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
  • EMCRIT
  • 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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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”

Posted on by craigb.rn | Leave a comment

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.

 

Posted on by craigb.rn | Leave a comment

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.

Posted on by craigb.rn | 1 Comment

There was a recent discussion on twitter about who runs a resus better.  Both Cardiac and Trauma were brought up.  On some side discussions, it was implied that nurses handle procedures and process better than the docs do.  So I set off to practice my crappy research skills, (first thing I discovered about myself when I became a grad student) and see what I could find.

Although I could never find a comparison study, I did find stuff on nurse run rapid response teams or RRT, as well as some stuff from area’s that, in the US at least, that don’t have MD’s on hand that say non MD’s can run a code just as well as the MD’s.

I started my career in EMS and as a military medic.   I was 18 years old when I ran my first code by myself, with my only personnel resources, a crew of volunteer firefighters.  It was actually successful.   The pt coded because of a non cardiac event that I was able to correct.  I spent a large potion of my career in the back of an aircraft or in locations were MD’s just weren’t around, so I KNOW that non MD’s can do as good a job.  But can I prove it?

That’s were I’m at right now.  Searching for instances of nurse run resus.   So if anyone has any comments, suggestions, programs, whatever, I’d appreciate it.

Posted on by craigb.rn | Leave a comment

Certification FAIL!

A co worker of mine recently got a specialty certification.  It really doesn’t matter which one.  Prior to taking the certification exam, she paid good money to take a review course, and had planned her testing for the day after she took the class.

 

They class she took is a nationally recognized course, presented by a well known nurse, who is very knowledgable.  She learned a LOT of really neat stuff, and a few things I didn’t know about.

 

Let me tell you a little about this nurse.  She’s 24 and graduated from nursing school a little over a year ago.  She started on the floor and per her words “Hated It” She’s been working in the ED here for about 7 months.   We’re a 4 bed ED that see’s on an average of 18 pt’s a day.   (A far cry from the 122K in my last ED)  We see a STEMI about once every 3-4 months, almost no trauma.  Over the past 7 months as far as I can tell, she’s never opened a book. I loaned her a couple of books, but they stayed in the department and I eventually took them back so they wouldn’t disappear.  She took the course, and now has her specialty certification.  I don’t begrudge her the certification, I question how she got there, and how the system is failing.

 

She has the knowledge of the important stuff.  But here is a list of things she didn’t know.   On the DKA patient, she didn’t know to prime the insulin line before starting the insulin drip,  She didn’t have a grasp that once the patients rate (A-Fib with RVR) was controlled the BP was going to go up, so not to worry so much about the fact that the med MIGHT lower the already lower BP,  A new midlevel ordered VitK in a patient with a St Jude heart valve for an INR of 10.9 without active bleeding any were.  She gave it without questioning.  Now don’t get me wrong, she is a good nurse, just inexperienced.

 

Where is the fail?  I’m thinking it’s in the system.  The system that chooses what is important for testing in certification exams, The system that seems to encourage CRAMMING for an exam. Maybe even the whole concept of specialty certification!

 

I don’t have any answers but I think there needs to be some discussion on the subject.  Anyone have anything to add?

Posted in Certification, Education, Opinion | 2 Comments

You notice a lot of things when your sitting, watching and waiting.

My mother passed away this morning, My father, my sister and I were both at the bedside. My mother was extubated early sunday morning, it became obvious pretty quickly that she wasn't going to do well. My dad had already decided that she wouldn't be re intubated and that had been communicated to the hospital staff already.

It took 14 hours from that time, till she took her last breath. During that time I kept occsilating back and forth from being a clinician and being a son. During those hours I watched the staff of the hosptital work. All the staff, not just the nursing staff. I have nothing but praise for the staff of the hosptital.

I did notice one thing that is reinforcing my thoughts that nursing needs to change if it's going to continue to flourish in today health care environment. Recently i saw a post on Pinterest that stated, “The Essense of Nursing is Caring” As I thought about it, and watched the staff of the hopisal, I felt even more that this mentality is wrong and is keeping nursing from advancing and taking it's rightfull place in health care. You see nursing no longer has the corner market on caring.

You knowed who cared for my mother and family? The housekeeper that came into the room andadjusted the temperature when she saw is with blankets. The respiratory theripist who help my mohters hand and talked to her explaingin the endo tracheal suctioning each time she did it, even though my mother was well sedated and not responding. It was the intensivst, who held my dad, and brought in extra chairs when we needed them. Yes it was the Doc who brought in the chairs. AND it was the nursing staff. Each different, each competent and caring. Even when they were busy. The nurse that was there at the end was quite and compasionate, and busy. But even though she was busy, she never gave the impression she was rushed when she was in the room. She took the time to provide oral care for my mom, and made sure my dad didn't need anything.

