Beverly George-Gay, MSN, AGPCNP-BC

Professional DNP E-Portfolio

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1918 Influenza vs. COVID-19

Several similarities can be seen between the 1918 Influenza pandemic and today’s Coronavirus Disease 2019 (Covid-19) pandemic even though occurred 100 years apart. Both pandemics are suggested to have been transmitted from an animal reservoir, the 1918 influenza by an H1N1 virus originating in birds, and the SARS-coronavirus-2 (the virus that causes COVID-19) from bats (CDC, 2020). They are also both considered “novel” viruses meaning, they are so new, no one in either era had any immunity to them. A striking difference between the two was the age groups affected. In the 1918 pandemic, mortality was highest among the 20-40 age group but mortality is higher among the elderly with Covid-19.

Even though there are antiviral medications and antibiotic treatments today that were not available for the 1918 pandemic, they both resulted in significant mortality and morbidity due to rapid community spread. Attentive nursing care proved the only effective treatment of curbing symptoms of influenza and preventing deadlier secondary pneumonia infections in 1918 (Jones & Saines, 2019). Confounding the crisis in 1918, the pandemic fell on the heels of World War I. Unlike today where a majority of medical practitioners have joined forces to treat and take care of sick patients, racial prejudice and political factors in 1918, barred qualified African American (AA) nurses from military practice (Jones & Saines, 2019; Keeling, 2010). While AA nurses are not excluded from caring for patients during the covid-19 pandemic, there is a disparity in access to care for vulnerable AAs and a higher rate of mortality in certain regions (Dorn, Cooney & Sabin, 2020).

Over the past 100 years, nursing has changed in response to pandemics. The emergence of Practical Nursing occurred in response to overwhelming need for nursing care (Bauers, 2018). Practical Nurses were able to complete training in 3-6 months to care for those in communities. As nursing roles were highlighted, the status of the nurse rose and attracted more people to the profession. Healthcare became population focused, and public-health services and disaster-preparedness policies and procedures grew with nursing recognized as a partner in decision making.

Today, attentive nursing care remains paramount in the care of patients with Covid 19 and nurses remain on the front-lines. While protective measures and social distancing are significant, nurses and other healthcare providers also play a role in flattening the curve of the spread of Covid-19 through their influence. Nurses are trusted, and therefore have a duty to educate their communities in prevention as well as to care for the sick.

References

Bauers, S. (2018, November 9). 5 questions: How the 1918 Spanish flu pandemic changed the nursing profession. The Philadelphia Inquirer. Retrieved from https://www.inquirer.com/philly/health/5-questions-how-the-1918-spanish-flu-pandemic-changed-the-nursing-profession-20181109.html

CDC (2020). Coronavirus Disease 2019 (COVID-19). COVID-19 Background. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html#background

Jones, M., & Saines, M. (2019). The Eighteen of 1918-1919: Black Nurses and the Great Flu Pandemic in the United States. American Journal of Public Health, 109(6), 877-884.

Keeling, A. (2010). “Alert to the necessities of the emergency”: U.S. nursing during the 1918 influenza pandemic. Public Health Reports (Washington, D.C. : 1974), 125 Suppl 3, 105-12.

Dorn, A., Cooney, R., & Sabin, M. (2020). COVID-19 exacerbating inequalities in the US. The Lancet, 395(10232), 1243-1244.

Ethical Lens Reflection

The Ethical Lens Inventory is designed to help individuals identify core values that drive ethical decisions. I found myself within the Reputation Lens of the Ethical Lens Inventory (ELI). The core ethical perspectives of the Reputation Lens (RL) surround my feelings of sensibility and equality.

Those who favor this lens use reasoning, fairness and justice for everyone to determine duties. As I reflect, I recognize that I do utilize my sense of fairness and justice and my intuition to guide how I approach ethical dilemmas. Justice for my community is very influential in my decision making. I choose to volunteer at a free clinic that serves the low income and uninsured for clinical practice. While there were several factors that influenced this decision, I believe it was the duty to do the greatest good and contribute to each member of the community, particularly in the allocation of resources and power as described in the RL, that ultimately made up my mind.

