time treating a computer than you do treating patients." He was absolutely correct. Before I became a nurse, I never could have imagined how much of my time would be spent hunched over a keyboard staring at a computer monitor, double and even triple-charting because the Electronic Health Record (EHR) programs we were using were poorly designed and not anywhere close to being user friendly. If I could go back and add-up the time spent waiting for a computer screen to change from one page to the next, or restarting the computer after it “froze-up” or crashed, I honestly believe that number would be measured in weeks and not hours. These countless lost hours have made real impacts on patient care, but not the type to brag about.
It is no secret that the Department of Defense (DoD) has been slow to upgrade to a faster and more efficient EHR, and my current clinical site will be one of the first to be able to test the new system that will be arrive in 2016. It was therefore fitting that I shared assignments on how to improve the current system and a timeline for the process that goes into implementing a new EHR system. My project on Clinical System Analysis was based on the idea that all EHRs nationwide should be able to share patient information no matter where that information is stored. Treating patients at a Military Treatment Facility is often difficult as patients have records from many different hospitals and clinics. Though most medical facilities in the DoD use AHLTA or Essentris, which allow for portability of patient records as the patients move from duty station to duty station, I often have patients who are referred out to the civilian sector or receive care at a Veteran’s Administration (VA) hospital or clinic, all of which I could not access. It was not until December 2015 that the DoD implemented a new system that allowed AHLTA users to access VA records. It is still slow and difficult to use, but it is a start.
The project Maintaining Data Integrity seemed like a no-brainer when I wrote it, but the ability to keep electronic data and patient information private has been quite a challenge in recent years. My current facility has to remind providers every few months to not send patient information through the DoD email system, and we have even had an issue with one employee checking her own health records even though she is not a healthcare provider. It is these two issues I outlined in my paper, as the level of computer access employees are given does not always needed for the position they hold. Though we bemoan the yearly recertification training we complete for HIPAA and computer data security, I believe they are necessary reminders to keep providers from making mistakes that may violate the privacy of our patients.
DNP Essential V: Health Care Policy for Advocacy in Health Care
Policy will always be a guiding force behind my practice, as it not only regulates what I can and cannot do, but it will also direct me as I support the health care rights of my patients. Policy can be a gray area, and so ethical dilemmas will often arise. Whether they are ‘hot button’ topics such as abortion or right-to-die, or personal held beliefs in regards to issues that run along cultural or religious/spiritual beliefs, a provider must set aside personal opinion and seek to put the patients’ health and desires first.
Throughout my career as a nurse, I have run into multiple issues regarding patient care that at times were quite distressing and would create significant division among the healthcare workers in a single ICU. Just a few of those are outlined in both the “Ethical Dilemma” and “Life Support” assignments included here. Even in my clinical practice, I often find myself having to stop my personal feelings from coming out, and so I must try to be as objective as possible when providing care though I might not agree with the patients' choices.
There will also be times when I as a primary care provider must help my patients through the long and difficult process of a Medical Evaluation Board (MEB) that can make the difference between staying on active duty or ending a career long before the service member had planned. There are numerous medical-legal documents that dictate how an MEB is convened, and it is my job as a provider to understand them so that I will know what I need to perform and/or document to best assist the service member. I have already been involved in several MEBs during my clinical time, and each case provides new and unique challenges that must be overcome. The example provided is a glimpse of what might be required of me during a single MEB.
DNP Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes
Collaboration with other healthcare professionals is vital to providing first-class patient care. Throughout the three years of the DNP program, students were given assignments that could only be completed by working with other students or by seeking assistance from members of the healthcare community. Group work can be difficult as it is easy to fall into the trap that the way you want to accomplish the mission is the best and only way. However, with each passing semester, I began to see the benefits that came from working on projects with other students. Everyone has his or her own strengths, and we began to learn over time what each student was best at. As our knowledge grew and we explored areas of medicine and nursing that appealed to each of us individually, we were able to come together to form cohesive groups and complete projects related to patient care at a high level of scholarship.
The first semester of the second year of the program revolved around the class Foundations of Independent Practice. This is when we were encouraged to really began thinking as Nurse Practitioners by completing case analyses of patients we might see in the clinical setting. The five cases I chose for this DNP essential were completed as group projects, and my group decided a different student would take the lead on each case. When not in the lead role, we made sure to never do the same part of a case, which allowed every person to contribute in a different manner each time. However, even though we each only contributed one part of every case to the final write-up, it required that we solve the entire case on our own and then come together to discuss our findings. I was impressed at how easy it might be to miss something important that was caught by a colleague. We worked quickly and efficiently together, and this type of group work really impressed on me that healthcare truly is a team effort.
