NURSE PRACTITIONER WEEK SPECIAL ISSUE NOVEMBER 2020
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Editor’s Notebook NPs are the MVPs in Health Care
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t’s been a big year for nurse practitioners—perhaps not in the way any of us could have imagined, but important nonetheless. With National Nurse Practitioner Week
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treated patients who have tested positive—all of this despite the fact that a third of NPs in the survey self-identified as being high-risk due to a preexisting condition or their age group. As a result, many have adopted or increased use of telehealth in their practices and have enhanced their screening protocols to provide safe and effective care to the community.
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ments to help fight the pandemic. We still have a long way to go before NPs have full practice authority in every state, but with any luck, these changes will become permanent in 2021 when the public can recognize and appreciate their significant contributions to health care. Despite what the president has suggested, we are not “turning a corner” with this virus. It’s not going to just magically disappear with the election in the rear-view mirror, as much as we all wish it would. Several states are currently experiencing a spike, with thousands of new cases being announced every day. Despite this, many Americans still refuse to wear a mask and practice social distancing. Indeed, it’s a sad day for medicine when politicians are being trusted over our public health experts. This is why it’s more important than ever for us to return the favor and advocate for them this time. —Megan Larkin
For editorial inquiries and submissions: editor@minoritynurse.com For subscription inquiries and address changes: © Copyright 2020 Springer Publishing Company, LLC. All rights reserved. Reproduction, distribution, or translation without express written permission is strictly prohibited.
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SHARE YOUR STORY 2
Nurse Practitioner Week Special Issue | NOVEMBER 2020
Your Experience with Coronavirus (COVID-19) Matters
BY CLAUDELLE PARCHMENT, PHD
A
s the world watches with bated breath, looking at the slow and steady march of Coronavirus (COVID-19) across fragile human bodies, we pause, only for a moment to acknowledge a public health infrastructure that is overwhelmed in what it was designed to do—to prevent emerging infectious diseases from marshalling through and negatively impacting the population. This shortcoming is more evident in the African American community and the more recent “voluntary” and refugee diasporic populations, such as those from east Africa or the Caribbean, where the plight of disparity in health, illness, and health care is ever present, and is only acknowledged when their stories found plastered across the news or on social media. COVID-19 has highlighted and magnified the plight of the diasporic
population’s health, access to, and use of health care, even though many health professionals were keenly aware, yet have little to no solution to address the disparity. The issue is further compounded by misconceptions that circulated
COVID-19 has highlighted and magnified the plight of the diasporic population’s health, access to, and use of health care, even though many health professionals were keenly aware, yet have little to no solution to address the disparity. throughout the community about the origin of COVID-19, its transmission, and the risks associated with it among other
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confounding factors, thus leading to the disproportionality of the African diaspora affected by COVID-19. The African diaspora is now keenly aware that those misconceptions are not true and are empowered to embrace the fight to preserve life. The African diaspora has to now work twice as hard to change the narrative about COVID-19 circulating through the community, through the use of storytelling and shared experiences. The Diasporic population has not been asked to share their stories through the normal channels, but the diaspora can change this narrative by collectively sharing their stories with each other as it relates to COVID-19. It’s time to shed the stigma and shame surrounding illnesses, that keeps the diaspora in a stupor of fear that prevents the community from speaking
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This promotes a shared experience that binds the community together.
about their experiences with illnesses, and by extension, with COVID-19, that is ravishing both the young and old alike. The diasporic population can speak openly and candidly to friends and families about what the signs and symptoms of COVID-19 look like for both those who have contracted the virus as well as those who are knowledgeable through health care training about the signs and symptoms. This promotes a shared experience that binds the community together. They can also discuss the challenges faced in accessing care, or even navigating the health care system in order to obtain testing for COVID-19. This helps
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those who are struggling with this issue to know that they are not alone, simultaneously validating the concerns they may have. Talking about the fears of contracting the virus and not being able to care for the ones we love, is just as personal for many individuals as it may be for you. Talk to each other
It is through the shared stories that we realized that we are not alone in the fight against COVID19, or any other emerging infection or chronic disease. about the challenges of practicing social distancing, while living in a multi-generational household and what that looks like for you and your family.
Nurse Practitioner Week Special Issue | NOVEMBER 2020
Openly discuss the stress of being in a sandwich generation, where you provide care for your elderly parents and your children, simultaneously working at a job where your chance of contracting COVID19 increases exponentially. This may bring solace to those who are in the same position and promote advocacy for change. Talk to each other about how the crippling impact of the fear you have for your life is inadvertently impacting the children in your care, and how these beloved children are dealing with the new normal that sometimes increases their own levels of fear, anxiety, and other psychosocial stressors. Express the emotions, thoughts, and feelings about death of the ones we hold so dear, and the process of grief that now envelopes you, while trying to maintain some semblance of normalcy.
Share with others the ways you have coped and improve your physical and mental health so that in turn you can care for each other. The diaspora can talk about the creative ways that each individual can draw on their ancestral past to help through this trying time. It is through the shared stories that we realized that we are not alone in the fight against COVID-19, or any other emerging infection or chronic disease. It is through these shared stories that light emanates throughout this tunnel called COVID-19. You should never be afraid to share your story—your experience with Coronavirus (COVID19) matters. It is through shared stories that we heal and become renewed. Claudelle Parchment, PhD, is a recent graduate of Walden University.
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How Nurses Can Fight Diseases of Despair 6
Nurse Practitioner Week Special Issue | NOVEMBER 2020
BY JEBRA TURNER
We have an American public health epidemic of drug addiction (especially opioid), alcoholism, and suicide that cuts across racial, ethnic, and economic segments. Nurses are in the middle of it all, often as caretakers, sometimes as patients, so they need to learn as much as they can.
