marachne

Whispera, thanks for your response -- I had a really strong reaction when angieRN used the word "dementia" no where in the description by the OP did she indicate that kind of cognitive change. Dementia is a very specific disease, where as cognitive changes are common with many terminal conditions (as well as acute onset issues like UTIs). One of the things I have become more and more aware of is the insidious issue of ongoing hypoxia in HF and COPD -- and how little it is acknowledged by professionals or explained to patients and their families.

I think things are changing -- thinking about my own institution, just off the top of my head, there is: A faculty member who was made full professor and more recently FAAN, has several RO1s and both recieved her MS and PhD from this institution where she is now. Another faculty member who recieved both MS and PhD from this institution, went and taught somewhere else for a while, returned, recieved tenure and is the director of a very well funded center.* Is it ideal? I don't think so for several of the reasons cited. Is it done? Probably a lot more than you might expect. One of the things that is recognized is work/life balance. Just like people are doing distance post-docs and there is more difficulty filling mid-career vacancies, the reality is that there is a growing pool of people who are either not as able or as willing to relocate for their career. *and yes, I realize this is not an adequate or necessarily representative sample, I am just pointing out that it can be done and one can not only be hired but successful.

Just one comment about the use of oxygen and comfort. Yes, oxygen can contribute to someone's comfort, but oxygen therapy can also, in and of itself be very uncomfortable! There are some people for whom a face mask is extremely distressing -- they feel clostrophobic, they can't talk, etc. Oxygen without humidication dries out mucous membranes. This, especially combined with poor oral care can lead to irritation and contribute to mucosistis. masks, tubing, prongs can all cause skin iriritation and breakdown oxygen with humidification can increase pulmonary secretions/congestion There are lots of components to comfort, and I think it is just as harmful to harrange a patient who is constantly taking off their oxygen (even if they are turning blue!) as it is to withhold it from someone whose O2 sats looks good but are in clear respiratory distress. More arguments for critical judgment and patient centered care (and yeah, sometimes we're treating the family as much as the patient towards the end).

I often get the "that must be hard, I could never do it," but don't necessarily see a wince or a shudder, more often appreciation and/or admiration." I usually say how I love it, how it feels like such a prividedge and humbling to be with people at a most vulnerable and intimate time. If they are a nurse or a nursing student, I'll often add something about how that's one of the wonderful things about nursing -- there are so many different things one can do and so many different kinds of people to fill those niches -- I doubt I'd ever be a good ED nurse, and my exposure to ICU made it clear to me that that was not the kind of nursing that I enjoy -- and I'm so grateful that there are others for whom it's a perfect fit.

I don't know anything about the Arkansas VAMC, but across the US the VA system is doing a really good job with palliative care. And the VA is a great system to work in.

Glad it worked for you -- really encourage checking out Outside In. They are set up to work w/students and HC professionals.

Two places that come to mind are Outside In, which provides services to homeless youth and has a huge volunteer program specifically for people w/a medical background, http://www.outsidein.org/volunteer.htm and Virginia Garcia Memorial Medical Center -- I don't know about volunteers and you probably need to have pretty good Spanish language skills. Also, Our House of Portland may be able to use you -- they work w/people with HIV/AIDs Finally, I just put into google health care volunteering in Portland and got a listing through Business Week, plus this one via Reed College: http://www.reed.edu/seeds/volunteer/volunteer_health_care.html It's amazing what one can find w/just using a search engine!

So what, exactly do you think is meant by "CNS aging?" I would also refer back to the article I cited in my earlier post -- the reliability of the FAST has studied and validated with AD, but I'm not so sure about its reliability or validity for other conditions. For example, we know that vascular dementia has a different presentation, and therefore may not progress in the same way. Lewy Body Dementia is even more of a different course, and we're still talking dementias. (the line in the abstract I'm referring to is: "This system has been studied extensively and proven to be reliable and valid for staging dementia in Alzheimer's disease (AD)" I guess the caveat/point I'm trying to make is just because a scale/instrument exists, doesn't mean it's the best thing to use. Now if funding is based on using it, then you're stuck until something changes. But my understanding is that even w/CMS no one expects agencies to use the FAST for anything other than dementia.

My thought is that someone needs to talk to you board of nursing about the behavior of the DON and NM. I would call them and ask about annonymous reporting, explaining, if necessary your concerns about your job/work relationships. Have you spoken to anyone in the hospice agency you worked with? They may be able to do an in-service on symptom management, that includes a discussion of the kinds of uncomfortable side effects that people can experience with opioids (and morphine often has the most uncomfortable effects, whether it is itching, or nausea, or just a feeling of vauge, general, discomfort), as well as a strong emphasis on patient-centered care, and how sometimes when we are medicating for (percieved) discomfort we are medicating the caregivers (paid or unpaid) as much as the patient! Good luck with this. I understand you being in a difficult situation regarding the work relationships, particularly in this economy, but you also need to be comfortable with your co-workers/superiors, and you do have an obligation both to future patients and the profession to report unethical/illegal behavior. One other thought, if going through channels does you no good -- contact a local television station and tell them you might have a story for them. Health care issues are allways good stories, and if you make it clear that you need to protect your annonymity, they will. I'm not saying this should be your first course of action, but if nothing else helps, bad publicity can be a very stong motivator to change bad practices!

Bumping this up in hopes of a reply.

