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Advocacy in Nursing

       By Rosabel Zohfeld, MSN, APRN, FNP-C

     Nurse practitioners advocate, speak for, and on behalf of individuals. They support and encourage healthcare, the nurse profession, and their role as providers through advocacy. Much more when the individual's ability to make choices and decisions is diminished due to illness and social circumstances. 

Political advocacy

        This is an essential tool for advanced practice nurses (APNs) to promote the healthcare interests and or needs of patients, communities, and their profession. Therefore, the APN needs to identify the current and most important issues in the nursing profession and personal interests. An example of a current issue in the advanced practice nursing profession is the different state limitations on NP's scope of practice. Having restrictions in certain areas have a negative impact on communities that require healthcare services. These individuals and organizations can benefit from healthcare provision from highly trained professionals such as NPs. Through political advocacy NP's can help change the different restrictions in state practice acts.

Key Points:

Be politically competent

Become familiar with policymakers, their positions, and interests

Be aware of health policy resources such as contributing and volunteering

Get acquainted with the state delegation, members of staff, and different committees

Know about laws and regulations related to lobbying and or its activities

Become familiar with Political action committees (PAC's)

Media coverage as an excellent resource for policymaking support

Social media is a great tool to reach out and interact with an audience

Partnerships and coalitions can help the NP's policies goal

Becoming politically competent: 

        To bring and be part of a change in healthcare and the nursing profession, an NP must learn how to utilize the legal and political resources available properly. Excellent communication skills, active listening, team building, and strategic planning are vital to becoming politically significant. A firm foundation on policy competency allows the NP to start a conversation on important issues that affect our nursing practice and healthcare delivery. 

Additional Developments:

        There is still much to do in the political advocacy arena. There is a real need for NP's to become politically engaged to protect the clinical practice and the welfare and interests of patients and communities. Currently, most NP's seem not to have much time to be involved in all policy issues; however, focusing on issues that affect their practice and patients while supporting professional organizations is a great start. 

Conclusion:

        In today's society, there are many political issues, among others, that directly impact the advanced nurse practice. Nurse practitioners can shape the future of healthcare delivery through effective political advocacy. By using various resources and policy tools already available, NP's can help advance the NP agenda. With the primary goal of providing quality, safe, and cost-effective healthcare, NP's are uniquely positioned to lead the way in health policy implementation. NP's have a professional obligation to advocate and to be engaged in the political changes of healthcare and the nursing practice profession.


Reference:

Kostas‐Polston, E. A., Thanavaro, J., Arvidson, C., Taub, L. M., & FAANP Health Policy Work Group.  (2015). Advanced practice nursing:   Shaping health through policy. Journal of the American Association of Nurse Practitioners, 27(1), 11-20. doi:10.1002/2327-  6924.12192

Delegated Authority

 by Rosabel Zohfeld, MSN, APRN, FNP-C

        According to Al-Jammal, Al-Khasawneh, & Hamadat, 2015, the delegation of authority is the transmission of power from a high entity power to a low entity power. The authorized individual or the person is giving the control exercises those powers through the agreement's duration between both parties. The individual in charge of the one who gives the authority decides what particular duties and tasks the authorized individual may or may not perform (Al-Jammal, Al-Khasawneh, & Hamadat, 2015).

Unfortunately, in Texas, Nurse practitioners, N.P.s, are required by the Texas Nursing Practice Act to have a written collaborative agreement. This agreement between a nurse practitioner and a physician refers to a physician's supervision of the N.P.'s work. It was not only until recently when Texas's state finally eliminated the full on-site presence of a physician to oversee an N.P.'s job (Blore, 2019). Under Texas law, patient access to N.P.s is restricted. Currently, they are not authorized to sign Do Not Resuscitate orders (DNR). N.P.s in Texas are only authorized to sign death certificates in some/certain circumstances (AANP, 2018a).