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o, what is a disease of despair? The term was first coined by economists who noted a shift in American society: white, middle-aged, working class adults were struggling with drug overdoses, suicide, and alcoholic liver disease. (Black Americans have always suffered greater income insecurity and had higher mortality rates compared to white Americans, though the gap is narrowing.) According to the U.S. Centers for Disease Control and Prevention, life expectancy in the U.S. is dropping or remaining flat, after decades of increases. Babies born in 2018 (the latest year we have statistics) can expect to live to age 78.7, a number that ticked up from 2017, though it is less
than the 2014 high of 78.9 years. Compare that to similarly wealthy countries where average life expectancy is now at 80.8 years—even though they spend half what we do on health care. In addition to drug- and alcohol-related fatalities and suicide, more young people are now dying from heart disease, diabetes, and other common conditions. One possible cause is obesity, which at 42.4% percent for American adults, is at a record high. (By contrast, in 2000 the obesity rate was an already alarming 30.5%.) Obesity also makes COVID-19 more deadly. A rising suicide rate— up 25% over the past two decades—is also a driver for early mortality. It was responsible for more than 48,000
deaths in the United States in 2018—while 1.4 million attempted suicide, according to the CDC. “I do believe a term like ‘diseases of despair’ is helpful, even if it may not be a classical medical diagnosis,” says Diane Solomon, PhD, PMHNP-BC, CNM, a Portland, Oregonbased psychiatric nurse practitioner in private practice. She encourages a broad definition that includes substance abuse and suicide, but also depression, anxiety, PTSD, etc. “To me, the term is really a place holder for trauma—and we all have trauma that we have to work out.” Solomon incorporates the ACEs model, based on the groundbreaking Adverse Childhood Experiences Study which showed a tie between
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childhood adversity and adult onset of chronic illness. During the COVID-19 pandemic, despair is common regardless of trauma history, caution many experts. “Isolation and fear has created a mental health pandemic that will be with us long after the physical pandemic is over,” asserts Solomon. “Anxiety and depression may be much worse because patients live alone, but being locked down with many people can also be problematic.” Recent studies show that health care professionals aren’t immune from diseases of despair. In fact, doctors die by suicide at double the rate of the general population. “White physicians have more diseases of despair than nurses, including burnout and
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suicide because of a culture of individualism,” says Solomon. “BIPOC and people with religious or spiritual beliefs are more resilient. I’m Jewish, which is not a part of standard white culture. It’s family and socially-based, communication, and collaborative-based,” which boosts resiliency.
Nurses are Poised to Lead in the Battle Against Diseases of Despair Social scientists may be the first to identify this public health crisis of despair, but it’s the nurses who are on the frontlines in the war on unnecessary deaths. “Our code of ethics is about the welfare of the sick, injured, and the underserved. Nurses have a strong role to act in order to change the social structure,” says Liz Stokes, JD, MA, RN, director of the American Nurses Association Center for Ethics and Human Rights. “Nurses have an obligation to care for everyone and to address social justice.
disparities. I spoke to a nurse in Texas who asked: ‘Why are most of the patients in my ICU Hispanic?’” Stokes is hopeful that awareness will spread out into the wider society and reduce bias in health care delivery. “Nursing is the largest health care workforce; we impact so many people,” she explains. The landmark 2010 Future of Nursing report recommended that nurses should be full partners in redesigning U.S. health care. Inspired by the report, in 2014 the Robert Wood Johnson Foundation (RWJF) launched the Nurses on Boards Coalition to put 10,000 nurses on governing boards by 2020. “We know that nurses need to be at every table to transform health care,” says Solomon, and diseases of despair present another opportunity for nurses to play a pivotal role. But leadership and activism aren’t the only ways to battle despair: nurse-based approaches, such as trauma-
During the COVID-19 pandemic, despair is common regardless of trauma history, caution many experts. “Isolation and fear has created a mental health pandemic that will be with us long after the physical pandemic is over,” asserts Solomon. Nurses know, and the public is aware, that nurses are against racism—we are nonjudgmental and unbiased.” The COVID-19 pandemic and Black Lives Matter protests have served to expose and amplify how racial and ethnic bias impacts on health care, Stokes says. “As nurses, we’re witnessing higher rates of death and health
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informed care, are inherently transformative. “Nursing as a discipline is all about collaboration. Nurses are treating diseases of despair, even when treating a patient for an ingrown toenail,” says Solomon. Nurse practitioners focus on preventative care and health promotion, an approach that could save the U.S. economy billions of
Nurse Practitioner Week Special Issue | NOVEMBER 2020
dollars and produce better health outcomes, she adds.
Overdose Crisis: an Epidemic that Proves the Power of NPs Over the past two decades, opioid use disorder (OUD) and associated deaths have skyrocketed; it is a major factor in declining American longevity. According to the CDC, a record number of Americans— nearly 27,000—died from drug overdoses in 2019. The COVID-19 pandemic is slated to fuel the rate of deaths due to opioid, cocaine, and meth overdose in 2020. Some experts blame the addiction epidemic on the widespread marketing of prescription opioids that started in the 1990s. But regardless of culpability, nurse practitioners have become an integral part of a pragmatic solution. “From a primary care perspective, nurse practitioners are oftentimes on the frontlines, working in rural and underserved areas,” says Sophia L. Thomas DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners. “Nurse practitioners who get specialized training can diagnose symptoms of withdrawal, such as excessive sweating and diarrhea, and prescribe medical assisted therapies (MAT) for patients who want to stop using opioids.” Greater access could help to raise the distressingly low 20% of people with OUD who receive treatment. “In Oregon, we have the most progressive laws in the nation—no physician oversight and wide ranging prescription authority,” says Solomon. “The law requires
Social scientists may be the first to identify this public health crisis of despair, but it’s the nurses who are on the frontlines in the war on unnecessary deaths. that nurse practitioners and physicians be paid the same per procedure code. This is the only state in the nation that requires this. Nurses like me can start our own practices and set our own way of working. It’s a very different model.” For Americans to defeat the addiction epidemic, more nurse practitioners must be empowered to provide OUD care—especially in rural areas, where the overdose incident rate is greatest and access to addiction specialists is most limited, according to Deborah Wachtel, DNP, MPH, APRN, FAANP, who practices at the University of Vermont College of Nursing faculty clinic. She focuses on integrating medication assisted treatment for OUD disorder into primary care. Though MAT is evidencebased care for a chronic disease, some clinics, courts, and families insist on complete abstinence. “We’re treating a disease that causes comorbidity, addiction, and chronic changes to chemicals of the brain,” says Wachtel. “If a patient had diabetes you wouldn’t tell them to ‘just pull yourself up by your bootstraps’ and not give them insulin. We say, ‘yes, you need counseling, peer coaches, and therapy—but you also need medication.’”
