My path to excellence. Step #2 Certification

As part of my ongoing path to excellence I had to look at my certifications.

During that time where I thought I knew everything I obtained both my CEN and my CCRN.  The CEN was a legitimate certification.   I actually knew that stuff.  I had been teaching it for years.

The CCRN on the other hand, not so much.  I crammed for it. I listened to prep courses and took the test.   I used a couple of reputable courses.  But I didn’t really learn it.   The only things I remember from the tapes are the protamine came from fish eggs, and that if you take to much phosphorus, it can look like you have MS.   And I learned I’ll never be able to understand a new york accent.   (yeah some of you will be able to figure out who’s tape I listened to.)

I set out to actually learn the material.   I started carrying reference material with me.  LOTS of books.  This was actually the early days of google.  I asked questions, Looked stuff up and in 2002 I took the exam again.   And FAIL miserably!  I went back and discovered I was just skimming the material because I thought I already knew it.  I started outlining, and making cheat sheets.  I focused my studying on patients I had.  Real patients, not simulated ones.   I studies the night before and was able to ask questions during rounds.

During the next year, something changed.  I had developed the habit of studying and working at it.  My standing among my peers and the Docs had risen greatly, to the point were I was asked to give presentation at Tuesday resident grand rounds.  It wasn’t until I failed though that i was able to learn my failings and REALLY try to change.  in 2005 I took the CCRN exam again and blew through the exam in 20 min, not quite acing it.  I still don’t know an IABP wave form from a hole in the wall.

Another thing happened.  My co workers watched what I was doing, and started along their own path to excellence.  We would meet after work and have study session at Jimmies over breakfast.   (Threw that in for my fellow Baltimoreans).

Without intending to, Others were motivated.

My patient care got better.  After 20+ years I actually felt that I could call myself a nurse.

Take certifications seriously!  Don’t just cram for it.  Take a year, set up a plan and work toward it. Go ahead and take the prep course, but do it as a refresher before you take the test.

Where are  you on your path to excellence?

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My path to mastery. Step 1.

So I’ve shown you what I read every month, and given you an idea on what I think a nurses path to mastery should include.

The one thing I didn’t mention is what really got me started on my path.

There was no sudden epiphany, I can’t really give you a time or date when it happened.   But one day I realized I wasn’t as good as I thought I was and I didn’t know as much as I thought I did.

I spent the first 20 years of my career believing that I know more than everyone else.  Yeah I know, what an ego.  I worked military, civilian, flight, I was teaching, even spent some time covering a President.  It started around 2001.  A cocky, “no longer young” nurse started working in one of the US premier teaching hospitals.  Over an 18 month period, I discovered that just about everyone there knew more than I did and was better than I was.  I crammed and got both my CCRN and my CEN.  There PROOF that I knew it all!

Nope, didn’t work.  Every time I turned around, there was something new, or a skill that I didn’t have.  Crap.  All that cramming didn’t work.  Besides,  since I crammed.  I didn’t retain all that stuff.   Still have no clue what a Balloon Pump waveform means.

Then I started to realize what was different about those nurses, who knew more than I did.   They knew in their heart and not just in their brain, that they didn’t know it all.  They approached things thoughtfully with the intent to be a better nurse, not just to prove they were better than everyone else.  That had been my biggest mistake when I took that those first steps to mastery.   I was doing it for the wrong reason.

I won’t argue that my ego still isn’t a strong motivator.  But it’s no longer a sole motivator.

So at that moment I took my first real step along my road to mastery.

Have you taken your first step?

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What does your path to mastery look like?

What does your path to Excellence/Mastery look like?

(Concept shamelessly stolen from Scott Weingart MD and his Path to Insanity podcast)

dreyfusWhere are you on this scale?

I have a goal.  I want to be a true expert in my field.  At one point I considered myself an expert, and had little tolerance for a lot of my peers.  But when I participated in some honest refection, I had to be honest with myself.   I was no more than a competent nurse.  When I realized that, I set a path towards excellence and expertise.  What I didn’t know until later on was that I was developing my own Personal Learning Network or PLN.

It started with a calendar.   I put my schedule in it and then I scheduled 4 hours a week to read journals.   I have the computer set up to feed me blogs.  I follow way to many people on twitter

I read a lot of journals.  Now I don’t read each and everyone one of them from cover to cover.   With the advent of online notification, I pick and choose articles from some of the journals, and others I read cover to cover.  Now that I can have a lot of them parked on my iPad, I can use downtime to read.