For me, working in the clinic addresses a social justice, as I do believe that everyone should have access to healthcare. The ideals of the RL oppose injustice and inequality including in healthcare. The words “injustice anywhere is a threat to justice everywhere” as spoken by Dr. Martin  Luther King Jr., is true in healthcare as it is in civil-rights. Healthcare is a right and not a privilege. As DNP leaders, we must advocate for social justice, equity, and ethical policies within all healthcare settings (DNP Essential V, 2006).

It is just as important to recognize individual blind spots associated with one’s identified lens. An ethical Blind Spots is when you are not ethically cognizant and so you may unintentionally make an ethical misstep (Baird, 2019). The ELI identified my blind spot as unrealistic role expectations. This is not a surprise to me. I recognize that I often bite off more that I can chew and I do not always accurately assess my own effectiveness. I am trying to be more aware of when I am taking on too much so that I can set more realistic goals and be more effective in smaller roles.

References

Baird, C. A. (2019). About EhticsGame. Retrieved from https://www.ethicsgame.com/exec/site/about_us.html

DNP Essentials (2006). The Essentials of doctoral education for advanced nursing practice.  American Association of Colleges of Nursing. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf

Leading Effective Teams

In Rath’s “Strengths Based Leadership”, a great team is described as one with individuals possessing diverse leadership strengths in multiple domains that can be called upon when needed, rather than having one dominant leader. Having diversity in leadership strengths as well as diversity in practice perspectives is important to a team’s success. It is important for team leaders to first identify their own leadership strengths. Analysis by the CliftonStrenghts inventory identified my unique strengths in team leadership within the Relationship Building and Executing domains. I therefore needed Influencers and Strategic Thinkers on my team to have well rounded representation of strengths from all domains and attributes of both strengths are identified in my team members.

The purpose of my DNP project is to integrate the role of a Nurse Practitioner (NP) into a pharmacist-led community based-clinic, the Center for Healthy Hearts, to increase access to comprehensive diabetes care. This is an interprofessional project, in addition to diverse leadership strengths, diversity in health professions perspectives was needed. My project team brings together a diverse, multidisciplinary team that includes members from nursing, pharmacy, and medicine, each with different strengths and perspectives.

Leadership is promoted in project planning and implementation as team members are supported to utilize their strengths as the situation arises. A culture of interprofessionalism, already present, is strengthened and supported by mutual respect and an appreciation for shared values.  Nursing played a significant role in the development of a shared vision along with medicine. The pharmacist was the influencer, in leading the practice change. In Grenny’s, “Influencer: The New Science of Leading Change”, I found that the keys to influence to create sustainable change is a learned skill. Working together to engage partners and stakeholders to support the project, team members identified measurable desired outcomes and the varied forces that shape the behaviors to be changed, to create a culture for change.

Outside of my immediate team, engagement with the VCU, School of Nursing (SON) to recruit NP faculty with their students was crucial to project success.  Clinical placements for NP students have been difficult both locally and nationwide. The clinic is an excellent placement opportunity for NP students and for faculty to practice to meet their certification requirements. An affiliation made the SON a partner and a stakeholder. Other community partners such as the East End Diabetes Collaborative, and La Casa, a Hispanic community health organization, serve as an external source for patient referrals. Emergency departments are also a significant source of referrals. These partners need to be kept abreast of clinic changes as they are implemented to ensure referrals are made appropriately and secure the sustainable success of the project.

This interprofessional project lends itself to the distributive leadership model utilizing the Institute for Healthcare Improvement (IHI) Leadership Snowflake diagram to demonstrate the interdependence of the leadership among team members.

Placing my interprofessional leadership team in the center of the Snowflake diagram, demonstrates how members can move back and forth, taking the lead and contributing to different initiatives at different times within the project. Interdependent movement between internal and external forces to create change by team members within this framework can occur while maintaining the project’s overall goals.

 

2020 VCNP Annual Conference

I had the privilege of attending the Virginia Council of Nurse Practitioners (VCNP) annual conference in Norfolk in early March just before the Covid 19 ramped up in our region. We were lucky to be able to complete the entire conference safely before travel suspensions and “stay in place” regulations were instituted. Sessions for leadership development, professional development and rejuvenation were plentiful. Many industry partners and educational institutions participated, providing great networking and learning opportunities. The VCNP’s mission was truly evident in this year’s conference.

VCNP Mission: “to facilitate the advancement and foster the professional growth of nurse practitioners, and to advocate for the improvement of health and access to care for all Virginians.”