Nurse practitioners provide complete, comprehensive care, including diagnosing and treating all of a patient’s medical problems: high anxiety, difficulty sleeping, etc., says Wachtel, “just like any other primary care patient.” Wachtel explains that a “hub and spoke” system is commonly employed. The hub is an intensive outpatient treatment facility where patients go every day to get their dose, which was originally methadone, now includes suboxone. When they become stable, they get treatment in a primary care setting, preferably on a monthly basis. Having to go to an outpatient facility every day for medication makes it hard to go to work, or take care of
children, and there’s a social stigma attached, she adds. “On the other hand, there are patients who really need to be out of their usual environment. Inpatient treatment, known as residential care, is best in that case—short stays of five to seven days, though longer is ideal, especially for methamphetamine users.”
Nurses Suffer from Diseases of Despair, Too Especially during the COVID-19 pandemic, many nurses are facing excessive job and personal demands, which may lead to PTSD, burnout, or even suicide, cautions ANA’s Stokes. “Social isolation and other psychological factors are affecting everyone right now,” says Stokes. “Nurses
“Nursing as a discipline is all about collaboration. Nurses are treating diseases of despair, even when treating a patient for an ingrown toenail,” says Solomon. Nurse practitioners focus on preventative care and health promotion, an approach that could save the U.S. economy billions of dollars and produce better health outcomes, she adds.
must learn to identify signs of emotional distress, both within themselves and within others.” Stokes explains that some nurses are experiencing a profound crisis and unable to fall back on their usual strategies for remaining resilient. “Nurses in the surge phase of Covid say one of the hardest parts is that in the past, if you had a bad day you could go
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to a coworker and get a hug,” she says. “You can’t have that physical support anymore. There’s social isolation at work at a time when you really need each other, during a very challenging time.” Additionally, because nursing is a predominantly female occupation, some common gender-specific coping mechanisms may be problematic. “Nurses probably go into
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the profession because they have certain trauma,” says Solomon. “Women tend to internalize trauma, and experience depression and anxiety. Nurses need to be aware of their own trauma and care for themselves in order to best care for their patients and not get burned out.” Nurses who have been in the profession for any length of time may have experienced multiple health care crises, loading trauma upon trauma. “I can tell you from personal experience, the way life has been during Covid has been reminiscent of Katrina. I had a house call business and worked during that time. I remember I was driving through Red Cross lines to get supplies, taking it one day at a time because the guidance changed daily,” says Thomas. “Nurse practitioners
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“From a primary care perspective, nurse practitioners are oftentimes on the frontlines, working in rural and underserved areas,” says Sophia L. Thomas DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners. are problem solvers. We get the job done for our patients. Sometimes we have to improvise. We put our lives, our health, and the health of our families on the line.”
Personal Well-Being Initiatives: Caretaking Begins with Self Most experts agree that to battle diseases of despair in America, we must address economic and social justice as well as access to health care, food, housing, and employment.
Nurse Practitioner Week Special Issue | NOVEMBER 2020
But in the meantime, nurses can take advantage of personal well-being initiatives, some offered by nursing associations. “During Covid, some nurses have been furloughed or made the decision not to work because they don’t feel safe. In addition, there’s racial and social unrest in the world, and a tremendous amount of turmoil,” says Stokes. “We must proactively address mental and emotional wellbeing and hospitals need to deploy resources on the unit
or deploy them virtually. Don’t wait for nurses to go to an EAP.” The American Nurses Foundation, along with other nursing organizations, is offering a mental health digital toolkit designed to help build resilience and mitigate distress. “It includes virtual support systems such as an emotional support app, and an expressive writing initiative,” Stokes explains. There are a variety of ways for “nurses to get support, 24-hours a day, 7 days a week, in an anonymous safe space during this time of racial and social unrest that continues to unfold,” she adds. Meredith Mealer, PMHNP, PhD, RN, is the nurse-scientist heading the innovative “Narrative Expressive Writing” program. Her work is informed by the research of
For Americans to defeat the addiction epidemic, more nurse practitioners must be empowered to provide OUD care—especially in rural areas, where the overdose incident rate is greatest and access to addiction specialists is most limited, according to Deborah Wachtel, DNP, MPH, APRN, FAANP, who practices at the University of Vermont College of Nursing faculty clinic. James Pennebaker, who found that writing about stressful and traumatic events has a number of physical and mental benefits. “During this extraordinarily stressful time, we asked ‘how can we train nurses to be more resilient?,’” explains Mealer. “It’s been three months now
and 300 nurses have taken part. We have mental health providers to read and provide feedback. We validate what they wrote but also challenge it.” The program involves five writing prompt-based sessions of about 20 to 30 minutes each week. “We have
two therapeutic intents with the writing and feedback: to reframe experience and to provide a form of exposure therapy,” she says. “I read the writing and give it thought and then provide feedback in four to five sentences. For example, to a nurse who’s overwhelmed during Covid, I might respond: ‘On the one hand you mentioned that you’re depressed, and can’t sleep, but on the other hand you did make it to work.’” Mealer’s focus is on challenging the negative and emphasizing the positive. It’s not easy during the pandemic and Black Lives Matter protests. “The narratives I’ve read so far are so powerful. Nurses
are stretched thin. They’re emotionally distressed—worried about the safety of their family and their own self during this time,” she says. “They’re really questioning if they’ll still be in this profession in the long term. I’m assuming we’ll see a lot of turnover and we’re short in the profession already.” (Want to try journaling, but don’t like to write? Journify.co is an audio journaling app that gives free access for a year to health care professionals.) Jebra Turner is a freelance writer located in Portland, Oregon. Visit her at www.jebra.com.
