AACN News—June 2003—Practice

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Vol. 20, No. 6, JUNE 2003

Here Is Some Practical Advice for the New Nurse Practitioner

By Angela Nelson, RN, MSN, CCRN, CS, ACNP
Advanced Practice Work Group

Congratulations! You're a new nurse practitioner. You have finished school and passed your certification exam. Now, you may be looking for a position.

Keep in mind that most NPs obtain their first position through contacts during their clinical experiences, an acquaintance or their current employer. So, don't rule out any of those avenues-aggressively pursue leads from these sources.

Many NPs demonstrate to prospective employers how they can fulfill a need that they have identified. This need may be identified in a clinical rotation or with a current employer.

The Job Network
Attending conferences to speak with exhibiting recruiters or networking at the local or state level, for example through chapters or state organizations, are excellent ways to seek out career possibilities. Often, job opening announcements are made at these meetings. One source for locating local and state NP organizations is the Clinician Reviews journal, which publishes an annual list in its December issue.

You can also find helpful links through online listservs. For acute care NPs, the ANPACC listserv includes job information from members nationwide. To subscribe, visit ANPACC@yahoogroups.com and type ANPACC in the search area. A number of state and specialty area listservs are also available. In addition, AACN offers a job posting section on its Web site at www.aacn.org > Careers >Job Postings. Of course, newspapers and professional publications are also valuable sources when searching for a job, as are individual hospital Web sites.

Keep a record of the positions for which you apply. Using a notebook where you can tape a copy of a job ad and notations about your application status, such as an acknowledgment that your CV was received, a call back or scheduled interview, is helpful. This record will help you recall the particulars of a position, especially because you may not hear from a potential employer for as long as eight weeks after submitting a CV. Sending a follow-up thank you letter after an interview is not only courteous, but also a good way to keep your name up front.

When negotiating for a position, do not sell yourself or the profession short. Do not underestimate the value of your nursing experience and how that experience will allow you to move up the scale from novice to expert NP more quickly than someone with fewer years of experience or experience not appropriate to the current position. You want to be paid not only fairly but also at a higher rate than your current RN position. Remember to negotiate for conference time and reimbursement, compensation for on-call duties, professional organization dues and reimbursement for Drug Enforcement Administration numbers, as well as the time frame and terms in which salary increases will be considered.

Meeting Requirements
Be aware of your state and board certification requirements regarding continuing education, including pharmaceutical content. You can meet these requirements in a variety of ways. For example, chapter meetings often feature speakers and offer CE units. In addition, professional journals publish CE articles, and many pharmaceutical companies offer CE units online or CD ROMs on which content can be reviewed and submitted for CE credit at nominal or no cost. If you are employed at a hospital, opportunities may exit to obtain free CE units. Although state, national and specialty practice conferences may be more expensive, they provide a great way not only to earn CE credits, but also to keep up to date on information.

By the Numbers
You can apply for your DEA online at www.usdoj.gov/dea > DEA Resources > For Physicians/Registrants > Registration. You will need DEA Form 224. The fee is $210.

To apply for your Medicare Provider Identification Number, contact your local carrier. A list of state carriers is available on the American Academy of Nurse Practitioners Web site at http://www.aanp.org.

Stretching Dollars
Is anything free? You can order personalized prescription pads from a company called Medi-Scripts at (800) 387-3636. In addition, the Nurse Practitioner Prescribing Reference is offered complimentary to certified NPs at (617) 923-8519. Many publications are offered free to NPs, including two online: Consultant at www.consultantLive.com and Advance for Nurse Practitioners at www.AdvanceforNP.com. You can also order Clinician Reviews by calling (973) 916-1000.

Remember that you may be the first NP with whom patients have contact. In fact, they may not even know what an NP is. Therefore, it is important to always present yourself as professionally as possible. First impressions are important and that first experience with an NP may form a lasting impression for a particular individual. If we all strive for our best, our profession will expand and grow by leaps and bounds.

Practice Resource Network
In 1994, a book titled Managing Clinical Practice in Critical Care Nursing was written. Are there any plans for an updated version of this series or other management publications?

A: Unfortunately, there are no plans to update this particular series. However, you may find a newer generation of books, some of which are listed below, helpful.