There were several evidenced-based presentations that addressed clinical aspects of my doctoral project relating to diabetes such as Clinical Lipidology, A1C control and pharmacological management of diabetes. What I also found interesting were the organizational leadership, regulatory practice and advocacy topics for APRNS including current trends in autonomous practice licensures. Autonomous practice is particularly important to me. With autonomous practice authority, NPs can engage collaborative practice agreements with pharmacists, and together, comprehensive care can be provided, increasing access to vulnerable populations. I was proud to see several VCU faculty presenting on meaningful topics.

The conference was dynamic and uplifting, addressing several of the Essentials of Doctoral Education for Advanced Nursing Practice. The VCNP team is a group that I am interested in becoming actively involved in, on the local and state levels in the future.

Emswiller Interprofessional Symposium 2020

I attended the 8th annual Jewell and Carl F. Emswiller Interprofessional Symposium that focused on building team skills for collaborative practice on Saturday, February 29, 2020. This symposium fosters interprofessional collaboration in practice and education.

“Provides a forum for health professional students, educators, practitioners, researchers, and policy-makers who have the power to improve health and wellness for individual patients, communities, and populations through innovation in interprofessional practice.”

The Keynote speaker, Joy Doll, was outstanding, a true champion for interprofessional education (IPE) and collaborative practice. Joy Doll is a Doctoral prepared Occupational Therapist and Executive Director of the Center for Interprofessional Practice, Education and Research at Creighton University.

Complex care for the nation’s chronic diseases requires interprofessional care delivery models. This symposium provided dynamic sessions on team building strategies, some of which were interactive, and innovative collaborative practice models for hospital and community based care. A poster session allowed practitioners and students to share their work with colleagues from local and distant regions.

The symposium allowed me the opportunity to present a poster on my DNP project. I was also invited to share my practice experience with colleagues, in a small group oral presentation. The experience was stimulating and unnerving at the same time. I am thankful to have had these opportunities which would not have come about were it not for my Doctoral education.

IPEC Experience

Miscommunication among health care providers is responsible for an estimated 80% of serious medical errors (Joint Commission, 2012, p. 3). In 2003, the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM), urged that the health care professions work in interprofessional teams to improve communication, cooperation, collaboration, and integration of patient care (Monahan, Sparbel, Heinschel, Rugen & Rosenberger, 2018). Failure to implement collaborative practice has led to fragmentation of care with dissatisfaction for both patients and practitioners and poor quality of care (Khalili, Hall & Deluca, 2014). This led to an imperative re-envisioning of how health professionals are educated.

Interprofessional education (IPE) incorporates two or more professional health students learning about, from and with each other to understand roles, enhance communication and develop collaboration skills, to improve health care outcomes (Monahan et al., 2018). IPE fosters mutual respect and an appreciation for shared values that learners will take with them into their future professional roles.

The Center for Interprofessional Education and Collaborative Care at Virginia Commonwealth University (VCU) houses educational and clinical programs for interprofessional practice.

“The Center’s vision is to become a national model for transforming communities and healthcare through innovations in education, scholarship and practice focused on increasing interprofessional care.”

I had the opportunity to formally precept in one of the Center’s IPE courses: Interprofessional Virtual Geriatrics Case (IPEC 561). I precepted two groups of interprofessional students (Medicine, Nursing and Pharmacy) through a complex, virtual, geriatrics case over a 10 week period. The students answered a series of case-based quiz questions, communicating through Discussion Board which I monitored and evaluated. I also communicated with the students through email. The questions ranged from specific geriatric pharmacology to medical-legal issues. Some questions were discipline specific, but most were not which allowed all students to provide input.

It was interesting to find medicine and nursing frequently referring to the pharmacy students about the patient’s medications. This is similar to real life clinical practice. Some weeks the discussion was extensive depending on the team leader. It was fascinating to see the difference in leadership strengths from the Executing domain to the Relationship Building domain (Rath, 2008). Looking back, a discussion following each quiz would have made the experience more fulfilling, something like a debrief. Overall this was a meaningful experience for both the students and I. It was certainly a refresher on the care of the geriatric patient for me and I would enjoy the opportunity to participate in this course again in the future.

References

Center for Interprofessional Education and Collaborative Care (2019). Retrieved from https://ipe.vcu.edu/

Joint Commission (2012). Hot topics in health care: Transitions in care. Retrieved from http://www.jointcommission.org/assets/1/18/hot_topics_transitions_of_care.pdf.