Voices of Nurse Practitioners on Turmoil and Despair Here, three nurses weigh in on minority nursing issues in their unique communities. “I’d say there is bias in treatment—I see the difference in how patients are treated here in rural Vermont. I had a white patient who went to the emergency department and was kept on the psychiatric unit for five days with a call to me before she was released. I had a Black patient who I sent to the ED five times and they did not treat her. They called her a malingerer—that’s on her electronic record. Finally, she came into the hospital in an ambulance and by that time she had kidney failure. They sent her for five days in an inpatient treatment center and discharged her to the community without any supports in place.” —Deborah Wachtel, DNP, MPH, APRN, FAANP, an adult nurse practitioner in Vermont “Economic distress, lack of transportation, increased mental health crisis, and just the everyday concerns for one’s health and wellbeing, nurses are poised to address the population-focused challenges I often see in my community and surrounding areas. And, especially when discussing the inequities I see in communities of color, the palpable intensity that is being drawn to the surface as it applies to the pressure that essential workers have in maintaining their home, the uncertainty parents and caregivers have in maintaining healthy and consistent access to food for their children, as well as the need for computers and stable Wi-Fi to allow access for schooling from home and virtual schooling, it has become even more apparent the divide of the ‘have’ and ‘have nots’ for all.” —Antonette Montalvo, MSN, CRNP-BC, BSN, RN, a apediatric nurse practitioner in rural South Carolina “I believe that minority nurses do suffer from diseases of despair more greatly than their white counterparts due to economic inequality and racial discrimination. While this can take many forms, the main causation of diseases of despair include a feeling of hopelessness about personal financial success, which is evident even among health care workers today. Minority nurses who experience discrimination are more likely to experience unfair treatment, harassment, and violence, which may not only exacerbate diseases of despair but also initiate emotional distress that may threaten the stability of their mental health.” —Jonathan V. Llamas, DNP, RN-BC, PMHNP-BC, PHN, ACHE, a psychiatric nurse practitioner in Beverly Hills, California
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Nurse Practitioner Week Special Issue | NOVEMBER 2020
PROJECT ECHO Reducing Health Disparities in Underserved Communities BY SALLY PARKER
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aunted by memories of war and genocide in their homeland, many of the Cambodian refugees and immigrants who come to the Metta Health Center at the Lowell Community Health Center in Lowell, Massachusetts, deal with depression, anxiety, and post-traumatic stress disorder. These challenges are daunting in their own right. But they also make it harder to maintain habits that combat diabetes, says Sarah Bradshaw, FNP, a primary care provider in the clinic. “Diabetes is an interesting disease in that your lifestyle choices make a difference,” says Bradshaw,
who has a grant through the Massachusetts League of Community Health Centers to improve health outcomes for Cambodian immigrants with the disease. “A lot of [our work] is focused on encouraging people and helping people believe they can make the lifestyle changes they need to control the disease.” To learn how to help patients in complex situations like this, Bradshaw turned to Project ECHO, a video-based mentoring model that brings specialist expertise to frontline medical personnel in underserved communities. The Joslin Diabetes Center Inc., a Project ECHO hub, provided the training.
“Depending on the diagnosis, you are looking into all different avenues and directions, including nutrition and lifestyle habits,” Omer says. “You try so many different things and you get stuck and you say, ‘What would be my second move?’ Experts help you to look into the different angles and figure out how to achieve the goal for a specific patient, because it has to be patient-centered care.” ECHO stands for Extension for Community Healthcare Outcomes. It is the brainchild of Sanjeev Arora, MD, a New Mexico gastroenterologist who in 2003 sought a way to treat a surge in Hepatitis C cases across the state. Troubled that many patients traveled hundreds of miles and waited up
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to eight months to see him, he conceived ECHO to bring specialist knowledge back to the community providers who serve those patients. ECHO is based at the University of New Mexico. More than 400 partner organizations now replicate the model around the world.
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Nurse Practitioner Week Special Issue | NOVEMBER 2020
Nearly 100,000 providers have taken webinars in dozens of topics over the years. ECHO’s mission is to democratize medical care and knowledge. It is one of six finalists tackling critical social challenges in 100&Change, the MacArthur Foundation competition for a single $100 million grant. Nearly 3,700 competition registrants submitted 755 proposals. A winner will be named in spring 2021. ECHO videoconferencing sessions connect experts in medical hubs with primary care providers who want to deepen their knowledge in specialty areas central to their work, such as pain care, behavioral health, HIV, complex case management, geriatrics, pediatrics, substance use, domestic violence, cancer prevention, tuberculosis, and many more. A typical session includes a 10- to 15-minute didactic, one or two case presentations, and a discussion among participants. The vibe is collaborative and supportive, says Rekia Omer, RN, clinical care
Nurses are accustomed to solving problems— quickly. But solving them all at once is not possible with complex cases, says Mary Blankson, DNP, APRN, FNP-C, chief nursing officer at Community Health Center Inc., a nonprofit agency serving nearly 100,000 patients across Connecticut. manager at Edward M. Kennedy Community Health Center in Worcester, Massachusetts. During her lunch break, Omer attended a weekly series on diabetes offered by Joslin. She and other providers submitted cases ahead of time, and experts asked questions and offered advice. Fellow providers weighed in with their perspectives. Most of Omer’s patients are poor. Many are immigrants, and some live on the street. Each patient comes with a unique set of concerns. “Depending on the diagnosis, you are looking into all different avenues and directions, including nutrition and lifestyle habits,” Omer says. “You try so many different
things and you get stuck and you say, ‘What would be my second move?’ Experts help you to look into the different angles and figure out how to achieve the goal for a specific patient, because it has to be patient-centered care.” Omer, who later became a certified diabetes educator, says the sessions looped in experts who could talk about the specifics. A pharmacist, for example, explained how diabetes medications work, and as a clinical care manager, she shared what she learned with providers in her clinic. After a session on diabetes care and cost savings—insulin and medication for the disease are notoriously expensive—Bradshaw took back to
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the clinic tips on how to spot insulin rationing and how to manage cases effectively with both care and cost in mind. She also learned about services that help patients who cannot afford insulin. “That’s one of the worst situations as a clinician,” Bradshaw says. “You’ve recommended something for the patient and they don’t have the financial resources for it. That’s a really helpless feeling. So I was happy to have some of those resources for my patients, and I actually have done so.” Nurses are accustomed to solving problems—quickly. But solving them all at once is not possible with complex cases, says Mary Blankson, DNP, APRN, FNP-C, chief nursing officer at Community Health Center Inc., a nonprofit agency serving nearly 100,000 patients across Connecticut. CHC is an ECHO hub, training its own staff and other organizations through the Weitzman Institute, a research and education arm. One of its most popular webinars is complex case management, a yearlong program that meets twice a month on Zoom. Nurses learn best practices for assessing and prioritizing a patient’s multiple health concerns. “Sometimes I think this is hard for a nurse. You want to tackle the diabetes, but you have to treat the depression first for a better outcome. You have to be able to tell the patient your A1C is going to be higher for a couple of months while we get the depression under control,” Blankson says. The ECHO covers ways nurses can make the best use of their time and skills. This may mean tapping team members
