sirI, MSN, APRN, NP Admin 101,881 Views
Joined Jun 24, '05.
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Does going to an online FNP program automatically translate to an easy A? Many believe that online FNP programs are less rigorous than traditional programs, especially when it comes to examination policies. Many falsely assume online students are given carte blanche during examinations, and can always look up answers, but that can be further from the truth.
Online FNP programs utilize various tactics to ensure students are held accountable during examinations:
1) Open Book Quizzes
For quick knowledge checks, programs will sometimes use timed open book quizzes. But please don't make the mistake of equating open book quizzes to being easy. In fact, open book quizzes tend to be harder than closed book quizzes. Why, you ask? Because students have access to resources, the questions are more difficult. To answer appropriately students are required to have a thorough understanding of the material. Simply memorizing and regurgitating information will not cut it, and is a sure fire way to do poorly!
2) Live Real-time Exam Proctoring by Professor
Students log in to their school's site at a specific time and must take the exam on camera as the professor monitors. Students must ensure appropriate lighting and noise level. Additionally, students can't take breaks/pause the exam or leave the room and must be alone throughout the examination. So taking the exam at the local bookstore or Starbucks is out of the question.
3) Automated Exam Proctoring Service
Students must first download a program from an automated proctor site (schools use various sites). When students are ready to take their exams there will be a link on their exam that will return students to the automated proctoring site. This site will not only confirm your identity and proctor the exam, but it also performs further analysis post examination. Things such as too much eye movement, getting a drink of water, using scrap paper, opening other screens or having notes on the screen will cause the automated proctoring service to close the exam and alert your school.
4) Proctoring Centers
Students go in-person to a designated proctoring center to take their examinations.
In this week's vlog, I go over how I got kicked out of my exam! You read right. This is not a typo! Some highlights include:
Fire on the Mountain
Last Tuesday evening at 6:15 pm, when my smartphone vibrated to announce an incoming text, I broke my personal rule against texting during meetings, and surreptitiously glanced down at the message. It was from my husband. The words, "We have been evacuated" stared up at me. I blinked twice to make sure I was seeing the message correctly.
I had tracked the wildfires' progress after waking up before dawn the day before (Monday, October 9, 2017) to witness a long line of orange flames marching atop a mountain ridge, approximately eight air-miles west of our home in Napa, CA. The sight was terrifying. I chose to cope with my fear in those initial moments by telling myself that I had seen such sights before.
Early local news reports indicated that the town of Santa Rosa was under siege. My husband, a former volunteer firefighter, and 30+-year local resident repeatedly assured me that the conditions were not right for the epic fire to become a direct threat to us in our isolated rural community. I trusted his judgment. So much so, that I felt confident about attending a meeting in Sacramento (more than an hour's drive away) on Tuesday evening. But no amount of professional expertise, experience, or local knowledge could have predicted the sudden wind change that caused the uncontained burn to jump a local road and trigger the mandatory evacuation of our neighborhood. How could I have so grossly underestimated the power of Mother Nature?
As the true meaning of my husband's text message sank in, a patchwork quilt of emotional and spiritual concerns descended over me. Fear, anger, guilt, blame, anxiety, and visions of my own mortality all manifested within me simultaneously. Physically, the sensation was a surreal combination of stomach ache, indigestion, and headache. My first thoughts were, "I can't go home tonight!" and "What if I can't ever go home again?" Then my mind jumped to the realization that I didn't have any toiletries with me. I immediately chastised myself for not doing a better job of preparing and planning, and then I felt even more deeply ashamed because I was worrying about ridiculous things, like my toothbrush, when so many other people nearby were losing far more important things, like their lives.
While I didn't have to run out of an actively burning building in the middle of the night to survive, as many others did, I found that the inability to return home carried a unique burden of stress. Our lives had been disrupted due to circumstances beyond our control, and we were being required to hang out and wait. Even if our home and property remained intact, how long would we be displaced?
Multiple variables including humidity, wind speed and direction, and air quality all contributed to the ambiguousness of the threat we were facing. We decided the best way to achieve peace of mind was to assert control wherever we could to reduce the power of the threat: We would control the things we could, and let go of the possible outcomes of the things we couldn't.