Nursing no longer hs the corner on “Caring” the profession is to complex now. Back in the days were we didn't have the technology and the clinical options we have now, that is what nursing had to offer. The bed bath, the back rub, fluffing pillows. And paraphrasing and old NCLEX question, sitting and holding the hand of the patient who you discovered was scared about their surgery the next morning.

Maybe the essense of nursing is “Having the tools to provide what your patient needs” I know that's not going to make a poster anywere soon.

I look at the sheer voume of information that a nurse has to deal with. Back in the dark ages, when I was a student, I could actually memorize every medication that I gave. There were only a few of them. Well more than a few. But one pack of index cards pretty much covered it. When I look at the different meds that were hanging, the one thing that nursing school didn't teach me was how to keep up with those changes on my own.

The paradigm of nursing school and NCLEX needs to change. It's time to re-identify the basic core of nursing and test for that. No longer is rote memorization good enough. We need to change our focus to teaching life long learning and instill those habits early on. We need to teach nurses to read journals, go to classes and listen during rounds. I know from personal experience that when the docs realised I was actually paying attention and wanted to learn, that they included me in the discusion. I wasn't just the person pushing the chart rack.

It's time to move on. Nuring needs to be practicing in the century we live in, not during the Crimea War. Maybe nursing's place is as the foundation of health care with skills and knowledge that overlap all the other disciplines.

To the Clinical and Nursing staff of Cooley Dickinson Hospital, Thank You for showing how it should be done!

Posted in nursing, Opinions, Personal | Leave a comment

Nurse can make a difference

This is a long video, but worth watching.
 
This is a bad outcome that could have been prevented. Two things about this video jumped out at me—well, 3, actually. The first was the tunnel vision and bad choices that the anesthesia staff exhibited. The second was that the nursing staff recognized the problem and what was going to be needed, and, third, that they didn’t take a stand.
I’m not going to talk about the anethesia part of the this at all. It’s the nursing response that I’m interested in.
I know I’ve said it before, but my nursing carreer has been blessed. The first nurse I remember was actually a fictional charachter: it was Dixie McCall on Emergency. She looked at and talked to the docs as an equal. So that’s how I thought nurses were supposed to be and act. Then when I actually got into nursing, a couple of the first nurses I remember were older diploma nurses; one was even a nun. Although I’m ashamed to say it, I can’t remember their names. They were both strong and stood up to the docs and were not afraid to tell the docs what the patients needed.
Most recently I was working in the SICU with Drs. Provost and Lipsett. They empowered the nurses to stand up to the docs when they weren’t following the established procedures. This was reniforced when I was working in the Emergency Department at the University of Colorado. The attending told the residents that the nurses’ job was to protect the patient from them.
Instead of nursing diagnoses and nursing “theories” we need to change the focus in nursing education to a focus on what it REALLY means to be a professional and a team member and have a VOICE in the care of our patients.
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Social Media. It’s not new and it’s not going to save the world.

I hate the term social media.  It’s a term that has been coined to cover technology and concepts that have updated to cover the new hardware that makes it easier for us to get distracted.

“According to wikipedia, Social media includes web-based and mobile based technologies which are used to turn communication into interactive dialogue among organizations, communities, and individuals. Andreas Kaplan and Michael Haenlein define social media as “a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of user-generated content.”[1] Social media is ubiquitously accessible, and enabled by scalable communication techniques.”

You see I’m an old fart, and I’ve been online for eons.  I bult my first computer back in the late 70’s.  Boy it’s amazing what you could do with 2k of RAM.  As money became available I moved up in computing power.  I started sharing online in college, back in those days there weren’t any PC’s and it was a bunch of geeky college kids and professors chatting using a number of different tools.  Some open that could be read by anyone, and some private.  these tools evolved into The Well, AOL, Compuserve, yahoo, ICQ, and a bunch of email front ends that made it “easier” to access.  Nothing is new but the name, and the only thing that has changed is that now we’re so distracted by it.

So what is all the hype about social media really about?

It’s about communication.  It’s about communication in a world were time is a commodity, and there is so much static in the air around us, we can’t sort it out. 

Science fiction has a running thread about information overload.  We’re almost at that stage now.  Instead of saving the world, isn’t it possible that “Social Media” is going to bury the world.

We are using our smartphones, out laptops, our tablets, and out computers to attempt to fill a need.  It’s the need to be a part of something, not feel isolated, and to communicate.

Social Media is nothing more than a tool to accomplish those things.  A useful tool, but a tool non-the-less.  You still have to get your but out of the chair and put skin to skin.

Posted in Opinion, Politics | Tagged , , , | 1 Comment