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The Project ECHO approach is a perfect fit for the work nurses do. It views the patient as a whole person in the context of family and community, says Lois Wessel, MS, RN, CFNP, a professor at Georgetown University’s School of Nursing and School of Medicine. to help with routine tasks or setting boundaries and expectations with patients. “Nurses are a finite resource in the practice where they work, so it’s really important to determine when they’re working harder than the patient,” she says. With nursing jobs in primary and ambulatory care on the rise, Weitzman in 2015 kicked off a nurse-centric model for the ECHO webinars it offers. The Project ECHO approach is a perfect fit for the work nurses do. It views the patient as a whole person in the context of family and community, says Lois Wessel, MS, RN, CFNP, a professor at Georgetown University’s School of Nursing and School of Medicine. In the rural U.S. and Latin America, Wessel has helped establish “culturally and linguistically appropriate” primary care providers who lead the way as health advocates in their communities. Of Project ECHO’s four guiding principles—to use technology to leverage scarce resources, facilitate case-based learning, share best practices, and generate patient data to track quality improvement— the last is most difficult. Most ECHO programs have generated little patient data, Wessel says. A key reason is that progress in many of the areas ECHO sessions now cover— such as autism, depression, and
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complex care management—is much harder to measure than that of Hepatitis C, the original ECHO focus. (A study found that local providers participating in that first ECHO program achieved Hepatitis C cure rates in their patients equal to those of specialists.) Nurses could play an important role in tracking down patient outcomes, she says, which could lead to more grants and funding opportunities for further study. Still, the ECHO model is flexible and robust in important ways. Participants learn from specialists, discuss and solve
real cases, and take that expert knowledge back to the office. Afterwards, they can tap into a support network of colleagues who are handling the same issues. Primary care providers who take a Weitzman ECHO series on chronic pain learn how to have challenging conversations about pain and medication with their patients. They also can log into PainNet, a website Weitzman created with studies, articles, and peer chat forums for support. “We’re building a knowledge network,” Blankson says. “We’re reminding providers
you’re not alone in this. We’re learning together.” Like other ECHO hubs around the world, Weitzman facilitates ECHOs for clinics and organizations on a wide range of topics from LGBTQ health to school nursing. “We want the ECHO model to spread because it’s helpful for everyone. When you really want to share knowledge, particularly with the frontline staff, this is a very effective way to do that,” she says. Sally Parker is a freelance writer and editor with more than 20 years of experience writing about health care, workplace issues, career development, and education.
“We’re building a knowledge network,” Blankson says. “We’re reminding providers you’re not alone in this. We’re learning together.”
How Project ECHO Helps Nurses Sarah Bradshaw, FNP, was working in hospital administration when she realized she wanted to switch to the clinical side. “I saw a lot of really great nurse leaders making what I perceived to be real differences in our organization,” she recalls. Bradshaw went back to school to earn her RN and, armed with a strong belief in health care for everyone, began working in a community health center. She earned her FNP soon after so she could have more patient interaction. “It’s definitely one of the reasons I wanted to be in primary care. Having relationships with our patients is something that motivates me every day,” she says. Bradshaw is a primary care provider at Lowell Community Health Center in Lowell, Massachusetts. Taking part in Project ECHO webinars offered by Joslin Diabetes Center and others has made her a more effective provider, she says. “Having the ability to hear cases and hear from the experts at Joslin on how to bring the new strategies in caring for people with diabetes back to our population at the center was really important to me,” she says. “The sessions are set up to be conversational. It’s all case-based, and they had questions throughout as the session went on.” She also attended ECHO training sessions on office-based opioid treatment. “I think especially for new clinicians it’s a really awesome opportunity in these small chunks to further your knowledge of things you’re seeing in your clinic every day,” Bradshaw says. “I feel like I’m really able to guide my patients and help them make decisions and support what they’re looking for.”
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Nurse Practitioner Week Special Issue | NOVEMBER 2020
imulation in Nursing BY MICHELE WOJCIECHOWSKI
In both practice and education, simulation in the nursing field has improved everything from treatments to patient outcomes.
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imulation—it’s something that nurses first encounter while still studying in nursing school, but that’s not where it ends. Experienced nurses continue to use simulation, for example, to improve practice, communication between health care providers, the cooperation between interprofessional teams, and to teach/learn new techniques. Before we explore its importance, let’s first understand what simulation is and the kinds that are being used today.
Imitation—the Safest Form of Practice “Health care simulation is the imitation or replication of patient care situations for the purposes of education, assessment, and/ or research to enhance patient safety and quality patient care delivery,” says Michelle Olech Smith, DNP, RN, CHSE (Certified in Health Care Simulation by the Society for Simulation in Health Care), the program director of simulation at Northwestern Medicine Central DuPage & Delnor Hospitals. Simulation also helps build confidence and competence in the nurses who are learning with it, says Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN, co-editor of Clinical Simulations for the Advanced Practice Nurse: A Comprehensive Guide for Faculty, Students, and Simulation Staff. “Simulation has become a widespread methodology because it is a hands-on learning strategy
that engages all sense of the learner,” says Alfes, who is also an associate professor and director of the Center for Nursing Education, Simulations, & Innovation at the Frances Payne Bolton School of Nursing at Case Western Reserve University. “During the COVID-19 crisis, simulation has become a tremendous tool for faculty and learners alike.” “Simulation is an effective strategy in acute care because it prepares staff for high-risk situations that may be encountered infrequently,” says Joni L. Dirks, MSN, RN NPD-BC, CCRN-K, manager of professional development at Providence Health Care. With simulation, those involved can slow down the learning, ask students to reflect on what they’re doing, and even stop what’s going on if students want to ask clarifying questions, says Jean S. Coffey, PhD, APRN, FAAN, director of the Plymouth State University Nursing Program, who has taught simulation in several nursing programs. Simulation also provides nurses and nursing students with the opportunity to fail—in a safe environment—due to their inexperience with the procedure, without putting an actual patient in danger, says Cindy Cain, DNP, RN, CNS, CCRN-K, clinical practice specialist, the American Association of Critical-Care Nurses (ACCN). “They can practice clinical responses or high-risk skills in an expertly guided setting with feedback for improvement.”