In contrast, the state of New Mexico, NM, authorizes N.P.s to practice to the full extent to their license and training. N.P.s in N.M. can evaluate, diagnose, treat, and prescribe medications. They can do so without physician supervision and or collaborative agreement. Also, N.P.s in N.M. can still sign DNR orders; however, they can sign death certificates (AANP, 2018b).

In the state of Texas, the Texas Nurse Practitioner (TNP) organization continues to support legislation to allow N.P.s in the state of Texas to have full practice authority. A statewide system that would enable patients to have full access to all N.P. Services. The TNP's 2019 legislative list includes the following topics on: 

H.B. 1792/S.B. 2438: Full Practice Authority; for N.P.s to practice to the full extent of their training and education

H.B. 2250/ S.B.1308: Adequate prescriptive authority to N.P.s for all scheduled II controlled drugs, regardless of specialty or practice setting

H.B.278/ S.B.311: The modernization of the current framework for the physician/N.P. delegation. To be able to have the meetings in any way preferred, such as videoconference, facetime, and not just face-to-face

H.B. 387/ S.B.1022: N.P.s signature recognition on health-related forms such as worker's compensation 

H.B. 3128: N.P.s signature recognition on sports clearance forms

H.B. 912: To improve the ability of APRNs to practice telemedicine and Telehealth as well as to expedite fast tracking licensure applications for those APRN's who would like to hold a TX license, and have agreements that recognize the APRN license across borders (TPN, 2019).

It is of great importance that N.P.s understand clearly how state regulations and laws impact their practice. A state with full N.P. Practice laws and licensure is the model recommended by the national academy of medicine. An entire practice authority state for N.P.s allows the N.P. to have full authority under the state board of nursing. Currently, Washington, Oregon, Idaho, Montana, Wyoming, South Dakota, North Dakota, Nebraska, Minnesota, Iowa, Nevada, Colorado, Arizona, New Mexico, Maine, Vermont, New Hampshire, Connecticut, Rode Island, Maryland, District of Columbia, Alaska, Hawaii, Guam, & the Northern Mariana Island, are states that have full practice laws for N.P.s. States like New York, Pennsylvania, West Virginia, Kentucky, Ohio, Indiana, Illinois, Wisconsin, Utah, Kansas, Mississippi, Arkansas, Louisiana, Alabama, Puerto Rico, Virgin Islands, & American Samoa have laws that reduce the N.P.s' abilities of engagement in at least one practice element. These states require a career-long collaborative agreement with a healthcare provider for the N.P. to provide care. In some instances, it limits to one or more elements for the N.P. Practice. States with the restricted practice for N.P.s limit and restrict the engagement of N.P.s' with at least one practice element. There is a requirement for the supervision and delegation (delegated authority) by a physician and or other health care provider for the N.P. to provide care (AANP, 2019c).

An important key point for my future practice and many other N.P.s practicings in the state of Texas is to be able to practice to the full extent of the APRN licensure. N.P.s are independent, knowledgeable, and skilled professionals that can practice under their licenses. They can practice independently from a physician and or without a physician's supervision (Buppert, 2018).

One could argue that states like New Mexico, for example, where there is full unrestricted practice for N.P.s, could offer more and better opportunities. Nonetheless, there are other factors and circumstances to be considered before making a decision. I think that Texas's state is moving towards free practice for N.P.s soon.  Later on, depending on how much progress is made towards full authority and other important issues, I may stay or relocate my family to an N.P. Friendly state with a full practice. All in all, through advocacy and legislation in Texas, we are getting closer to many positive changes that will impact the future of the N.P. Practice (AANP, 2019c).


References:

Al-Jammal, H. R., Al-Khasawneh, A. L., & Hamadat, M. H. (2015). The impact of the delegation of authority on employees' performance at great Irbid municipality: case study. International Journal of Human Resource Studies, 5(3), 48-69.