First, we made sure our basic needs were met. We stayed with friends the first night, then chose to hotel-hop after that instead of going to a community shelter. We did not take an out-of-town vacation this year, so I suggested pretending this was our vacation. While it sounded like a good idea at first, as a way of achieving some semblance of control, the fear of the unknown looming in the background lent an unsettled quality to the occasion that was difficult to deny. At least my husband and I were able to enjoy each others' company as well as the love and support of friends and family.
The stress and smoke inhalation took a physical toll, causing upset stomachs and wheezy lungs. Our solutions: eating wisely, getting back to exercising regularly, staying properly hydrated, and thinking optimistically.
Beyond basic needs, we sought the best information we could find about the status of the fires and our immediate neighborhood. We obtained useful information by drips and drops through texts and emails from John's fire department contacts. Through public and private news sources, we learned that our property was secure and that we would likely be able to return after a reasonable amount of time away. The satellite imagery we found online confirmed the other news we were able to gather.
Looking Within and Looking Ahead
Facing this type of fear of the unknown gave me an opportunity for introspection. I realized, among other things, that I need to work on my personal priorities. During his time in the fire department, my husband adapted the standard emergency prioritization protocol of people property and environment to advise homeowners facing evacuation to consider saving people, pets, prescriptions, and papers-- in that order. Knowing this recommended order of prioritization will help me rethink how I prepare for adverse circumstances in the future.
Meanwhile, in introspection mode, I began to see areas of my life where my priorities have been misallocated all along. For example, since attending nursing school, I have tended to prioritize paper over people, and I think that might be worth changing!
Our six-day mandatory evacuation put me in a holding pattern that forced me to take stock of my life in a way that I'm not sure I would have done otherwise. I realized how unimportant material things are, and how little control we actually have over any external circumstances in our lives. I can't say I won't be caught off guard in the future, but I can say that I will be much more conscious and conscientious about my priorities and preparations moving forward.
Applications to Nursing Practice
As a nurse, I can't help thinking how this experience will inform my practice. Disasters affect those who are touched by them in different ways. Remember that those who are marginally affected are still affected. That's because stress is stress in terms of the body's response.
Many have lost their homes and lives, during the catastrophic California wildfires, and thousands more fall into a middle ground or gray area of being affected. These people have significant needs. And the stresses are ongoing, as the immediate neighborhood and local region is changed forever, and strives to rebuild. No one stays the same after something like this-we all have to get our lives back.
The secret to getting our lives back is resilience. In a month, when the immediate danger has passed and the national news has moved on to the next high drama, we will still be rebuilding our lives and our communities. There is a profound opportunity for caregivers in communities rebuilding post-disaster, to help those who are non-critically affected. Encourage resilience by listening to their stories, offering support, and steering them toward any and all available resources for physical and psychological health.
As for that patchwork quilt of emotional and spiritual concerns that initially enveloped me when I learned that my neighborhood was being evacuated, the initial fear, anger, guilt, blame, anxiety and visions of mortality have transformed into strength, acceptance, and resolve. My experience is but a microcosm of all the cataclysmic events that have claimed lives and property and shaped current events over the last few months. Long-lasting consequences including Fear of the unknown, survivor guilt, and the need for resilience will continue to affect our residents and communities here in California Wine Country long after the wildfires have been contained and the imminent dangers are over.
Questions for Discussion:
Have you been touched by disaster? What are your priorities? How might building resilience help you or those you know and love who have been affected by disasters?
Sources and Resources:
Gift From Within – PTSD Resources for Survivors and Caregivers
Guilt Following Traumatic Events - Survivor Guilt - PTSD Resources - Gift From Within
Study: Fear of the Unknown Compounds Many Anxiety Disorders
Study: Fear of the Unknown Compounds Many Anxiety Disorders | Psychology Today
What is Resilience?
What is Resilience? | Psych Central
Sara, thank you so much for sharing your story. You were able to do what many in this nursing community wanted to do but couldn't.......
I just felt strongly like I needed to go do something.
I work as an RN in Las Vegas and took care of several shooting victims in the ICU. It was several days of tears and team work.
Thank you to all the hospitals and staff nationally that donated free food and gifts to the affected families and staff.
Amidst tragedy, there were some happy endings.