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Our experts identify the following as the most common types of simulation: • Low-fidelity manikins: These tend to be used by nursing students to practice skills such as taking vitals, giving bed baths, and other types of care. • High-fidelity manikins: These life-like manikins are computerized and can be programmed to talk and respond to students’ questions, as well as with physical characteristics like coughing and blinking. They can be programmed to exhibit clinical symptoms like trauma, cardiac arrest, maternal hemorrhage, and malignant hyperthermia. • Training devices: These look like individual pieces of anatomy and students use them to practice specific skills like IV training on an arm. • Standardized patients: People, often hired actors who have been trained in responding to various clinical scenarios and settings. Students practice their interviewing skills and nonverbal/ verbal communication skills. • In situ: Coordinated simulations that happen in an actual clinical setting. • Computer-based/virtual programs: Various software programs use interactive avatars and case studies to create different scenarios. Some of these include pre- and postquizzes to test students’ know-how.
Use in Nursing Education Because students can use it without fear of hurting someone, simulation is essential, says Nancy A. Mimm, DNP, RN, MSN-BC, APHN-BC, assistant professor at Harrisburg
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University of Science and Technology. In addition to being certified in clinical simulation, Mimm also heads the MSN program. “It is well known that students learn from their mistakes, which helps them avoid them in the future,” Mimm points out. “Simulation provides hands-on or tactile learning opportunities for students that cannot be achieved during a lecture.” Simulation also provides educational opportunities when clinical sites aren’t available. “In nursing education, despite the need for more nurses in the practice setting, over 75,000 qualified applicants were not accepted into baccalaureate and graduate nursing programs in 2018 due to lack of faculty and classroom space. However, one of the biggest reasons was lack of clinical sites,” explains Julie Stegman, Vice President, Nursing Segment, Health Learning, Research &
Nurse Practitioner Week Special Issue | NOVEMBER 2020
Simulation also helps build confidence and competence in the nurses who are learning with it, says Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN, co-editor of Clinical Simulations for the Advanced Practice Nurse: A Comprehensive Guide for Faculty, Students, and Simulation Staff. Practice at Wolters Kluwer. “Additionally, because of the increasingly complex health care setting, students may not have the opportunity to ‘practice’ appropriately. Evidence suggests that only 23% of new graduates have entry-level competencies, and many of the errors related to patient safety are caused by ineffective clinical judgments. These gaps in nursing practice of new graduates are attributed to ineffective communication, the complexity of the clinical environment, lack of knowledge about patient care, and lack of experience in working in teams.”
Coffey states that simulation can also helped advanced nursing students. “Simulation provides the opportunity to synthesize their learning and apply it within a simulated patient scenario,” she says. “The group debriefing at the end of any simulation helps the students all learn from each other and think about how they approached the situation and what might go differently next time they are in the situation.” Some nursing schools like Plymouth State University have their own simulation centers on site. “This provides us the opportunity to run simulation
scenarios all semester and offer time for open lab to support students practicing skills such as inserting a catheter. Each nursing course and clinical class incorporates simulation into their lesson plans. The novice nurses learn how to take vital signs and give bed baths in the lab. The juniors learn about pediatric diabetes and respiratory problems. They also participate in a Social Determinants of Health lab focused on the impact of poverty on individual and community wellbeing,” explains Coffey. “In the senior year, there is a disaster lab with a mock explosion. Standardized patients from the theater department participate in the lab, in moulage that looks like actual wounds and burns. The students triage the victims to get care or move to the morgue. These labs help the students to
learn to provide wholistic care for their patients. It also provides them an opportunity to test themselves in a very highpressure situation with no risk for patient harm.” Other schools are in the process of building simulation labs. “Harrisburg University will have a high-fidelity virtual simulation environment that we will use to teach nursing, health professions, and other community partners using human simulation,” says Mimm.
Simulation in nursing education programs yields good results. “A survey of the Essentials of Critical Care Orientation users showed an 83% increase in nurse recognition of stability changes in patients, a 73% increase in knowledge of evidence-based best practices, and 72% of the nurses who took the course reported significantly higher confidence in applying the concepts of critical care nursing (AACN, 2020),” says Cain.
“It is used most-often to promote the confidence and accuracy of clinical skills. One example is practicing patient resuscitation or advanced assessment skills used by advanced practice nurses, such as Nurse Practitioners, Clinical Nurse Specialists, or Nurse Anesthetists,” says Cain.
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Practice Makes Perfect Once nurses are practicing, they work with patients. So why do they need to use simulation? “It is used most-often to promote the confidence and accuracy of clinical skills. One example is practicing patient resuscitation or advanced assessment skills used by advanced practice nurses, such as Nurse Practitioners, Clinical Nurse Specialists, or Nurse Anesthetists,” says Cain. “It has been shown to build a nurse’s confidence, prioritization, decision-making, clinical judgment and critical thinking skills.” “One of the most important aspects of using simulation in ensuring the nurses learning have an opportunity to debrief, ask questions, and identify opportunities for improvement,” states Cain. Mimm says that using simulation in practice is necessary for professionals who want to have the best possible outcomes in different settings. “For example, simulation is used to practice low-volume, higherrisk situations like a postpartum hemorrhage after a woman delivers a baby. This allows the team of providers to practice that scenario even though they might not see it regularly,” says Mimm. “Nurses learn many different things with simulation; it allows them to work critically and think through the process of caring for this patient before they ever experienced it in person. They can practice the skills and interventions that they need to use to achieve the best outcomes and immerse themselves in the emotions they will experience during a highly stressful situation. That way, they feel more.”