Academic Journals

  • Academic Emergency Medicine
  • Advanced Emergency Nursing
  • Air Medical Journal
  • American Journal of Cardiology
  • American Journal of Critical Care
  • American Journal of Emergency Medicine
  • American Journal of Nursing
  • Annals of Emergency Medicine
  • Chest
  • Circulation
  • Clinical Pediatric Emergency Medicine
  • Critical Care Medicine
  • Critical Care Nurse
  • Disaster and Prehospital Medicine
  • Emergency Medicine Journal
  • Emergency Medicine Clinics
  • Evidence-based Health Care and Public Health
  • International Emergency Nursing
  • JAMA
  • Journal of Critical Care
  • Journal of Emergency Medicine
  • Journal of Emergency Nursing
  • Journal of Infusion Nursing
  • Journal of Nursing Edcucation
  • Journal of Nursing Management
  • Journal of Trauma
  • Journal of Trauma Nursing
  • Medical Education
  • Nursing Made Incredibly Easy
  • Prehospital Emergency Medicine
  • Resuscitation
  • Shock
  • Wilderness and Environmental Medicine
  • Random articles recommended by the people on twitter I follow

Blogs/RSS Feeds/Podcasts

  • Life in the Fast Lane
  • Pharm
  • Academic Life in Emergency Medciine

YouTube Channels

  • IMedicalSchool
  • Patwari Academy
  • ECGTeacher
  • Khanacademymedicine
  • MEDCRAMvideos
  • TheSMACCchannel

As a nurse, again I was fortunate to work with a group of MD that pimped the nurses as much as they pimped the interns and residents.  I learned from the beginning of my career to ask questions.  It took awhile to become confident enough to ask questions about treatment decisions though.  As my knowledge base increased I found I was able to speak the language better and point out things that I had found in my assessment that the residents many not have.  As my knowledge base grew I was better able to present things in a way that got me listened to.

I attend conferences.   I try to attend at least one conference a year.  I alternate Emergency, Critical Care and a “Doc” conference.  I budget for the conference as a necessary professional expense.  Sometimes that means I have to work overtime shifts to pay for it.

Networking.    Over the years I’ve developed a network of people I trust and can depend on to respond when I need more information.   With the advent of social media, that network has expanded a bit.  Even though it’s been 10 years since I left Hopkins.  Peter Pronovost, MD still answers my emails.  🙂

Using twitter as part of my networking, I identify topics that I”m interested in, and taking guidance from there, research and apply to nursing.

OK.  So I’ve bragged enough, were are YOU on your path to being an expert?   Do you have a roadmap to get there?

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Nursing Theory or Nursing Philosophy?

Grad school makes you look into things that you normally wouldn’t look into.   The key is to look into it with an open mind.  When I started  in this business nursing theory wasn’t as big a deal as it is today.  To be honest, I’ve always thought that nursing “theory” was nothing more than an academic exercise by Doctoral candidates in nursing.  Mental masturbation as it were.

As I was forced to read nursing theories I had an epiphany.  It’s not that nursing theories are inherently bad, the problem is they aren’t theories, they are philosophies.    The only theorist that I had any respect for was Patricia Benner.  Her theory on Novice to Expert seemed to make sense.   As an educator I saw it played out on daily basis.

However she lost a little credibility when I started researching clinical education and found that there really wasn’t anything new in her theory.  About 4 years prior to her publishing hers the Dreyfus Model of skill acquisition was published.  As I looked farther into it.  You can actually find references from the middle ages as part of the old guild system and the apprentice, journeyman system.

As I looked farther my own thoughts on nursing theory have started to develop.   They aren’t really theories.   They cant stand up the rigorous scrutiny that true scientific theories have to.  The level of peer review is minuscule.   Now at this point I”m not going to say they are totally useless.   I’m starting to see them more as a philosophy and not a theory.  As a philosophy, grey area’s are more acceptable.  The one concept in he Dreyfus/Benner model is the concept of intuition.  I have a hard time accepting the term intuition as something not based on scientific fact.

Well it’s off to study and read some more.  The kicker to this is. I’m having to come up with my own theory.   I’m going to refuse to use the word theory and use the term philosophy.