Many of us may wonder what it would be like to be faced with a disaster right in our community. Sara D. is an oncology nurse in a large hospital in Vegas and reported to work in the middle of the Las Vegas massacre. She generously agreed to share her experience.
Sara, what happened that night?
Sunday was my night off. I am always off on Sunday nights and it's my time to completely relax and re-charge. So I was sitting at home and watching an absolutely terrible movie (laughs). I happened to look at my phone and saw CNN breaking news that there was a huge shooting. I thought there's no way!! This is insane!
I just felt strongly like I needed to go do something.
Did you ever think beforehand about what you would do if a disaster happened and you were not at work?
I always thought, living in Vegas, that something would happen-it was just a matter of when. We're a target. I've been in the hospital when we had an active shooter or bomb threat and I know the drill. Close all the doors, make sure the patients are safe. My hospital had regular disaster drills. But never anything like this.
What motivated you to go in that night?
Literally, because they described it as a massacre. I figured it's what you do. I know that I can respond in an emergency situation.
I thought "They are going to need anyone who knows how to do anything at this point".
I posted on Facebook, "Does anyone know how nurses can help? Where can nurses go to respond?" So then I called the charge nurse on my floor and at that time she hadn't heard yet what was going on. She called the house supervisor and he said to come in right away.
I got dressed and went in immediately but I texted my Mom first. "You are going to hear about this soon, Mom. I'm going into the hospital. Don't freak out." She started crying and then said she was proud of me.
What was your assignment when you got there?
They put me down in ED hold, which is overflow. I dealt with the non-traumatic patients coming in with chest pain and syncope, and so on.
Then we had to open up a second overflow unit and move patients over there. The front ED was designated for shooting victims. We had five victims when I got there. I remember looking down the hall towards the bathroom. Near the bathroom was a man with his back to me. He was wearing a plaid shirt, all bloodied and dirty on the back. Standing next to him was a girl on crutches.
Did your hospital do a good job in an emergency?
Everything flowed super well. We were able to get everyone taken care of - that was the main point!
We were on lockdown, which meant putting our victims and victim's family in separate rooms. No one was allowed to leave until they talked to Metro. We had Metro at all of our entrances and inside the facility.
There really wasn't a lot of confusion like "Are we using this room or that room?" because we had excellent teamwork and we were ready to work in a massive disaster from previous training.
What inspired you?
I'm so proud to be from Vegas. Because people don't understand that we're not just strippers who live in hotels and gamble. I was raised here. Educated here. It's not just a transient town, a tourist town; it's my hometown - since I was three years old.
We're a community.
The outpouring of love and support was insane. For a week afterward, the staff at every hospital got meals delivered. A local tattoo artist offered Las Vegas Strong tattoos for a $50.00 donation that went directly to the Victim's Fund.
It's really strange. As awful as it was, I felt the power and goodness of my community.
How has it affected you emotionally?
It was an absolutely, incredibly horrible event, we still don't know the motive, there's still so much confusion. It was so much bigger than anything we ever imagined would happen.
And people are all thanking me for my part, but I feel like I didn't do anything special. It feels weird. What I saw and did wasn't close to what others saw and did, so I feel weird getting credit.
I was definitely like in a funk for about a week.
It was surreal. And then I still had to work my normal workweek.
There was a very weird feeling in the hospital as well. I felt empathetic to everyone's emotions. I had a friend who was at the concert who had people shot and killed right next to her. I have friends from high school who were there and I'm still hearing who was there.
Ya…., it gives you a weird sense that something really big did happen right here where you live. Driving down the strip, I see shattered windows. It feels heavy driving down strangely quiet streets at 2 am. It makes you more aware of your surroundings but for me personally, I haven't changed my routine. I actually have a concert tomorrow night at Mandalay Bay that I'm going to.
I don't want to always to be afraid. I'm not going to live in fear because then the bad
I'm not going to just stay in my house because you know what, I'm going to die eventually anyway.
Nothing good comes of me not going out and living my life.
I take care of people dying from cancer. It's what I do. As an oncology nurse you face your mortality sooner anyway, you know, so it's how I deal.
Is there anything else you'd like to share with your fellow nurses?
It felt awesome being part of something so much bigger than myself, no matter how horrendous it was. Even if you feel you didn't make a difference...you did. Being there to go get a patient a cup of ice was more fulfilling than if I had just sat there and done nothing and watched my fellow co-workers and my hospital go through all this.