It's All About You: A Blueprint for Influencing Practice (AACN)
Acute and critical care nurses can use this blueprint as a development tool to communicate, to educate and to identify strategies that affect nurses' professional growth, enhance their collaborative skills, deal with difficult situations and effect change.
Item #120635
Price: $10 ($12 nonmembers)

Staffing Blueprint: Constructing Your Staffing Solutions (J. Medina)
This comprehensive resource addresses staffing issues. The blueprint emphasizes patient-focused care and can be used to assess your own knowledge, plan collaboration interventions, evaluate the effectiveness of your plan and assist you in becoming a knowledgeable resource in solving staffing problems.
Item #300117
Price: $26 ($35 nonmembers)

Standards for Acute and Critical Care Nursing, 3rd Ed. (J. Medina)
The newly revised Standards for Acute and Critical Care Nursing Practice describes the practice of the nurse who cares for an acutely or critically ill patient. The measurement criteria, which detail how nurses meet each standard, were evaluated and revised to reflect the unique aspects of acute and critical care nursing practice.
Item #130300
Price: $20 ($25 nonmembers)

Clinical Delegation Skills (R.I. Hansten, M.J. Washburn)
This book presents many new facts, strategies supported by recent research and skill-building tools. It is ideal for anyone who deals directly with the clinical delegation process.
Item #120904
Price: $55 ($57.95 nonmembers)

To order any of these resources, visit AACN's Bookstore online or call (800) 899-2226. The print Resource Catalog also lists audio tapes or CDs of presentations at NTIs, which can be purchased through National Nursing Network. To request a print catalog, call (800) 899-2226.

Critical Care Patient and Family Guide Is Now Available in Spanish

For Those Who Wait: A Guide to Critical Care for Patients, Families and Friends is now available in Spanish. Titled Para Aquellos que Esperan: Una Guia Pura Pacientes en Cuidados Intensivos Sus Familias y Amigos, this 24-page guide focuses on admission through discharge, including visiting the patient and the need for a family spokesperson. It reviews the critical care team, advance directives and possible equipment used in the critical care unit. This product is appropriate for pediatric and adult ICU patients and families and provides a helpful glossary in easy-to-understand terms.

Publication of the Spanish-language guide, which has been endorsed by the National Association of Hispanic Nurses, was financed in part by an educational grant from Wyeth Pharmaceuticals.

To order, call (800) 899-2226 or visit the AACN online Bookstore at www.aacn.org. Request Product # 120638. Price is $1.50 ($1.75 nonmembers). Quantity discounts are available.

Public Policy Update

Congress Approves Smallpox Compensation
Congress has approved a package of payments for people injured by the smallpox vaccine, a move praised by healthcare unions and those hoping to move the stalled inoculation program forward. Under the bipartisan agreement, people disabled by the vaccine could get up to $50,000 per year in lost wages, which is significantly more than the Bush administration proposed.

Officials hope that establishing payments for those injured by the vaccine will encourage more people to be vaccinated. The agreement was negotiated between Sen. Edward Kennedy (D-Mass.) and White House Chief of Staff Andrew Card.

Under the legislation:
� Families of people who are killed by the vaccine and die without dependents are entitled to a lump sum payment of $262,100, an amount based on an existing compensation program for police and firefighters.
� Estates of those who are killed and have dependents could choose the lump sum payment or up to $50,000 per year to make up for the deceased's lost wages. The payments would continue until the victim's youngest child reached age 18.
� Those who are totally and permanently disabled would get up to $50,000 per year for lost wages until age 65, with no cap.
� Those who are permanently but not totally disabled and those with temporary disability would get lost wages up to a maximum of $262,100.

Informed Consent Changes Urged for Critical Care Patients
Critically ill patients often aren't asked permission before undergoing potentially risky invasive procedures, according to a recent study published in the Journal of the American Medical Association. Such procedures frequently are viewed as emergencies, and doctors have little time to get permission from patients who might be incapacitated or from hard-to-reach relatives, the University of Chicago researchers said.