American Association of Nurse Practitioners, AANP. (2018a). Texas State Policy Fact Sheet. Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/texas-state-policy-fact-sheet

American Association of Nurse Practitioners, AANP. (2018b). New Mexico State Policy Fact Sheet. Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/new-mexico-state-policy-fact-sheet

American Association of Nurse Practitioners, AANP. (2019c). State Practice Environment. Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment/state-policy-fact-sheets/new-mexico-state-policy-fact-sheet

Blore, J. (Ed.). (2019). Texas Nurse Practitioner Practice Authority: The Fight for FPA. Retrieved from https://www.nursepractitionerschools.com/blog/texas-np-practice-authority/

Buppert, Carolyn (2018). Nurse Practitioner's Business Practice and Legal Guide (p. 8). (6th ed.). Jones & Bartlett Learning. Kindle Edition.

Texas Nurse Practitioners, TPN. (2019). TNP's 86th Legislative Session Recap. Retrieved from https://www.texasnp.org/page/AdvocacyIssue

End of Life

When doing my intensive care unit rotation during nursing school, I witnessed the case of a patient in her 70's who was on life support in the medical ICU. She was initially in a nursing home, and she was a DNR while in there. She suffered irreversible brain damaged after a stroke and was now having severe sepsis due to other medical underlying causes. No relatives reported to the nursing home or hospital until they learned that she was in critical condition, and imminent death about ensued. Then one of the daughters appeared suddenly as her legal guardian and placed the patient on a full code, so the patient was kept alive through life support. The medical team advised the family that they couldn't do anything for the patient as she was starting to show signs of organ failure, and no longer had any brain activity. The ethical committee had a meeting scheduled that evening. The nurses that were taking care of the patient expressed their concern about how emotionally exhausted they were beginning to feel.  Some of the nurses were feeling frustrated in front of the family demands.  The family members didn't fully understand that their beloved one was lifeless and had no quality life. This patient was now in the ICU for about 3-4 weeks. A social worker got involved. According to another family member, the legal guardian (daughter) had some particular interest in keeping her "alive" to continue to receive the patient's monthly pension and other financial allowances. The ethics committee needed to have a meeting and review the case to decide whether it was in the patient's best interest to keep her on life support even though she was declared brain dead. This situation had both a legal and moral/ethical component that needed to be addressed. As a student, I did not know the details of the case. I wasn't part of the nurses caring for this particular patient.

In Texas, the SB11 law signed into effect on April 1, 2018, sets parameters for physicians DNR orders for a patient in the hospital setting. The final rules took effect on September 14 of the same year. It requires a hospital to adopt, implement, and enforce all DNR orders given by the hospital attending physician. According to the SB11, the hospital did the right thing to notify the family members. DNR orders were entirely in place after notification. That is when the family member came out with a medical power of attorney (MPOA) that legally gave her the right to revoke the DNR order at the time.

Interestingly, the SB11 law in Texas does not go against the hospital ethics and medical committee (046 processes) known as the dispute resolution process. An attending physician can refuse to honor the patient's advance directive on behalf of the patient. I do not see how the case ended, but it seems to me that the physician may be able to decide on behalf of the patient here in Texas. Based on clinical judgment as being medically appropriate and reasonable to allow natural death to occur, the attending physician can proceed with the DRN order (THA, 2019).

I believe the SB11 law helps avoid these issues where the patients are ultimately in the middle of a legal-family battle. The attending physician should be able to act on behalf of the patient as medically necessary. These situations are traumatic for the patient and the caregivers (THA, 2019).

References:

Justia (2019). 2015 Code of Alabama:: Title 22 - HEALTH, MENTAL HEALTH, AND ENVIRONMENTAL CONTROL. :: Title 1 - HEALTH AND ENVIRONMENTAL CONTROL GENERALLY. :: Chapter 8A - TERMINATION OF LIFE-SUPPORT PROCEDURES. :: Section 22-8A-11 - Surrogate; requirements; attending physician consulted, the intent of patient followed; persons who may serve as a surrogate; priority; the validity of decisions; liability; form; declaratory and injunctive relief; penalties. Retrieved from https://law.justia.com/codes/alabama/2015/title-22/title-1/chapter-8a/section-22-8a-11/

Texas Hospital Association. THA. (, 2019). SB 11 - Inpatient DNAR Orders. Retrieved from https://www.tha.org/SB11


Skin Care Case Study


 

A 42-year-old female presents to your clinic with an approximately 4 mm changing mole or skin lesion (see picture) on her left shoulder. 