My hospital is my second family. I see more of them than I do my own family. You never want to be in an internal disaster triage or an external disaster triage that affects your hospital and your work family.
All us nurses have this common bond, a natural need to take care of people. So if you're my co-worker, and you're inundated, I will gladly come behind you and pass ice or start an IV. And that's what I got to do that day.
I love that we came together.
Sara, thank you so much. You make us all proud and remind us why we chose this profession.
We've all made errors -- some of us are fortunate enough to have caught our own error (or had it caught by others) before there was harm to the patient. I've been in both positions. I have also been involved in a sentinel event -- one of a series of health care team members who overlooked a critical lab value until it was too late. I was the last one in the chain . . . closest to the outcome. Although it was many years ago, I still wake up in the middle of the night, heart pounding and horrified once again. For months after the event -- more like two years, I would wake up in anguish over my failure to catch that lab value and intervene. When the patient's status changed, I attributed it to the reasons outlined by her medical team. Had I noticed that one lab result, I would have known better. Had I noticed it in a timely fashion, I could have changed the outcome. I know that I'm not the ONLY person who should have noticed and could have changed the outcome -- my charge nurse, the intern, the resident, the fellow, the attending and the consulting teams could have and should have noticed as well, but didn't. Nevertheless, I am the one who "took the heat" for it because I was the one at the bedside. And for years I beat myself up over it.
I kept my job, but it was rough for a long time. There were investigations into the event, investigations into the investigations and investigations of my state of mind, critical thinking skills, knowledge base and fitness for my position. Those endless interviews with risk management, nursing management, the medical team, etc. were difficult to endure but hopefully necessary to the process of ensuring that a thing like that never happens again. After a few years, I didn't think of that incident every time I walked past that patient room but there were whispers in the break room that would suddenly stop when I entered. A few "well-meaning" folks went out of their way to "tell you what people are saying about you behind your back." That still happens from time to time.
Years after the event, a nurse practitioner who was one in the chain of folks who ALSO should have noticed sought me out because she was leaving the hospital and wanted to talk to me first. She told me that in M & M Rounds, the attendings, the fellows, the residents, the interns and the NPs involved in the patient's care blamed the entire event on *my* failure to notice that lab result. But one nurse practitioner stood up and said "If I was operating in the same conditions as Ruby with the same access to information and the same support as she had, I would not have done anything differently than she did." I needed to hear that. Then she told me that some of those most vociferous in blaming me for the entire chain of failures were also beating themselves up about their part in the failure -- including herself. I needed to hear that, too.
A few years after the event, researchers came to our unit to discuss their ideas for a study of what would be most helpful to secondary victims of a medical event. It was the first time I'd heard the term. I'm glad that more research is being done, more help is being offered to those who have found themselves involved in medical errors and sentinel events. I wish that there had been something available to me in the time that I most desparately needed it.
We have all heard of the concept bullying. A sometimes over-used word but one that needs to be addressed. AllNurses staff recently attended the 2017 Magnet Conference in Houston. We were fortunate to catch a presentation by Jay Parchment, PhD, RN, NE-BC, Arnold Palmer Medical Center about evidence-based practice as it relates to the workplace bullying.
Dr. Parchment presented research study results involving over 200 nursing managers. Nursing leaders are often caught in the middle and squeezed from the clinical staff on one hand and THEIR nursing leaders on the other. He presented research study results involving over 200 nursing managers. Here are the demographics of the respondents:
Many nursing organizations have addressed this in one way or another. In 2015, the American Nurses Association penned a position paper that states:
Nationwide Children's Hospital, located in Columbus, Ohio is a nationally ranked pediatric care center which spans 68 facilities caring for the sickest children in the state. While they care for children, they also care for their staff.
The Agency for Healthcare Research and Quality describes second victims of medical errors: "While the focus of the patient safety field has mostly been on improving systems of care, such systems include real people, and safety events may take an emotional toll. Frequently, clinicians review medical errors and understand what has unfolded, reacting with appropriate sadness and concern. Such errors occasionally result in an intense period of professional and personal anguish, even among the "strongest" caregivers."
So, how do we care for the second victims?