They found a simple solution: a permission form given to patients or relatives when they enter an ICU instead of minutes before a procedure is done. The form lists eight invasive procedures commonly performed in such units, including the insertion of breathing tubes and catheters, and spinal fluid collection. The form also included explanations of risks and benefits, both key in obtaining informed consent. Using the forms nearly doubled the rate of obtaining informed consent at the university's adult hospital, said researcher Jesse Hall, the university's chief of pulmonary and critical care medicine. The study appeared in Vol. 289, No. 15, April 16.

Report Cites Effect of Working Conditions
The Agency for Healthcare Research and Quality has released the summary of a report titled The Effect of Health Care Working Conditions on Patient Safety. Produced by AHRQ's Oregon Health & Science University Evidence-based Practice Center, the report concludes that the evidence is sufficient to make recommendations on specific strategies for improving patient safety, including increasing nurse staffing levels in acute-care hospitals and enhancing systems for communicating between hospitals and other healthcare settings. However, the report also identifies several other specific working conditions for further research. Among the patient safety research projects being funded by AHRQ are several to address some of the issues cited in the report.

FY04 Budget Moves Through Congress
Vice President Dick Cheney cast the deciding vote as the Senate voted 51-50 to approve a $2.2 trillion FY04 budget (S. Con. Res. 23). The plan includes the $400 billion over 10 years that President Bush requested for Medicare reform, including a prescription drug benefit. The resolution would fund domestic security as well as the drug benefit. The same day, the House passed its FY04 resolution, which also includes $400 billion for Medicare reform.

Meanwhile, both the Senate and House have voted to pass a $79 billion FY03 supplemental appropriations bill, which funds the war with Iraq and homeland security issues. The bill includes $16 million for studies on severe acute respiratory syndrome (SARS); $42 million for compensating those injured by smallpox vaccinations; and $100 million for the implementation of the civilian smallpox vaccination program. Officials said they hope the new smallpox vaccine compensation fund will increase vaccination rates.

4-Year Degree Mandate Removed in North Dakota
After nearly two decades, North Dakota's requirement that all registered nurses have bachelor's degrees has disappeared. With passage by the North Dakota Senate of House Bill 1245, the state fully retreated from its solitary place in nursing education standards. Although other states were expected to follow North Dakota when its 1985 Legislature passed the law, none did. Critics charged that it exacerbated the nursing shortage, because graduates of three-year RN programs in other states could not practice there.

The North Dakota Legislature weakened the four-year-degree requirement two years ago when it allowed the transitional licensing of out-of-state RN graduates. The practical effect was that no one needed the four-year degree to practice in the state, except North Dakotans. The bill ensures that the state Board of Nursing has the authority to approve all nursing education programs offered in the state.

Pain Care Policy Act Introduced
U.S. Rep. Mike Rogers (R-Mich.) has introduced legislation (H.R.1863) to recognize pain as a priority health problem in the United States. The National Pain Care Policy Act calls for the establishment of a National Center for Pain and Palliative Care Research at the National Institutes of Health and the development of six regional pain research centers throughout the country. The legislation would provide for a White House Conference on Pain Care, education and training programs for healthcare professionals, and the development and implementation of a national outreach and awareness campaign to educate consumers. It would also require development and implementation of a pain care initiative in all military healthcare facilities and pain care standards in military health plans and Medicare+Choice plans.
AACN's Strategic Plan reflects objectives to address priority issues related to providing optimal palliative and end-of-life care.

New Medical Privacy Rules in Effect
Patients will have the right to view and, in certain cases, restrict the sharing of their personal health information as the first federal safeguards for medical records take effect. Millions of doctors, hospitals, health plans and others must comply with the medical privacy rules, which cover a broad range of practices, though they are not as strong as some patient advocates had hoped.

The rules require providers to give patients a notice detailing how their information will be used. Patients will have rights to view and copy their records, and to request corrections to errors. Most "nonroutine" disclosures, such as giving information about an employee to an employer, will be forbidden without the patient's permission.

In addition, smaller steps will be made to keep as much information as possible confidential. For example, sign-in sheets in doctors' offices should not display patients' medical problems, the Department of Health and Human Services advises. "These new federal health privacy regulations set a national floor of privacy protections that will reassure patients that their medical records are kept confidential," said Health and Human Services Secretary Tommy Thompson.