 



Goals:

1.     Develop a list of equipment need to biopsy this lesion. 

2.     Choose an appropriate method for the procedure

3.     Discuss the appropriate discharge instructions


Overview: 

 

Skin biopsies are performed in order to obtain tissue for further examination in the laboratory. It is the purpose of a skin biopsy to further characterize the nature of a skin growth or eruption and assist in diagnosis by allowing histopathologic evaluation of a tissue sample. Skin biopsies have a relatively low risks compared with biopsy of other organs. A skin biopsy can be safely and routinely performed in an outpatient or ambulatory setting, as well as an inpatient setting.

 

Chosen method: 

 

For this lesion I have chosen to do a punch biopsy due to this lesion being less than 5 mm. The punch biopsy instrument is used to obtain a cylindrical, full-thickness specimen, and it is a good choice for the removal of small lesions less than 5 mm. A punch biopsy is strongly recommended when melanoma is a consideration because it provide detailed information about the depth of the lesion.

 

Equipment:

 

1.     Sterile tray

2.     Alcohol wipe to clean area

  1. Pathology container filled with 10% formalin solution or normal saline and laboratory requisition form
  2. Gauze, 2 X 2-inch or 4 X 4-inch

5.     Surgical marker

6.     Cleansing agent (betadine swab).

7.     Drape 

8.     Disposable punch instrument (from 2-8 mm in size)

9.     Sterile gloves

10.  Anesthesia (1% lidocaine with epinephrine)

11.  Iris scissors

12.  Forceps with teeth

13.  Desired size of sutures, with a needle holder

  1. Petrolatum or antibiotic ointment
  2. Bandage or nonstick bandage and tape

 

Procedure:

 

1.     Prepare a tray with sterile materials (sterile technique is used in order to suture wound). 

2.     Down gloves. 

3.     Cleanse the area with alcohol wipe. 

4.     Mark the area with a sterile marker. 

5.     Prepare the site with betadine. 

6.     Do a field block anesthesia by placing a ring of anesthesia around the lesion. Use a ½ inch 30 G needle with the appropriate anesthetic (1% Lidocaine with epinephrine). 

7.     Use a drape to cover the area whenever possible, depending on the location of the lesion.

8.     Apply traction to skin, position the punch instrument (4 mm punch biopsy) and then rotate (twist) clockwise. 

9.     Hold the lesion with the forceps, snip and place the specimen in preservative (labeled correctly) to be send to lab. 

10.  Place 1 -2 sutures on wound, apply antibiotic ointment and a band-aid (Prather, 2017).

 

Discharge instructions for patient:

 

·      Leave your wound dressings in place for the rest of the day of the biopsy and keep them dry. You can change the band-aid daily starting the next day after the biopsy. 

·      It ok to shower the day after the biopsy. Leave the band-aids in place while you shower and change them after you dry off.

·      During the time period of daily band-aid changes, do not soak in a bath or swim to avoid infection in the site. The average time for daily band-aid changes is 5 to 6 days (range is from 1 or 2 days up to 2 weeks). 

·      Continue to change the band-aids daily until there are no open wounds. If you need to use anything to clean the wound, hydrogen peroxide is recommended. If there are no signs of infection, all that is required is a daily band-aid change. 

·      Usually, the local anesthetic used for the biopsy will usually last for 1 to 2 hours after the procedure. After it wears off, you may have some mild, localized soreness and tenderness at the biopsy sites over the next day or two. 

·      You may find regular Tylenol is helpful for the discomfort. Refrain from doing extremely strenuous activity for the rest of the day of your biopsy (such as running or heavy lifting) to prevent bleeding of the site.