AN recently interviewed Jenna Merandi, PharmD, MS who is the Medication Safety Coordinator; Director, at Nationwide Children's Hospital. Her educational credentials include: PharmD, West Virginia University School of Pharmacy and an MS in Health-System Pharmacy Administration, The Ohio State University.
1. The nursing community has heard of second victims committing suicide. (Kim Hiatt, RN). What happens if an employee is terminated due to an error? Where can they go for support?
Generally speaking, we do not terminate an employee for one mistake as everyone is human and we can all make errors. Each situation is evaluated on its own merits to determine the appropriate course of action. For any employee who makes an error, they can reach out to their supervisor, peer supporter (one is available in every department), or Matrix services for support. Very difficult situations are also presented through our Schwartz rounds.
2. What measures are in place to ensure that what is discussed in the peer to peer discussions is not discoverable if a lawsuit ensues?
We train our peer supporters to focus on providing emotional support to individuals, not discussing the details of an event. No information is recorded or documented that relates to the event itself. The main goal of peer support is to provide one on one assurance to second victims and support them emotionally.
3. Can a second victim utilize EAP at the same time as this program?
Yes, EAP is actually a part of our program. We utilize the "Scott Three Tiered Interventional Model of Support" which consists of:
Tier 1 support – could be provided by a manager, supervisor or colleague to recognize the signs and symptoms of a second victim and provide reassurance to that individual.
Tier 2 support – consists of trained peer supporter who has been trained with the basic skills of responding to second victims and who provides one on one interventions and potential team debriefings
Tier 3 support – our professional resources which include Employee Assistance Program (EAP), Clinical Psychologist, Social Work and Pastoral Care
Second victims who need additional help beyond that of a peer supporter can utilize our EAP.
4. Has there been culture-wide education? By that I mean, when a nurse/provider/someone else makes a mistake, one of the common phrases heard is "well that could never happen to me because I'm too careful." Its the whole system that needs to change.
Yes, there has been culture-wide education both related to Zero Hero and our peer support program and as it relates to safety in our organization. The safety culture is incredible at Nationwide Children's as frontline staff feels comfortable reporting adverse events and working to try and prevent harm. We have a "just culture" at our institution which means there is shared accountability and follow up actions match the behaviors regardless of who is involved and what the outcome is.
5. Are there any additional measures in place in case of the death of a patient due to an error? Is critical incident stress debriefing used at all?
Yes, we have a Critical Incident Stress Management (CISM) team and debriefings could be conducted for larger group intervention (that beyond the role of peer supporter).
Second victims are often forgotten in the scheme of an error. Nationwide Children's Hospital is at the forefront of programs designed to decrease the trauma of being a second victim.
What is your facility doing to help the second victim? Please share.
The difference between your dreams and reality is action. One of the hardest parts of FNP school is finding the balance between schoolwork and life. On one hand you want to be present for friends and family, but on another hand you’re committed to realizing your dream of becoming a FNP! Nothing worth having is easy to come by. The sacrifices made today is what will help to secure your future. However it doesn’t have to be all or nothing. Take reasonable time to enjoy your life while also remaining cognizant that for the time being grad school must take priority! Remember FNP school is only for a few years, not forever. You've got this!
In this weeks vlog you'll see me juggle keeping up with my FNP School deadlines while also heading out of town for a weekend wedding. Some highlights include:
- Collaborative practice agreement vs independent practice agreement, why is it important?
- What is the most important part of the patient assessment?
- Weekend wedding highlights
- Deadlines are fast approaching, will I make it?
Who knew scope of practice wasn't the same in all 50 states? There can be major differences and its important you know what is required in your state.
Obtaining a history from a patient is usually very detailed and points you in the direction of the primary diagnosis, differential diagnoses and enables you to formulate a plan.
I hope you enjoy Follow Me Through Grad School (#FMTGS) Episode 202: Juggling FNP School Deadlines + Weekend Wedding. Let me know below, what tips you use to balance schoolwork and life. Please like, comment, share and subscribe!
Until Next Time,
Bizzy Bee Nursing
Fuel your passion. Fulfill you purpose.