States may require even stronger protections. The federal rules were issued by former President Bill Clinton shortly before he left office in January 2001. Although the Bush administration agreed to implement them, changes were made that critics said significantly weakened the protections. The Bush version removed a mandate that providers obtain patients' consent for disclosing information for purposes of treatment, payment and other healthcare operations. Officials said that could have interfered with medical care. They instead required notification of information-sharing practices.
A coalition of consumers and healthcare providers have challenged the rules in court, saying the lack of a consent requirement actually results in broader access to patients' files for insurers, law enforcement and others. Patients cannot sue over violations under the rules, but can file complaints with the government, which can impose penalties.

Healthcare providers, many of whom complained that the rules would be costly and burdensome, have had two years to prepare. Consultants have advised everyone from large hospitals to nursing homes and small town clinics on how to comply.

Public Policy Snapshot

Healthcare Reform

� 61% of Americans say the healthcare system needs fundamental changes.
� 25% of Americans say the healthcare system needs to be completely rebuilt.
� 12% of Americans say minor changes are needed.
� Although reforming the healthcare system is a priority in public opinion surveys, issues such as fighting terrorism, improving the economy, improving education and schools, and protecting Social Security rank higher.

Source: ABC News/Washington Post

Public Policy Information Online

The Center for Nursing Advocacy
The Center for Nursing Advocacy seeks to increase public understanding of the central, front-line role nurses play in modern healthcare. The focus of the center is to promote more accurate, balanced and frequent media portrayals of nurses and increase the media's use of nurses as expert sources.

Stateline Healthcare News
This site is operated by the Pew Center on the States, a research organization administered by the University of Richmond, and funded by The Pew Charitable Trusts.Stateline.org was founded in order to help journalists, policy makers and engaged citizens become better informed about innovative public policies.

The Latest on SARS

Scientists Identify Cause of Outbreak

� Dutch scientists have produced the final pieces of evidence needed to conclusively link the microbe, known as a coronavirus, to severe acute respiratory syndrome (SARS), scientists at the United Nations body concluded.
� The Centers for Disease Control and Prevention continues to work with state and local health departments, the World Health Organization and other partners to investigate cases of SARS.
� As of April 30, a total of 289 SARS cases among U.S. residents had been reported to the CDC from 38 states, of which 233 (81%) were classified as suspect SARS, and 56 (19%) were classified as probable SARS (more severe illnesses characterized by the presence of pneumonia or acute respiratory distress syndrome). Of the 56 probable SARS patients, 37 (66%) were hospitalized, and two (4%) required mechanical ventilation. One patient (2%) was a healthcare worker who provided care to a SARS patient, and one (2%) was a household contact of a SARS patient. The remaining 54 (96%) probable SARS patients (including the six patients with positive SARS-CoV laboratory results) had traveled to mainland China; Hong Kong Special Administrative Region, China; Singapore; Hanoi, Vietnam; or Toronto, Canada.
� As of April 30, the SARS outbreak control strategy for the United States had included issuance of travel alerts and advisories and distribution of health alert notices to travelers arriving from areas with SARS to facilitate early identification of imported cases. Current travel alerts and advisories can be found at www.cdc.gov/ncidod/sars/travel.htm.
� Healthcare workers have been identified as a primary "at risk" group for exposure to SARS. Caring for and treating persons with SARS exposes individuals to infectious droplets. Possible ways SARS can be transmitted include touching people's skin or objects contaminated with infectious droplets, then touching your own eyes, nose or mouth or through airborne inhalation of aerosolized droplets.

For general information about SARS, visit www.cdc.gov/ncidod/sars. For a list of updated CDC Infection Control Guidelines, go to http://www.cdc.gov/ncidod/sars/ic.htm.

Research and Creative Solutions Abstracts Invited for NTI 2004

Sept. 1 is the deadline to submit research and creative solutions abstracts for AACN's 2004 National Teaching Institute and Critical Care Exposition May 15 through 20 in Orlando, Fla.

Guidelines and resources are now available online. The application will be available in July.

Online Quick Poll

Should beta blocking agents be avoided in heart failure?

