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.

If you want to go for a PhD, another thing to look for are programs that have recieved GAANN funding, which is often specifically aimed at people who plan to teach. I don't know where you are located, but I googled "Nursing PhD programs with GAANN funding" and found several programs that have recieved these grants. If you get into a school and get a GAANN fellowship, it can be renewable for up to 5 years. It covers tuition and a stipend -- I believe the funding is somewhat based on need. Below is the statement from AACN about GAANN funding for SONs New Funding Opportunity for PhD-Level Nursing Education AACN is pleased to announce that nursing has now been designated by the U.S. Secretary of Education as an "area of national need" under the Graduate Assistance in Areas of National Need (GAANN) program within the Higher Education Act. As a result, new funding is now available to nursing schools offering PhD programs. GAANN provides funding for fellowships to attract students into graduate programs in specific disciplines. Nursing has now been added to the list of national need areas that also includes biology, chemistry, computer and information sciences, engineering, geological sciences, mathematics, and physics. This important addition resulted from a three-year legislative and regulatory lobbying effort led by AACN. AACN is grateful to Representatives Jon Porter (R-NV), Carolyn McCarthy (D-NY), and their colleagues for their ongoing efforts in the House to make this important amendment to the GAANN program. Advocates in the Senate have also addressed this need with their legislative efforts. On August 29, the Office of Post Secondary Education within the U.S. Department of Education issued a call for applications to schools seeking GAANN funding in FY 2006. Schools of nursing are invited to apply for funding to offer fellowships to graduate students with excellent academic records who demonstrate financial need and plan to pursue a PhD program. The Secretary is "particularly interested" in applications from nursing programs that focus on the preparation of nurse scholars at the PhD level for educational leadership roles. Graduates of this type of program will become the teachers preparing students for careers in nursing and will disseminate to the public new knowledge gained from disciplined inquiry related to nursing and nursing education. Fellowship monies will cover the costs of tuition and fees as well as student expenses. The Department of Education estimates awarding to schools of nursing approximately 96 grants averaging $211,000 each.

I guess I'd love to hear more specifics about what you are interested in...that is if you want any more feedback. From the the few hints you have offered, I will tell you this: 1) If you are interested in palliative care, then yes, to be effective you need to get an advance clinical degree (NP or DNP) What I would caution you about that, however is do NOT get an NP in palliative care -- I know of at least one person who did this and when she moved to another state her NP was not recognized and she had to work as a CNS (which is fine, but still -- you want to get a more generalist NP and then you can get specialized training either through a palliative care fellowship (I've done this) or other training. From what I can see, many, many palliative care programs employ APNs. Again, you want to look at things on a state-by-state basis in terms of what APNs can do. For example, in WA and OR, NPs can work independently and can prescribe most to all drugs. In Florida, they are very, very restricted in what they can do. 2) If you are interested in something like a psych/MH NP, there are lots of good programs out there. The caveat with this degree is that many programs will hire a PMHNP basically as an RN writer, and the opportunity to provide more of a clinical role may be limited. That said, this is one area that many universities insist that you maintain a practice as well as teach/research, so if you want to stay involved in clinical practice, it is very likely to happen. I personally think that a certain amount of involvement in the clinical setting is VITAL for both teaching and research in order to maintain relevance. 3) Don't forget that policy is also an important part of what nursing professionals w/terminal degrees can have an impact on, whether it is on an institutional level like llg does or on a larger societal level. Academia has 3 legs: research, teaching and service. Usually the "service" arm is an implication that you need to serve on umpty-ump committees, but it can also be that you continue to serve the community through a clinical practice. But I'll repeat what I said below, and also what I say to new PhD students -- while it's good to have an idea of what you want to do/study, it's also important that you leave yourself open to what you experience as part of your education and the people you meet along the way. I never had any intention of getting a PhD -- maybe an AP degree, but not this route, and yet, when presented w/the opportunity, and after great consideration, I realized that it was a good fit for me. Furthermore, while my focus had been on EOL care for patients, my vistas were opened and I moved to a focus on family caregivers. My visions was the family member caring for a terminally ill person at home. My focus further moved to FCG of people w/dementia, but my diss is actually on FCG of people in assisted living, a setting I knew little to nothing about until I was a research assistant on a study in that setting and saw the gaps in our knowledge the need for change in policy and practice. Will I stay in this setting? I don't know. My work in the VA system has made me aware of the needs around PTSD at EOL and that too pulls me. It really is true, an RN is just the beginning to having a multitude of opportunities. Don't limit yourself by what you precieve to be the inherent limitiations of the profession.