Khalili, H., Hall, J., & Deluca, S. (2014). Historical analysis of professionalism in western societies: Implications for interprofessional education and collaborative practice. Journal of Interprofessional Care: Special Themed Section: Historical Perspectives, 28(2), 92-97.

Monahan, L., Sparbel, K., Heinschel, J., Rugen, K., & Rosenberger, K. (2018). Medical and pharmacy students shadowing advanced practice nurses to develop interprofessional competencies. Applied Nursing Research, 39, 103-108.

Rath, T., & Conchie, B. (2008). Strengths based leadership : Great leaders, teams, and why people follow. New York: Gallup Press.

DNP Project: A final Reflection

The DNP is much more than I initially anticipated. It does not simply bring scholarship to the bedside, rather it produces influencers to lead change to improve sustainable healthcare outcomes. My DNP project provided me the opportunity to develop the skills needed to re-envision the culture of healthcare delivery and lead change.  The purpose of my DNP project was to increase access to comprehensive care for patients with diabetes by integrating an NP/PharmD dyad care delivery model in a community-based primarily pharmacy-led free clinic for the uninsured.

Integration went well as the PharmD faculty and students in the practice were already interprofessionally focused and readily accepted the NP faculty and students. Active leadership lead to the implementation of a collaborative patient visit (Co-visit). In this co-visit the patient is interviewed by the NP and PharmD together and treatment goals were initiated and evaluated. A culture of safety was developed as the NP faculty integrated into the clinic practice through open communication and a shared interprofessional focus. The integration of NP practice led to expanded patient services which should have resulted in increased patient census but this was not initially the case. Medicaid expansion which occurred just prior to project initiation, resulted in a census reduction as many clinic patients became Medicaid insured. This was of significant concern because state funding was based on number of unique patients. We shifted our focus to dissemination of our expanded services. As clinic expanded services became known throughout the community, referrals from local emergency rooms and other free clinics slowly increased. The NP/PharmD dyad and co-visit protocol is now integrated into the clinic structure and patient census is starting to increase.

This work created significant impact in three ways. First, the NP/PharmD dyad allowed the  standards of care as set forth by the American Diabetes  Association (ADA) to be met, enhancing the comprehensive care for a vulnerable population, uninsured patients with diabetes. There was a statistically significant reduction of the clinic mean clinic HbA1c from 7.9% to 7.4% after project implementation. Second, while there was an initial decrease in patient census due to Medicaid expansion, as dissemination of the expanded services increased, new patient appointments increased by 6 per week and an increase in clinic appointments by 30%. This led to increased access to care for more Virginians. Third, the dyad demonstrated interprofessional behaviors for PharmD and NP learners to emulate, promoting improved collaboration for these future healthcare professionals.

I learned that creating change involves understanding your own leadership style and the styles of your team. Leading through relationship building was my strength and led to the creation of a team that is committed to each other and can work together to reach a common goal. We committed to a culture of safety with shared core values and this supports sustainable change. I find myself more willing to speak up and share my opinions because I have a deep appreciation of my  new skills that the DNP has afforded me and the confidence to influence change.

Clinical Site Exemplar/Case Study – Ethics

The decision to withdraw life support is an ethically challenging one. It is discussed in nursing programs and experienced in the clinical setting by new and veteran nurses.  However, when the decision to withdraw is for your mother, much of your training and education gets lost, at least it did for me.

My mother had a massive stroke in 2014. She was hospitalized and placed on mechanical ventilation. I was 10 hours away by car but started my journey. Two hours later, I received a call stating the intensivist was going to withdraw support. I know it was the correct decision, but I could not let that happen then. My brother and sister were present and agreed to it. It was the classic textbook ethical scenario. I did not want anyone else to make that decision, I was the healthcare professional in the family. However, Mom was taken off life support and passed before I arrived to say goodbye.

In the DNP Essential II, strategies for managing ethical dilemmas are discussed. I learned that your own biases, challenges and personal experiences have an impact your decision making lens. My lens has evolved since that experience.

I recently completed the Ethical Lens Inventory, designed to identify individual core values. Baird (2019), an ethics researcher, based ethical decision making on four core values named, Four Ethical Lenses (Responsibilities, Relationships, Results, and Reputation). I learned that my preferred lens is the Reputation Lens valuing sensibility and equality, which I believe my personal experience helped form.