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Who is this Katie Duke person? @thekatieduke

First of all I don’t have a television, so I’ve never watched the program in question.   Recently Katie Duke has been trending on twitter.  Everyone wants to be Katie Duke, and or is in awe of her.

For those of you who don’t know who she is, Katie Duke is an RN working in NY in the show NY ER.  I had to be sneaky to get a copy to watch an episode.  She’s an attractive, strong, knowledgeable nurse in one of the busiest ED in the country.   If you follow her on twitter, there are nursing students who want to be her and talk about channeling their inner “Katie Duke”

Now I admit that I’ve only watched parts of a couple of episodes.  But the one thing I’ve notices.  I know many “Katie Dukes”

Look around, or look in a mirror.   You might be surprised.  Katie Duke may be working next to you, or you might even be “Katie Duke”

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Establishing a culture were certification means something.

In an earlier post I questioned the validity of specialty certification.   With people cramming for certification, I think they have lost a little of what they used to mean.

That doesn’t mean however that certifications are a waste of time or money.  So how can we make sure that we are using certification for what it was meant to be.

1.  We need to establish a culture of certification in each facility.  Using certification as a means to show a certain level of knowledge.

2.  Establish a culture of learning.  This is probably the most important step of all.   All need to be involved,   Attendings, Residents, Physician Assistants, Nurse Practitioners, Managers, etc.   EVERYONE needs to be involved and supporting it.  Although I had always been the type of nurse or medic that wanted to know more, it wasn’t until I got to Johns Hopkins that the whole culture of learning thing really came to it’s current level of importance in my thoughts on things.   The attendings were as happy to teach the nurses as they were the residents, AND the nursing staff got pimped as much as the residents did.    For somethings, if the resident didn’t know it, the nurses EXPECTED to know that answer.   It became a challenge and as nurses we where looking things up on our own so we would know it when asked.    The new nurses were actually comming in early so they would have time to look stuff up before rounds.

3.Make certification like a final exam.   The goal is learning, the certification exam is the icing on the cake.

4.  Set realistic time lines and goals.    You really can’t go from zero to CCRN in a month.

5.  Support REVIEW courses.    After people have attended, and studied and learned, go ahead and send to a review course.    They are a good review and especially helpful in the areas that your patient population may not have given you a lot of exposure one.    I had never taken care of a patient on a balloon pump when I took my CCRN exam, the review course gave me some pointers that I might not have remembered if I hadn’t taken the review course.

6.  Support certification.   The whole hospital needs to support certification, and recognize those who have put in the work.   And then tell the community about it.


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Preparing for NTI 2014. @AACNme #NTI2014

I started preparing for AACN National Teaching Institute or NTI 2014 in Denver, in May of this year, while NTI 2013 was going on in Boston.  This is my plan. (now I’ve also applied to be faculty, so who know’s I may not need to spend as much money as I”m budgeting)

  1. I set up a separate savings account and had money from every overtime shift I work place into it.   This account is not attached to my ATM card, it’s not part of my overdraft protection, it’s labeled Professional Education.
  2. Set up a budget.  I start out by ball-parking how much money I’ll need.  Is start by getting on a travel site like Travelocity and figuring out a best guess how much it will cost me, and add a fudge factor.  I look at hotel cost, flight cost and food cost, as well as if there is anything i would like to do while i’m there.
  3. I put in for the time off.  I do this early and I check it every month to make sure the request doesn’t get lost.
  4. I check hotel cost every month.  I tend to use Priceline.   In New Orleans I paid $95/night for the same room that others pain almost $200.  You have to check blogs and forums to see what people are paying for rooms in the same area.   Sometimes, you really don’t have a choice, but when your budgeted for a higher rate and you manage to get it for a lower one,  That’s a win.  I really start to ramp up this search in Oct when the details of NTI are posted.
  5. I do the same thing for plain fair.   I use fairwatch on each of the travel sites and keep an eye on it.
  6. Start selling NTI to co workers and the bosses.  Who knows if you sell it well enough, you boss might actually pay for some of NTI.
  7. Last but not least, I make sure my membership in AACN is always current.

Sometimes it’s not easy.  But I’ve found that one overtime shift a month,and saving that money, pretty much covers my expenses if I start planning early enough.

If you haven’t gone to NTI, you need to!  It’s educational, uplifting and recharging.

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