What I find most striking is that, as someone who is still in their basic RN education, you seem to have found fault with everything! The large universities, with a focus on research and tenure-track positions: Research institutions are too limiting geographically, money's no good, don't like teaching. FYI not all academic institutions are high-powered ones -- I was recruited for U of Idaho Boise, and while it is not a tier one research institute, they made it clear that I would have support for my program of research, as well as be encouraged to continue my clinical practice (and/or work with in the community). Don't want to get into management Found a tele unit boring Think that research w/i a hospital setting would be all "medical model" and not focus on psychosocial issues (which is pretty absurd, since, 1) some of the research would/could be around issues r/t nursing such as burn out, learning styles, knowledge processing, or any of the multitude of holistic aspects of the nursing scope of practice) I have to ask -- just what do you think nursing is about? What are you goals and aspirations for your nursing career? Also, as I said, the VA system (which is all over the US) has a very strong nursing research presence, and not all of it is hospital based. For example, there is a center in Florida that looks at safety and falls -- I know of at least two nurse-researchers working there. With all the focus on TBI they are getting a lot of $$ and interest right now, and it is not only the physiological but also the psychosocial aspects of these conditions that are of paramount importance. I would ask again -- what do you think you want to do? What is important, where are you willing to let go of? No matter what, it sounds like the best thing would be for you to finish your undergrad program, go out and work some, get that clinical knowledge and experience under your belt -- see what the clinically relevant issues are and then see if a PhD would be a way to address those issues for you.

I thought of you, and this thread last night. I was watching (ok, until I fell asleep ) a lecture from Loma Linda University's Center for Christian Bioethics a lecture presentation by an academic who, if I remember correctly, was also an RN. The lecture was about the role of health care professionals in dealing with patients spiritual distress. She started by giving painful examples, ranging from the person who offers to pray to Jesus to save an atheist who is dying to the RN who who, when asked directly by a patient to pray with them answers very coldly to a physician who ignores a patients questions with spiritual content. (These examples are part of a prior qualitative research study the lecturer did about how HCP deal with spirituality at work) I'm afraid I didn't catch much more, it was very late when I tuned in, but you might want to check out this center and their offerings -- it seems very much up your alley! If nothing else, you should check out their website. Some of their material is available as .pdfs and videos. https://religion.llu.edu/bioethics/

Glad you had a good first year -- hard to juggle that full-time work (esp teaching, with all the outside of class time work) and school. I do know others who have gone part time and progress does come. How exciting about your plans for next year. Hope to hear more as it all unfolds. Hope "just" working over the summer gives you a little bit of relief!

I just started a thread over in the graduate student forum for people to talk about how their year went -- please come share!

Hi, I know there at least three of us, and maybe others who are lurking, or curious about the process. So, how was your year? What stood out for you? What are you looking forward to? This was a big year for me. I successfully defended my proposal in October, obtained IRB approval and started recruitment and data collection in March. (I've also learned the fine art of modification requests ). I have done 4 interviews and observations on two of my participants, and I have 3 agencies that have agreed to allow me to recruit through them (including one that that I had to go their their IRB as well -- and it was relatively painless!) What stood out for me was really getting that the dissertation process is about learning how to do research. The learning curve has been steep, but I have learned so much. I am also getting good data, but it is this parallel learning that has been most striking. I am looking forward to (hopefully) finishing my data collection by fall, and hopefully having done a good enough job of "constant comparative analysis" that my analysis will be far enough along that I can start writing during the winter....maybe to graduate next spring?

dianacs, hi! I'm sorry I had forgotten about you -- how is it going?

Joe, you talk about salaries, and it's true that (depending on where you are) starting academic salaries can be less than you get bedside but: It can range fairly far, and if one moves up into more administrative roles (dean, associate or vice deans, department heads) it can be commiserate. The rise is not necessarily as quick or as direct, but I'd say there are lots of opportunities for growth. Not to mention that there are still tenure-track positions out there, and has the potential for a fair amount of job security. You also talk about geographic limitations, and I'm wondering what you mean? Reports state that the need for instructors is even greater than for bed-side nurses. So, while you can't just pick any town, you probably have a fair range of options of where to wind up. That said, if what you want to do is be in a large, research-based institution, you are more limited because there's just fewer of them. In terms of non-academic positions, as llg pointed out, there are hospital-based positions, not only in education but in administration, and in some systems, like the VA, there are even research positions. The other place that I think is really important, and that more people are thinking about are positions of leadership and policy. There are those who say we need to have an office of the National Nurse. I'm not sure about that, but I do wish that more of the health policy advisers were nurses rather than physicians! I do know of nurses at the state level who do head up these kinds of departments, but the more our voices can be heard, I think the better for the country. Hope that gives you a few ideas, and yes, I think probably any of us who have spoken up would be happy to talk to you about our experiences. miriam

If you really want to teach, and you want your options to be more open, I would think a PhD would be a better path than a DNP. The fact that your institution's DNP program combines admin and teaching, seems rather odd, since my understanding of the DNP is that it is an advance/terminal clinical degree. While there is a desire to include a systems-level understanding and approach, the focus is still a clinical one.