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Mimm says that using simulation in practice has reduced medication and clinical errors, improved patients’ understanding of their plans of care, and also improved discharge needs and follow-up needs. Olech Smith says that simulations in the clinical environment have additional benefits. “In situ simulation allows for the recreation of events to observe, modify, and evaluate health care,” she explains. “This may include discovering latent system hazards before they impact patients and helps us understand and reinforce appropriate actions and resources.” While Dirks points out that there isn’t a ton of research on simulation’s impact on patient outcomes, she says, “We’ve encountered a number of pro-
an increase in the nurses’ ability to recognize deterioration in patient condition and an overall decrease in adverse patient outcomes,” she says. One is “Simulation in Nursing Practice: The Impact on Patient Care,” a 2013 study published in the Online Journal of Issues in Nursing. Simulation also helps people from various health care fields learn to work together. “Simulation is now recognized as an effective tool for engaging interprofessional teams and evaluating clinical processes. For example, instead of having each profession practice their skills in isolation, we pull the emergency response team together and put them through the drill,” says Dirks. “They learn about each other’s roles and how to communicate
“Simulation is now recognized as an effective tool for engaging interprofessional teams and evaluating clinical processes. For example, instead of having each profession practice their skills in isolation, we pull the emergency response team together and put them through the drill,” says Dirks. cess improvements based on staff experiences during the simulations. For example, we identified role confusion regarding management of the airway during different phases of resuscitation, which led to clarification and an identified hand-off between staff,” she says. “We have also found gaps in knowledge related to use of equipment and logistics issues for obtaining supplies on off-shifts.” Nevertheless, Cain says there is some research to back the benefits of using simulation. “A number of studies have shown
with each other.” In her 2019 Critical Care Nurse article “Effective Strategies for Teaching Teamwork,” Dirks writes, “Providing opportunities to apply teamwork during simulated scenarios or other group activities allows team members to identify areas for improvement and recognize the value of working collaboratively to achieve goals.” During the pandemic, being able to do online simulations has allowed them to continue. Dirks says that their simulations have transitioned to an online format allowing staff to view
During the pandemic, being able to do online simulations has allowed them to continue. Dirks says that their simulations have transitioned to an online format allowing staff to view a video of a clinical scenario. “Participants pause the scenario and respond to questions to develop a plan of action. A facilitator then debriefs the group using a Teams meeting.” a video of a clinical scenario. “Participants pause the scenario and respond to questions to develop a plan of action. A facilitator then debriefs the group using a Teams meeting.” In order to make sure that simulations are successful and effective, facilities need to make sure that what they’re offering follows best practices. Alfes says, “Some of the best resources for best practices are the Society for Simulation in Healthcare, the International Nursing Association for Clinical Simulation and Learning, and the National League for Nursing. Coffey says that their nursing program—much like others—asks students to complete simulation-specific evaluations. “These evaluations inform our simulation plans,” she says. “You need to have people who are experts in simulation and debriefing orchestrating the simulation to ensure the students or practicing nurses will have a successful experience,” says Stegman.
Looking to the Future Our sources agree that virtual reality—which is already being used in many facilities and nursing schools—is the wave of the future. “This rather new method of simulation allows learners to be immersed in a virtual environment that can be
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interacted with a seemingly real and physical way, using a head-mounted display,” says Olech Smith. “This can include as many senses as vision, hearing, touch, and even smell.” Virtual reality simulations are currently being used, including examples like fiber-optic bronco scope for airway management, ultrasound diagnosis, and endoscopic and laparoscopic surgery. It’s also being used to allow students to walk through a specific organ like the heart as they learn anatomy and physiology,” says Mimm. “I perceive nursing education simulation to continue to grow and develop. Professors will be able to use simulation in almost every part of their teaching, including online as students social distance. Simulation truly is the missing part of nursing and health profession education because it allows students to practice without doing harm to the patient.” Michele Wojciechowski is a national award-winning freelance writer based in Baltimore, Maryland. She loves writing about the nursing field but comes close to fainting when she actually sees blood. She’s also author of the humor book, Next Time I Move, They’ll Carry Me Out in a Box.
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Nurse Practitioner Week Special Issue | NOVEMBER 2020
Storytelling as Nursing Pedagogy BY TAMIKA DOWLING, DNP, FNP-c, PCCN
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eing an educator in the profession of nursing provides a chance to give back to the profession. As an educator, I am always reviewing the evidence for increasing engagement and understanding of my nursing and nurse practitioner students. The context of pedagogy describes the methodologies used in the practice of education. As we explore pedagogical
Sharing stories about controversial topics can encourage the student to participate, ask questions, and meet the overarching goal of increasing student engagement. approaches, some included open-ended instruction, integrated learning, inquiry learning, differentiated instruction, experiential learning, cooperative learning, assessment and
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evaluation of student learning and case studies. All of these methods can and have been effective. Narrative pedagogy has been a hot topic for nurse educators. Ironside and
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As I discussed experiences combined with evidence-based science, I have had many providers discuss the relevance of the information, and they implement changes in their practice.
I have found that when I share my personal stories and experiences of my past and current practices, the students warm up and we can have an open dialogue, which helps to facilitate their learning while improving their understanding. Hadyen-Miles (2012) noted that a shift in the education process that is focused on processes and outcomes that encourage thinking about daily experiences and learning how nurses listen and respond to practice encounters. These have a significant impact on thinking and learning. As a nurse educator, I have used many of these approaches. However, there has been one approach that I would like to discuss that has been efficacious in my practice as an educator.
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What About a Different Pedagogical Approach? I recall at my alma mater, Norfolk State University, many of my professors’ shared experiences, and previous scenarios. Their stories helped me visualize, understand, and further engaged me even more as a pre-licensure student. In an article published in The Midwest Quarterly last year, Deborah Fischer noted that storytelling helps to humanize the information, while
Nurse Practitioner Week Special Issue | NOVEMBER 2020
encouraging the students to view their professor as a practicing nurse, instead of being seen only as a provider of knowledge. Sharing stories about controversial topics can encourage the student to participate, ask questions, and meet the overarching goal of increasing student engagement. This is important. As an educator, I want to be relatable and approachable for my student. I have found that when I share my personal stories and experiences of my past and current practices, the students warm up and we can have an open dialogue, which helps to facilitate their learning while improving their understanding. In a 2014 article published in the International Practice
Development Journal, author Sharon Edwards indicated several implications for practice: • It can help the student understand that learning is part of our daily practice. • It is so powerful that it can elicit change in one’s practice, while having an impact on policy change. As a nurse educator, preceptor and provider, I’m constantly wearing all hats. I use storytelling while working clinically, as well. As I discussed experiences combined with evidence-based science, I have had many providers discuss the relevance of the information, and they implement changes in their practice. Storytelling is not new. However, it has been impactful in my practice as a nurse educator. It provides me with great joy when I have a student contact me and tell me they recalled a story or could hear me in their head while they were taking their boards. Storytelling is truly a successful pedagogical approach. Tamika Dowling, DNP, FNP-c, PCCN, is currently working parttime as an urgent care nurse practitioner, and she teaches on levels in nursing.