No 72%
Yes 28%

ECCO Users Share Successes in Integrating Critical Care Program

E-Learning Approach Maximizes Flexibility

Launched less than one year ago, AACN's electronic Essentials of Critical Care Orientation has attracted increasing attention as healthcare institutions across the country implement the Internet-based program. And, last month's National Teaching Institute and Critical Care Exposition in San Antonio, Texas, was a great place to find out more.

For example, representatives from the University of Kentucky and Rush-Presbyterian-St. Luke's Medical Center in Illinois shared their experiences with the program in a session titled "Successfully Integrating E-Learning With Critical Care Nursing Education."

According to Susan Huerta, RN, MS, director of nursing systems at Rush, the decision was made two-and-a-half years ago to reintroduce clinical nurse specialists throughout the hospital to focus primarily on staff development in specific, unit-based clinical areas. Once the critical care CNS positions were filled, the group began to re-envision how they might offer orientation.

The goal was to equip nurses to provide safe, effective and competent patient care. Each specialized ICU concentrates on its specific educational requirements during formal orientation. Education would then continue beyond this specified knowledge and accompanying skill sets as a way of extending nurse development.

"A patient with a head injury today can have multisystem failure tomorrow," Huerta said. "The nature of critically ill people is that anything can happen. A patient can really go beyond the presenting problem, and we want to be sure our nurses are fully prepared.

"With the ECCO program, when a person is ready to progress to the next level of content, they move on," she added.
Rush has traditionally offered a formal critical care orientation course four times a year in a classroom setting. Flexibility became a key component of restructuring the orientation process.

"We desired flexibility rather than being locked into standard courses that could not be as individualized. With the ECCO program, we can be flexible in terms of when we offer the course and we can tailor the education to meet each individual nurse's needs," Huerta explained.

Consistency and standardization of information and training across the various critical care areas were also important to Rush.

"The CNSs articulated common competencies across critical care areas, then we matched these with the different modules within the program. Since all new critical care nurses will go through the entire program during their first year, we can be sure that they will have received the same theory in the same format," said Huerta. This goes a long way to ensuring a common standard of care."

Nancy Silva, RN, MS, clinical nurse specialist for surgical intensive care and postanesthesia recovery, agreed.

"The fact that the content is up to date is a benefit for us. Literature changes take time to publish. You usually have to wait for the next edition," she said. "Having everything online means changes can be quickly posted to the program and our nurses benefit from up-to-date content."

Silva explained that new nurses appreciate having concrete literature to draw on both during and after the orientation process.

"I think participants have an increased comfort level knowing that they'll have access to the structured content once their orientation is complete. This ability to review the information provides support to the new nurses as they begin to work with patients," said Silva.

Huerta shared that the decision to implement the ECCO program came after evaluating the program in terms of meeting the educational needs articulated through the re-envisioning process, while simultaneously scrutinizing the resource commitment required versus the benefits to be gained.

"We determined the breadth of content would be useful for achieving our goal of consistent orientation in a variable environment," she said. "The program enabled us to define and articulate the modules to be completed for each unit and couple this with the skill sets to be demonstrated in the clinical arena for a usual customary assignment for that unit. We could then determine how to build the next sets of skills so that, at the end of a year, we would have an expert nurse."

Like many hospitals, the staff at Rush works unique hours, with staggered, 12-hour shifts.

"One of the benefits of using this program is we don't have to ask nurses to come back to work on a day off or to stay awake all day after working all night to participate in an orientation class," said Huerta. "Since it can be accessed 24/7, nurses can progress through the assigned modules in snippets, sitting for 30 minutes to one hour, whenever they have time."

Silva added: "We give them time to complete the courses at work, but they always know they can spend extra time with the content at home if they want to."

She said the nurses also know that the instructor can review their progress to determine if someone is having difficulty with the content or needs to take a test more than once before getting a passing grade.

"This is a useful tool for keeping us informed," said Silva.

Huerta also shared a couple of program features that she particularly liked.

"The breath sounds in the pulmonary module were fairly realistic, even to the point of one being hard to catch," said Huerta.

She also liked the fact that doctors' orders were inherent within the patient presentation section of cases.