·      Once you are without the band-aid, the biopsy sites may look slightly red or darker than the rest of your skin. This discoloration will gradually fade and blend back with your normal skin color. This fading process may take anywhere from a few months up to a year. It is normal for the biopsy sites to bleed a little bit or drain pink fluid for a day or two after the biopsies. They should not bleed excessively (i.e., through the band-aid) after that time. They should never drain pus. 

·      If you do experience problems with significant bleeding, redness, infection, or other problems, call your doctor's office. It is very rare for people to have any problems during the healing period.

References:

 

Pfenninger, J. L., & Fowler, G. C. (2011). Pfenninger and Fowlers procedures for primary care (3rd ed.). Philadelphia: Mosby Elsevier.

 

Prather, C. L. (2018, August 17). Skin Biopsy Periprocedural Care. Retrieved from https://emedicine.medscape.com/article/1997709-periprocedure#b4

 

Swift, F. (2015). Patient Instructions for Biopsy Site Care. Retrieved from https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/cutaneous_nerve_lab/physicians/patient_instructions_biopsy_site_care.html

 

National Average Salary for A Family Nurse Practitioner?


By: Rosabel Zohfeld, MSN, APRN, FNP-C

According to the Nursing Process.org, 2019, an FNP in the U.S. has an average yearly salary of $109,705. The U.S. Money, News & World Report, 2019, states that the median salary for an FNP in the U.S. averages $103.880K yearly. The online resources, PayScale.com, 2019, states that an FNP averages a salary of $92,548K. While there is a slight difference, this is not surprising. The are many variables in play, such as bonuses, call pay, benefits, and depending on the state. For example, According to U.S. Money, 2019, California is one the state with better pay for FNP.s $151,660; however, if one looks at the cost of living, it may not be much of lavish pay. 

Austin, TX, for example, pays an average of $102,196K, but the cost of living is way much less than California, so again it is all relative (Nursing Process.org, 2019). There is no new information; I have been aware of the N.P. Salaries across the nation since been a nurse. In the past, have practiced in Alabama, and the average pay there for a beginner N.P. was around $87-90K. Again the cost of living was way lower than any other state, so pay goes a long way in a small town in rural Alabama. Depending on experience and degrees earned such as DNP, the FNP can make even more than just the average. Again, not surprised about any of these figures, employers and employees play a bit with numbers regarding what is covered, whether there are bonuses included, call pay, vacation time pay, the fee for services, Etc. 

References:

Nursingprocess.org. (, 2019). Family Nurse Practitioner (FNP) Salary - 2019 National & State Figures. Retrieved from https://www.nursingprocess.org/family-nurse-practitioner-salary/PayScale, Inc. (2019). Average Family Nurse Practitioner (N.P.) Salary. Retrieved from https://www.payscale.com/research/US/Job=Family_Nurse_Practitioner_(N.P.)/Salary

U.S. News & World Report L.P. (2019). How Much Can a Nurse Practitioner Expect to Get Paid? Retrieved from https://money.usnews.com/careers/best-jobs/nurse-practitioner/salary


Geriatric Case Scenario

An 85-year-old male presents to your clinic for his 3-month check.  He is well known to your clinic.  His medical history includes hypertension, myocardial infarction followed by quadruple bypass at 60 years-old, atrial fibrillation, hypercholesterolemia, and early Parkinsonism.  His medications include metoprolol, Sinemet, clopidogrel, and atorvastatin.  He told the medical assistant that he recently moved into a retirement center after he lost his wife.  Vital signs:  T 97.7F; P 78; R 20; BP 180/96; height 68 inches; weight 135, BMI 20.5.  The provider notes that his blood pressure is 180/96 and that he has lost 10 pounds since his last visit.  The provider's physical assessment is normal for his age and health status.  When the provider states that his blood pressure is high, the man states that he has forgotten to take his medication.  The provider stresses the need to take his medication regularly and provides him with prescriptions for all his medications and requests that he come back in 3 months.