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The Zen of Zoom BY FIDELINDO LIM, DNP, CCRN
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Nurse Practitioner Week Special Issue | NOVEMBER 2020
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he onslaught of COVID-19 caused considerable havoc to work-life balance. As essential workers continued to physically report to work, countless others, including myself (I am a fulltime faculty), sheltered and worked in place. Overnight, I became a naturalized citizen of Zoomland—the one place coronavirus has not reached. Like any newcomer to an unfamiliar “space,” I was both getting disoriented and lost, often stopping to stare (or glare), to make some sense at sign-posts such as breakout rooms and share screen. After thirteen weeks of zooming, I can say that my new reality is not bad. It can even be very good, sometimes, considering the speed with which we have to adjust to a new normal.
punch the whole way). The current pandemic made ordinary citizens at ease in saying “ground glass opacities” and “contactless delivery” in everyday conversation. These
Zoom! My Vocabulary Expands
days, the 14th century word “quarantine” is more than just a household name. It is now a lived experience. As work moves online, the word “remote” is no longer just the modern-day magic wand— it has become a way of life. Add “remote” to any verb, and voila, you have coined a new phrase (e.g., remote teaching, remote concert) and possibly started a new social media trend. I am not suggesting that the world needs a pandemic to enhance our facility for language, but only to reflect on the idea that singular novel events accelerate all aspects of life, including language.
One of the fascinating side effects of historic events is they expand people’s vocabulary. For example, the Bush and Gore election debacle of 2000 gave the English-speaking world the phrase “hanging chad” (a little piece of paper left dangling when you punch a hole in a card, and it doesn’t
But, oh how I miss those random visits by students. I am convinced it is during those unannounced friendly visits, unrelated to academic issues, that meaningful connection is forged between students and faculty.
The Office Got Bigger and No One Came to Visit The lockdown transformed my living room into an officeclass-conference room. Now, I work in a 10th floor “office”
with six windows, twice the size of my regular office, and with the company of a plump feline who loves sleeping behind the laptop while I zoom away. But, oh how I miss those
had with students and alumni when they dropped by, not because they wanted something (although some came for the candies and chocolates I stock on my desk), but
Can you imagine if the current pandemic took place in 1985? The socioeconomic toll, on top of the health devastation, would be much more catastrophic. Zoom and its ilk became our salvation and a means to an end. random visits by students. I am convinced it is during those unannounced friendly visits, unrelated to academic issues, that meaningful connection is forged between students and faculty. Given that it is impractical to simulate an open-door policy via zoom, I offer virtual office hours, log on early before class, and leave late after class, allowing time for an informal chitchat and to listen to the life stories of students. While waiting for the return of business-as-usual, I reminisce with fondness the many delightful Kaffeeklatsch I’ve
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simply because they wanted to have a conversation and a presence—the essence of all human bonds. In preparation for when we are back at baseline, I imagine to having “kind” office hours, not just “kind of” office hours.
Saved by Zoom Can you imagine if the current pandemic took place in 1985? The socioeconomic toll, on top of the health devastation, would be much more catastrophic. Zoom and its ilk became our salvation and a means to an end. The internet
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The mute button is there to remind us to not just disable the mic, but to reduce the internal chatter in our heads during meetings, and to know when to stop talking. and all its splendor is by no means the panacea of what plagues human communication, but under the current circumstances, it is the best we have. In a recent Zoom presentation, I noticed that the internet connection was choppy. Every 15 minutes or so, I would be bumped offline for a few seconds. These instances allowed me to catch my breath (literally and figuratively) and refocus on what I was saying, giving me the opportunity to ask the audience if they had any questions. When connectivity was back, I took that opportunity to scan the audience screen and “see” faces, to look for engagement cues, meet someone’s gaze and connect. Zoom was founded in 2011 by Eric S. Yuan, a Chineseborn engineer. According to its website, their mission is to make video communications
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frictionless. Frictionless? I wondered what kind of meetings Eric Yuan and his team have been to before. Meetings, in general, can be the bane of professional life. In spite of wellknown rules of engagement for “frictionless” meetings, we see their rampant disregard. To those with refractory texting compulsion, the Zoom option to turn off the camera adds a virtual cover for blatantly impolite and dreadfully annoying behaviors such as incessant texting during live meetings. I save myself distress, by not being an eyewitness to that. The mute button is there to remind us to not just disable the mic, but to reduce the internal chatter in our heads during meetings, and to know when to stop talking.
All in a Day’s Work It was 9 o’clock on a Sunday. I polished my shoes, laid out
Nurse Practitioner Week Special Issue | NOVEMBER 2020
a dress shirt on the bed, and tried to find a matching tie. Then, I put a pair of socks on top of the shoes. This is a ritual I’ve done for many years on the eve of teaching; it is almost automatic. Somehow, there is a meditative quality to preparing one’s attire ahead of time. And then, I realized, I was just going a few feet away, to sit in front of my laptop and Zoom. But, I got dressed anyhow. And still do for every remote teaching session I continue to do. I may have retreated during this quarantine, but I will not surrender doing what I consider important in professional comportment. Putting on a professional attire is a way for me to honor the teaching profession, a privilege not open to all. Dressing up is a way for me to show my respect for the efforts of my students who sit through with me for twelve sessions of two hours and forty-five minutes. I suspect the world is getting good at Zoom and its many variations. Ironically, we might actually be getting out of it, as we cautiously emerge from the pause and back to the regular playing field. This
would be a welcome relief or prophylaxis for Zoom fatigue. Video conferencing, with all of its pixilation, out-of-synch audio, and the potential threat of Zoom-bombing is an idea whose time has come, for better or for worse. It has enabled nurses to transcend distance in
It has allowed providers to use one of the most powerful tools in health care—the therapeutic use of self. channeling empathy when it is needed most in time of quarantine. It has allowed providers to use one of the most powerful tools in health care—the therapeutic use of self. In spite of the pandemic, Zoom allowed me to continue to do what I love most: teaching. And for that I am most grateful. Fidelindo Lim, DNP, CCRN, is a clinical associate professor at the New York University Rory Meyers College of Nursing.