Accidental Pill Pusher
In the early 80’s nursing education about pain management took a turn. Gone were the days of observing the patient for non-verbal signs of pain or of watching the clock to see when the next dose of Demerol and Phenergan were due. In its place came the pain scale that we use today and the altogether new approach, “A patient’s pain is what they say it is.” Unspoken was the undercurrent that pain is the enemy to be removed completely whenever possible.
At the same time, we began to see the development of long-acting narcotics and a plethora of opioid presentations that seemed to promise to wipe out all physical pain. While helping our patients get through post-operative pain or chronic pain, we saw opioids as our allies in the battle, and actively participated in educating our patients in using them for pain management.
Then came the problems. They started slow but have snowballed to mammoth proportions in the past few years. We live in a nation that takes pills for everything. The evidence is everywhere: even the evening news slot advertises for pills to help people have a bowel movement when they have narcotic induced constipation—like this is a normal thing that we should all know about!
The statistics are appalling:
Humor is an often-neglected emotion in nursing. We are all so very busy, rushing here and there and trying to get the impossible done in the shortest time possible. However, here is some comic relief for our hectic lives.
As nurses, we are exposed to both the best and worst of heath care situations. Few professions have more impact on people who are often experiencing the worst day or hour of their life. We have been entrusted with the responsibility as soon as we passed our licensing exam. We know that having a sense of humor extends our lives. Laughter really is the best medicine. There’s even been research conducted on nursing humor. For instance, a 1997 study published in the International Journal of Nursing Studies wanted to describe the meaning of nurses' use of humor in their nursing practice. Five themes emerged in which humor was found to:
Compression socks…..no longer just for grandma. Although compression socks look different from the grandma socks of the past, they still perform the same functions, only in a more stylish way.
Let’s refresh your memories as to why you should wear compression socks and give you great explanations to tell your spouse, significant other etc. why they cost more than a regular pair of socks. If the sight of your edematous feet and ankles and multiplying purple and blue varicose veins are not enough, hopefully, this explanation will help.
You already know that oxygenated blood flows to the extremities including the muscles of your overworked legs and feet. Once the oxygen is delivered, the blood carries the lactic acid and other waste products that have built up in your muscles from all the walking you do and attempts to carry it back to the heart and lungs. Ideally, this should be a smooth process, but this is an uphill battle as the blood struggles to flow against gravity through tired veins and venous valves. This is when things can start to back-up and the fatigue, pain, and swelling begins as the lactic acid and fluid continues to build up in your feet and leg muscles. It’s important to keep this process moving along effectively. This is where compression socks come to the rescue.
Compression socks are designed to provide graduated compression, higher compression at the foot and ankle and decreased compression moving up the leg. This type of constant graduated compression works to assist the unoxygenated blood flow up the leg against the force of gravity and back to the heart.
Compression socks come in different grades, depending on the degree of compression (in mmHg) at the narrowest point of the ankle. It is usually recommended to select the highest grad sock you are able to tolerate. Grades include Light Support (12-14 mmHg), Moderate Support (20-30 mmHg), and Therapy Support (30-40 mmHg).
At the recent Emergency Nurses Association Conference in St. Louis, we had the pleasure of talking to Kelly Krumplitsch, President of ATN Compression Socks. She explained the importance of measuring the ankle and calf circumference to get the proper fit.
Kelly says that the ATN socks which are all 20-30 mmHg provide the following benefits:
Just wanted to add, for anyone reading ... if you or someone you know is struggling with thoughts of suicide, please get help. That National Suicide Prevention Lifeline number is 1-800-273-8255.
I am so, so sorry for the loss of your friend and coworker. I have experienced this too, and I know it's easy to beat ourselves up and wonder what we could have done, how we missed it ... that answer is that it is NOT our fault. Ever. *hugs* This is going to be a tough loss. You know about the stages of grief, and that the way out is through. Lean on your work family and celebrate your memories of this member of your family. We really do bond, and you're right - people don't always understand it. But being in what is often a pressure cooker for 12 hours at a time with these folks, it really changes you together. People who haven't been there won't ever really get it.
Please, please, please - stop beating yourself up. And please don't keep those feelings inside - if you have an employee assistance program (EAP) at your hospital, make use of it. Use your resources, and help each other through this time.
Well...the title says it all: when do you know its time to move on? There are lots of reasons but here are some of the more common ones:
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