What would you have done differently, and why?

What is your number one priority in this scenario, and why?

At this point, according to the health history, this older adult has early Parkinsonism. Just by telling/stressing this patient to take his medications won't be enough.  I will arrange a social worker visit,  possibly home health, or a consult with the retirement center. They usually have aids that help patients with their daily medications and assist with other daily living activities. If the patient has forgotten to take his blood pressure medicine and his BP is not under control and with his cardiac history, this does not paint a good picture. Just because he has the drug at hand that does not mean he will be compliant. This patient needs help beyond a simple to follow up visit. In this case, it is essential to review the patient's ability to perform daily living activities in association with their mental status functioning. Are there any impairments that we need to be aware of? Does the patient has a caregiver, meals provided, medication monitored, and delivered to the patient? Is this patient driving himself to places? Are they any safety concerns? (Seidel et al., 2019. p. 97).

According to Blumenthal et al., the aging population (the elderly) who has chronic conditions account for an increasing proportion of our healthcare system. As healthcare providers, we must understand that many of these older patients have multiple needs that while they may be stable with treatment, they may still have some functional limitation that may hinder their care. As practitioners, we must see our patients regarding their age, gender, and where they are in regards to their social factors and support systems (Blumenthal et al., 2016).


References

Blumenthal, D., Chernof, B., Fulmer, T., Lumpkin, J., & Selberg, J. (2016). Caring for High-Need, High-Cost Patients — An Urgent Priority. New England Journal of Medicine, 375(10), 909-911. DOI:10.1056/nejmp1608511

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis: Elsevier.


Bullying in the Workplace

By Rosabel Zohfeld, MSN, APRN, FNP-C


When starting my career as a nurse I experienced bullying and harassment in the workplace. I will never forget when I was left alone to care for a patient bleeding to death. "Figure it out yourself," You need to learn how to deal with the situation independently; that was the answer from the nurse in charge. I spoke up and said, "this is not the time to evaluate my competencies; this is the time to care for this patient. I need extra help to send her on her way to the operating room as soon as possible. I needed five more hands to collect extra information for admission, lines started (at least 2), blood draw, urinary catheter, vital signs, patient sign consent, and be a translator because English wasn't her first language. I asked for at least one nurse walking by to give me a hand, the answer I got was: that is the most stable patient we had in the unit at the moment," so deal with it. I can't even begin to give the details of the bullying and shaming I received from other coworkers after that incident. I always have, though, that nurses work better as a team. Unfortunately, many views are: "that's your patient, not mine." Situations like that where I felt little support and much shaming got me to leave that particular job environment. 

Unfortunately, bullying in health care is documented as far as 35 years, but there are far more research studies, employment laws, and literature about bullying in Europe than in the U.S. Bullying is often an abuse of power. The primary culprits are typically supervisors, department managers, and executives of the organization. Usually, the perpetrator holds a higher rank than the victim. Even though public awareness of bullying in the workplace continues to grow, approximately 72% of employers discount, deny and rationalize the disruptive behaviors. Often the bully is the one who receives support from the organization. Bullying victims lose their jobs at a much higher rate than the perpetrators. At least 82% of the victims lose their jobs versus18%, including voluntary resignation, termination, or being forced out of the organization. Bullying has become so concerning that the Joint Commission has implemented two additional leadership standards to address this inappropriate behavior. Still, nothing seems to be enough, and that is why I think many are leaving the nursing profession.

Today, I advocate for nurses and patients. I say no to bullying and no to shaming at the workplace. We have to help each other. We have a common goal that is to help our patients to overcome sickness and possibly death. If it takes one or two more working together towards it, so be it. Let's work together and not against each other. 

Advocacy in Nursing

        By Rosabel Zohfeld, MSN, APRN, FNP-C        Nurse practitioners advocate, speak for, and on behalf of individuals. They support and ...