The Patient Centered Medical Home (PCMH) presentation was originally supposed to be the beginning of the work I would complete as my final DNP project. This project was completed during the last semester of the first year, and it was our first chance to dive into the literature and learn how to find relevant material to either support or refute a clinical question. The first challenge was creating a PICO(T) question to start us off on what was to be a two-and-a-half year project, so considerable time was spent reviewing literature to determine what might be best to study. From there, we had to split the project into smaller parts so we could divide and conquer, yet still come together weekly to analyze our findings. It was a grueling process in the beginning, but as we broke the parts down and shared ideas, the project picked-up speed and the group threw themselves into completing out first presentation. Though this project would eventually be turned-over to a different clinical site, it set the foundation for how the students would need to work together to complete our final DNP project. Looking back, I see that it takes this type of dedication and teamwork to solve real problems in the healthcare world, which is just one more reason I look forward to spending a career with other scholarly-minded professionals providing world-class care to our nations’ heroes and their families.
DNP Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health
Before I entered into the DNP-FNP program, I never gave much thought to preventative, population, or community health. I spent my years as a nurse working in the ED and ICU, so I was always focused on returning patients to health, not prevention of disease. It wasn’t until we began discussing the differences between primary, secondary, and tertiary prevention that I realized how great a span of healthcare that my career as an FNP would cover. I thought as an FNP that I would spend my days deciphering patient symptoms and handing out cures. It wasn’t until our course Population Health and Epidemiology in Advanced Practice that I realized how important my role would be in population health. This would mean evaluating each of my patients and determining what preventative health measures would apply best to them. I have found during my clinical practice that handouts are a quick way to provide education, and that a 1-2 page handout not only improves adherence to treatment regimens, but it also prompts them to share their new knowledge with friends and family. I have therefore provided two handouts I created during the didactic portion: one on Vitamin D and the other on Osteoporosis.
A very important aspect covered in two different classes was the reiteration that my role as a primary care provider in the military health system can have far-reaching effects. For both classes, we were required to complete group projects related to health in other countries. For Care of the Military Member, each member of the class performed medical threat assessments of an assigned country that would cover all health hazards that might be encountered by members of our military should they be deployed there for any reason. For this assessment, we were to analyze the health infrastructure, prevalence of any community health problems, and the environmental threats. We then converged to pool our knowledge and create presentations to brief a General on the threat assessments of specific regions. This was not just an academic exercise, but rather a very real example of something I might be called to do at any time in the future. For that project, I have provided my individual paper, “Medical Threat Analysis of Fiji”, and the group project, “Medical Threat Analysis of the South Pacific.”
For Population Health and Epidemiology, we completed a similar task as a group, but this time we were to look at how the military would respond for a humanitarian relief effort to a country devastated by a natural disaster. We first crafted a paper to present to a team that would be part of a Humanitarian Health International Team to Cuba by analyzing the population, health care infrastructure, and endemic health concerns, in addition to what potential government and non-government partners they might be working alongside. Then, we created the presentation “U.S. Response to a Cholera Outbreak in Cuba” to be given to military members outlining what their response might be to an earthquake in Cuba, specifically after there had been an outbreak of cholera. This object was to educate responding teams what to watch for, how to protect themselves, and what part they would play in quelling the outbreak and restoring clean drinking water. Finally, we created a handout on cholera to be placed throughout the living quarters and medical facilities of military members to remind them how to protect themselves and patients from cholera.
DNP Essential VIII: Advanced Nursing Practice
This Essential is really what ties all of the others together. As an Advanced Practice Nurse, my role is to never stop learning so that I might always provide the best care possible for my patients. This means keeping current on any recent changes to clinical practice guidelines, building knowledge through continuing education, and staying abreast of new literature that may impact my practice. It also means remaining actively engaged with my patients and being an advocate whenever a need arises.
Being a Family Nurse Practitioner truly is “cradle to the grave” care, as my patients for a single day may range from 3 days old to 90 years (or more!). What strikes me as most unique about my new title is the word “family”. I envision one day being able to spend many years caring for the same members of multiple families. Having a single provider care for your family and most of their needs does not happen much anymore, but when it does, it is a special thing. When a provider takes the time to truly get to know his or her patients, they can build a strong bond of trust. I believe this is quickly disappearing from healthcare and we must fight to bring it back.
As an FNP in the Tricare system, I have the additional role of needing to evaluate families to determine what special needs they have specifically due to having one or more family members on active duty. Military families don’t always fit the mold of one might consider a traditional family. These families are often blended and dual-military, separated from loved ones, or single parents (by choice, deployment, and too often times death), and so they present with their own unique challenges. I provided several examples of assignments that support this Essential, all of which required me to do exactly what I believe a “Family” provider should do: get to know the families. This can be accomplished on a one-to-one basis, such as a complete history and physical, or by looking at the family as a whole.
The assignments “Family Assessment” and “Cohabitation” required me to evaluate families and their relationships with one another to determine what their needs might be, which meant looking at the family structure, individual roles, communication, and stressors. A family evaluation can be directed by the use of a health care model, but the one used should be relevant to the family. I have provided some examples of health care models and how they might be used to accomplish this task.
Finally, the JBLM handbook was a joint venture with fellow students to provide a look at a fictional military family and provide a detailed plan of care for each member, in addition to listing local community resources that are available to them. This handbook has turned-out to be an excellent clinical companion, and I have been able use it several times to assist my patients.