According to Silva, the first group of nurses to use the program did not exhibit apprehension about using an online education program.

"New grads are familiar with the character of education and technology, so they did not think it unusual that the program was computer driven." Huerta said, noting that computer-based learning will likely be the wave of the future, Rush has made a concerted effort to provide technology training for all their nurses to make sure they're comfortable with computers.

About Rush

Rush-Presbyterian-St. Luke's Medical Center is an academic medical center that encompasses the 824-bed Presbyterian-St. Luke's Hospital (including Rush Children's Hospital), the 110-bed Johnston R. Bowman Health Center and Rush University. The Rush Institutes bring together patient care and research to address major health problems, including arthritis and orthopedic disorders, cancer, heart disease, mental illness, neurological disorders and diseases associated with aging. In June 2002, Rush became the 51st medical center in the country to earn the prestigious Magnet Award for excellence in nursing services, the highest honor awarded by the American Nurses Association.

Who Is Using ECCO?

California � Naval Medical Center San Diego
� Regional Health Occupations Resource Center-Butte College
� Stanford University Hospital
� Sutter Coast Hospital

Colorado � Memorial Hospital Colorado Springs

Florida � Broward Community College
� Lee Memorial Health System
� Department of Veterans Affairs Medical Center, Miami
� Department of Veterans Affairs Medical Center,
West Palm Beach
� Mercy Hospital (Miami)

Illinois � Rush-Presbyterian-St. Luke's Medical Center
� Sherman Hospital
� Scott Air Force Base (375th Medical Group)

Indiana � Department of Veterans Affairs Medical Center, Indianapolis

Kentucky � University of Kentucky

Maine � Maine General Medical Center

Maryland � Suburban Hospital

Massachusetts � Good Samaritan Medical Center

Minnesota � Allina Hospitals & Clinics

Missouri � CoxHealth System

Montana � Benefis Healthcare
� Frances Mahon Deaconness Hospitals

Nebraska � Good Samaritan Health System

New Hampshire � Mary Hitchcock Memorial Hospital

New Jersey � Atlantic City Medical Center

New York � Champlain Valley Physician Hospital
� St. Mary's Hospital (Seton Health)

Ohio � Department of Veterans Affairs Medical Center, Cincinnati

Oregon � Oregon Health and Science University

Pennsylvania � Dubois Regional Medical Center

Texas � Denton Regional Medical Center
� Harris Methodist Fort Worth
� Presbyterian Hospital
� University Hospital
� Hendrick Medical Center
� Southwest Texas Methodist Hospital

Utah � HCA-St. Mark's Hospital

Virginia � Bon Secours Memorial Regional Medical Center
� Martha Jefferson Hospital
� Northern Virginia Community College

Washington � Capital Medical Center
� Kadlec Medical Center
� Northwest MedStar
� Sacred Heart Medical Center
� Sunnyside Community Hospital
� Northwest Workforce Development Council
� Yakima Valley Memorial Hospital

West Virginia � Princeton Community Hospital

Wyoming � Campbell County Memorial Hospital

Canada � Queen Elizabeth II Hospital, Grand Prairie, Alberta

Japan � U.S. Naval Hospital, Yokosuka, Japan

Sepsis Education Program Available

Eli Lilly Grant Underwrites Purchase Fee for CD-ROM

Identification and Management of the Patient With Severe Sepsis," AACN's national sepsis education program for nurses, is now available in a self-paced CD-ROM format. Funded by an unrestricted educational grant from Eli Lilly and Company, this program is sponsored by AACN and is accredited for 5.0 contact hours of CE credit for single users.

Narrated by clinical expert Barbara McLean, RN, MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive view of the latest information on the diagnosis and care of patients with severe sepsis.

The 170-page, audio/slide CD-ROM study guide includes pathophysiology of severe sepsis; identification of acute organ system dysfunction; antibiotics, source control and monitoring in severe sepsis, including investigational and new approved therapies; hemodynamic, ventilatory, renal and other aspects of care; and nursing care of patients with severe sepsis. Case studies are also included in the presentation.

To order this cutting-edge learning program for only the $7.50 shipping and handling fee, call (800) 899-2226 and request Item #004060. Quantities are limited.

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