I can't speak specifically for in-patient hospice, as you are still going to be w/i whatever is the culture of the institution -- after all, ICU RNs have a lot more autonomy, than the average med/surg RN, but that is going to vary from hospital to hospital, as well as the relationships between physicians/NPs and RNs. If she/he is a good one, having a certified hospice/palliative care physician will make a big difference, because the traning includes an emphasis on working cross- inter- disciplinary, and recognizing that that the folks that are at the bedside have the best picture of the current situation. Ideally, the RNs who are going to be working w/the doc would get to be part of the hiring process, but that's probably asking a bit much.

Without getting into a "AD vs. BS" fight, I would argue that there ARE advantages, in terms of learning things at another level in getting a BS. In addition, even if base pay is the same, somepositions are often only open to those with a BS. Sometimes it is stated with the caveat "or equivalent experience," but that's a very subjective term and you are at the mercy of the person doing the hiring.

Abosolutely agree w/what everyone has said, and here's a few other things to think about: besides dose, what is the action (as in time to effect/half-life) of the med? For example, po tab morphine is going to take longer and stay in the system longer than IV morphine, so dosing timing will vary. Also, where is the patient in terms of their needs? If pain/anxiety/SOB, what ever is being tx is labile, you may be using the PRN more frequently. If there is a clear escalation of symptom, or tolerance, you're going to want to do whatever you need to keep on top of it (boney mets?) If we're talking incident pain (pain with movement, like when cleaning up or changing position or dressing change), you want to plan those PRNs to coincide with need. Another thing that hopefully is being looked at is the PRN useage -- if there is a consistent pattern of high PRN useage, it's time to adjust the scheduled dose to more frequent and/or higher dose (or other agent/route!)

Hi all, I have an interview a week from Tuesday with Kaiser Hospice, and I have a few questions, and a request. First of all, as those of you who've hung around here know, I have a background in both hospice and palliative care, but it's a bit different from the norm. My hospice (and some of my palliative care) background is in the VA, in patient. So the biggest difference is that I'm not dealing with Medicare at all -- no COPS, no (traditional) certification/recertification, little dealing w/outside primary docs (and they all tend to be w/i the VA system). Our palliative care pts are often folks are sometimes people who need their symptoms controlled, but often they are admitted into the unit b/c they are getting a radiation series, often for head and neck cancer so they need supportive care, either because they are from other parts of the state, or they have no support system while they are going to get debilitiated and likely need support in terms of tube feedings and the like. Sometimes tx doesn't allow for discharge and they just seamlessly move over to hospice care. Also, while we try and limit the time that our hospice patients are with us (after having the first few be with us for over a year) we're not talking GIP where the requirements are very strict. LOS sometimes IS hours (when they get sent over from the hospital at the last minute), but it can be months. The other, large part of my palliative care expierience was in a role that is usually more an NP role where we do hospital consults for symptom management, goals clarification, care planning, etc. What is of course the same is that I've dealt with all the stuff around EOL -- symptom manaagement, dying trajectory, pyschosocial & spiritual issues, family support / conflict resolution, supportive presence, education, etc. The other thing that is different for me is that I was never hired specifically as a hospice nurse. The unit is part of the skilled/LTC facility, and really, my interview was kind of a formality anyway, because my mentor (who worked for quite a while as a CNS in the facility) and is close to the DON basically said "she's a good one, hire her." So: I've never worked community based hospice (although I have some knowledge/experience w/it) I've never interviewed for a hospice position I've never worked community palliative care (and while I know that Kaiser does have community-based palliative care, I'm not sure if the same folks do both). I'm interviewing for two positions really, one is a per diem, one is part time (benefited). I have been told that the job requires working one weekend a month, and being backup on-call once a month. I can't work full-time right now anyway, because I'm still finishing up my PhD dissertation. I have read through some of the prior posts here about interviewing for hospice positions, but I'd appreciate any words of advice and wisdom y'all can give me. The other reality is that I haven't worked outside of the VA, and have only done a few nursing interiviews of any kind before. So, anything about interviewing for a nursing position in general, for a hospice position (not full-time) specifcially, and for the Kaiser system in particular would be appreciated. And the other request? Think good thoughts for me on 7/28! miriam

As others have noted, many, if not most universities that have PhD programs will have faculty pages that list current, or most salient publications/active funded research. Looking at this information will give you info regarding what their research focus areas are. As was mentioned, it is also good to do a lit search on the research area in CINAHL and see what names come up, and then what unis they are at. One caveat about that -- if you depend on the listing on the article, they may no longer be at the institution listed on the morificecript. If you think you are iterested in a particular institution, I would contact their graduate department, tell them where your interest lies, and ask what faculty are engaged in research in that area. I just went and looked at the Capella site. I would be very cautious about getting an EdD from a generic institution like this. While there is certainly aspects of education that is cross-discipline and profession, there are also aspects of nursing education that are much more specific to the profession. I would wonder about the quality/appropriateness of the education you recieved, as well as your marketability as nursing faculty w/o some connection to nursing education. When I did a search on PhD in nursing education distance programs, I see that Capella came up, but the fact that when you go to their site you don't get any kind of listing of the specific faculty to me is not encouraging. Not saying you shouldn't explore it as an option, but I'd say look at other options that might serve you better. Ask to be able to interview faculty. Ask for names/contact info of graduates from the program who you can talk with. Really do your homework, as it's too much of an investment of time and energy to not get what you want or need.