Baird, C. A. (2019). About EhticsGame. Retrieved from https://www.ethicsgame.com/exec/site/about_us.html

Social Media as a Policy Tool

Social media refers to electronic communication platforms that allows people to  share information, ideas and network quickly, efficiently, and in real-time (Hudson, 2019; Merriam-webster, 2019; Ventola 2014). According to the Pew Research Center (2019), 72% of Americans use some type of social media. Advanced Practice Registered Nurses (APRNs) can use social media as a tool to enlighten policymakers to affect health policy change and advocacy.

Social media allows us, APRNs, a platform to share personal successes of policy enaction to improve patient outcomes or how a particular bill enaction would improve access to care and reduce healthcare costs. These stories are told through nursing and other healthcare organization sites, both local and national, as well as advocacy organizations such as AARP. The CDC for example, now tweets regularly and has hundreds of thousands of followers (Grande et al., 2014).

APRNS can inform policy decisions by sharing quality improvement projects and research related to healthcare policies on social media such as tweeting and blogging. Policy makers and much of the public do not read nor do they understand nursing research. Tweeting and blogging allows information to be communicated for understanding by our policy makers more effectively.  We must let go of the historical view of social media as an unprofessional media or media that is disrespected in the academic world (Grande et al., 2014).

Policy makers are dependent on policy tools for policy design. Social media is a tool that our policymakers are attune to and we should utilize this media to reach them.

We, APRNs have an obligation to inform and be involved in health policy design. Social media provides an avenue for APRNs to persuade our policy makers to either support or oppose a policy.

References

Grande, D., Gollust, S., Pany, M., Seymour, J., Goss, A., Kilaru, A., & Meisel, Z. (2014). Translating research for health policy: Researchers’ perceptions and use of social media. Health Affairs (Project Hope), 33(7), 1278-1285.

Merriam-Webster (2019). Social media. Retrieved from https://www.merriam-webster.com/dictionary/social%20media

Pew Research Center (2019). Social Media Fact Sheet. Retrieved from https://www.pewresearch.org/internet/fact-sheet/social-media/

Ventola, C. (2014). Social media and health care professionals: Benefits, risks, and best practices. P & T : A Peer-reviewed Journal for Formulary Management, 39(7), 491-520.

Leadership and Team Simulation: Everest

When I first learned of the Everest simulation I didn’t think there was much to it to worry about. I thought it would be simply a fun activity. As I looked more closely at the introductory slides and videos I started to feel a little intimidated. This was especially true with the Simulation Tips slides. One of the tips said “you will encounter challenges that require calculations” and I immediately knew I was in trouble. I remembered how poorly I performed when calculating air consumption during scuba diving lessons many years ago that led me to decide not to dive . Another tip stated we didn’t have to stay together  but we couldn’t receive medical supplies if separated from the Physician. This brought on fears of being separated from the group, getting lost and needing medical supplies. Did I say intimidated…I think I was closer to anxiety-stricken.

I persevered and found my role. I was the photographer. Relieved that I was not the team leader, I dug deeper into my role. I wasn’t just a any ole photographer, I was an Emmy award winning photographer and had been to the summit twice before. This time, I had my own agenda and even some secrets to keep from my fellow climbers. I wasn’t sure how I felt about holding back information from my team. It didn’t seem right, but I tried it during our first run, when I ended up being rescued anyway, I decided to spill the beans. We had some technical difficulties in any case, that first time and we decided to try again another day. We all shared some secretes that day which I feel was really good for the team to progress as one unit. A team has to know each other’s strengths and weaknesses to function well.

As a team, we actually made 3 attempts to reach the summit together. On the third attempt, we knew to look out for each other and were cognizant of each other’s needs. By the time we got on a role and were close to all of us making it to the summit, we had another technical glitch and one of our team members got rescued. We believe that there may have been a miscalculation. This was extremely disappointing for all, but I could tell that some felt it more than others.

For me the take-away was to be open and share all information, keeping secretes will only hurt the team. Working out compromises among team members will help the team get through times of crisis. This reminds me of my Strength Based Leadership Assessment where Harmony was identified as my strongest theme. Harmony, particularly seeking common ground and listening to each team member’s point of view got us as far as we did. If my team wanted to go back to Everest, I would definitely go with them. Maybe I’ll try scuba diving again as well.

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