CRNA prescribing practices: the Washington State experience.

One year after implementation of a 2005 Washington State law that granted Certified Registered Nurse Anesthetists (CRNAs) authority to prescribe schedule II through IV controlled substances, only 30% of CRNAs held prescriptive authority. The purpose of this study was to describe Washington State CRNA prescribing practices and workforce and practice characteristics. A questionnaire was mailed in 2006 to CRNAs licensed in Washington with addresses in Washington, Oregon, and Idaho. A typical respondent was 51 years old, white, and equally likely to be male or female, with 19 years of experience. More than half (52.2%) of the CRNAs were employed by hospitals, and 22% were in solo practice. Forty-one percent of the sample had prescriptive authority; however, 11% had prescriptive authority without Drug Enforcement Administration (DEA) registration. Respondents without prescriptive authority used the Nurse Practice Act provision to "select, order and administer" as the foundation for practice. Of CRNAs with prescriptive authority, 94.7% prescribed anesthetics, 60% prescribed nonsteroidal anti-inflammatory medications, and just 53.3% prescribed narcotic analgesics. Professional and policy controversies about autonomous prescribing for CRNAs are discussed. Further research is needed to determine the factors that limit CRNA prescribing and the transition to a new scope of practice.

Doctor of Nursing Practice program evaluation and beyond: capturing the profession's transition to the DNP.

The Doctor of Nursing Practice (DNP) educational preparation for advanced practice nursing and DNP role development are innovations that require intense scrutiny through formative and summative evaluation. It is imperative to move beyond standard curriculum evaluation approaches to capture the transformation of advanced nursing practice and the profession. The University of Washington School of Nursing designed a comprehensive DNP evaluation plan that focuses on both program effectiveness and the experience of transition as described by faculty and students. The evaluation plan is outlined, and lessons learned regarding data collection, student and faculty participation, and institutional review board approval are discussed. Examples of instruments are included.

The Washington State Nurse Anesthetist Workforce: a case study.

The purposes of this study were to describe the Washington State Certified Registered Nurse Anesthetist (CRNA) workforce and analyze selected dimensions of their clinical practice. We developed the 31-item CRNA Practice Questionnaire. After receiving institutional review board approval, the questionnaire was mailed in 2003 to CRNAs licensed in Washington with an address in Washington, Oregon, and Idaho. Statistical analysis included descriptive statistics for all variables and was performed by University of Washington Center for Health Workforce Studies staff. Results indicate that the typical Washington State CRNA is 50.7 years old, white, and equally likely to be a man or woman. More than half of the Washington State CRNAs are master's educated and have an average of 19 years of CRNA experience. Most work at least 40 hours a week, take call, and earn more than 100,000 dollars per year. Almost all have hospital privileges, but only 30% believe they are equal colleagues with physicians. A chi2 analysis comparing urban and rural respondents yielded few differences except that rural CRNAs reported seeking significantly less consultation and were more likely to take call. Workforce data may assist CRNAs when negotiating with employers and institutions and in resolving interprofessional conflicts and can have implications for scope of practice, policy, and legislative issues.

Screening for Posttraumatic Stress Disorder in Civilians With Mangled Hand Injury: A Practice Enhancement Approach.

Posttraumatic stress disorder (PTSD) is a symptom cluster of intrusion, avoidance, negative alteration in cognition, and alteration in arousal and reactivity following trauma. PTSD occurs frequently after a physical trauma such as a severe hand injury. It is often not recognized and consequently untreated. Previous research has shown that 10%-40% of civilian trauma survivors experience PTSD in the first 12 months after injury. There is great urgency to identify patients in the early stage of recovery from trauma, as PTSD becomes more difficult to treat in its chronic form. Mangling hand injuries are particularly disabling because they are an integral part of our social body image. We wanted to investigate the degree of PTSD screening and the follow-up-referral procedures in all mangled hand cases at the hand clinic of a large Northwestern Trauma Center. A retrospective medical record review was conducted from January to December 2012 using an existing PTSD screen with data from the electronic medical records. We found that 40% of the patients with mangled hand injury were classified as "at risk" according to our PTSD screening but only 22% of those cases were referred to rehabilitation psychiatry for further evaluation and treatment. The low rate of referral for PTSD after mangled hand injury was alarming. On the basis of this, we instituted a new screening protocol for all patients with mangled hand injury using the 4-item Primary Care-PTSD screening tool and provided an informational brochure on PTSD. The investigation led to a positive change in the practice environment and workflow of the clinic. We have not conducted any follow-up study as yet, but our goal is to screen all patients with mangled hand injury and refer all patients for psychiatric therapy who have positively answered 3 of the 4 screening questions.

Opening doors: The practice degree that changes practice.

This descriptive, qualitative research study describes the educational experience and preparation for future practice of the initial three cohorts of DNP graduates of a Northwest university. "Opening doors: The practice degree that changes practice" was the overarching theme identified. Five additional themes included students and faculty as colearners; explaining the DNP; thinking differently about practice; navigating the capstone; and building bonds/collegial connections.

TNEEL workshop. Interactive methods for teaching end-of-life care.

Nurse educators have identified lack of end-of-life content as a serious deficit in undergraduate nursing education. TNEEL, a new software program with tools for teaching end-of-life topics, was created to help educators overcome this problem. The authors implemented an experiential workshop to help educators learn how to use TNEEL's wide variety of educational tools. Trainers provided information about TNEEL and coached participants (N = 94) as they practiced using laptop computers to increase their familiarity and comfort in using the toolkit. Workshop participants completed pre- and posttest evaluations addressing their opinions and beliefs about using this computer tool. Findings support the workshop as an effective way to facilitate adoption of this innovative educational resource and support the development of a nation-wide training plan for TNEEL with experiential workshops.

Two overlooked mood disorders in women: subsyndromal depression and prenatal depression.

The purpose of this article is to assist nurses in developing a heightened sense of awareness about two often-overlooked types of mood disorders that can have a profound effect on women lives subsyndromal depression and prenatal depression. Subsyndromal depression can no longer be considered "minor" because we now understand the intense negative effect on many women's everyday lives. Screening for this disorder needs to be a routine part of care given to women in most health care environments. Simply helping women with subsyndromal depression to recognize that they may not feel sad or blue will create new opportunities for women to seek care when they are weighed down by symptoms such as sluggishness, foggy thinking, irritability, and food cravings. Nonpharmacologic interventions for subsyndromal depression dovetail with the holistic perspective that is the hallmark of nursing practice. Prenatal depression is a particularly hazardous condition because it isa "silent" form of depression that impacts women and their developing fetuses. It is often difficult to recognize against the backdrop of pregnancy and the tendency to blame emotional changes on pregnancy hormones. Practitioners must be aware of this phenomenon and take it seriously. Prenatal depression can have far-reaching effects if left untreated, impacting the pregnant woman and following that soon-to-be-born child through-out life in various detrimental ways. The pregnant woman who is laboring through the transitions of pregnancy and preparing to transition to the mother of a newborn baby should not be further burdened by the impact of depression.

The development of practice scholarship in DNP programs: a paradigm shift.

Doctoral education in nursing is undergoing a paradigm shift. The doctor of nursing practice (DNP) degree was conceived to improve practice expertise and accelerate the translation of evidence into practice. The need for doctoral preparation that focuses on both expert practice and practice inquiry acknowledges the complexity of evidence-based practice. The DNP prepares graduates to practice at the most advanced level of nursing and to evaluate current practice approaches, to appraise evidence, and to use this knowledge to create clinical strategies that improve practice and health outcomes. DNP curricula need to evolve through shared best practices grounded in financial sustainability. Because of the evolutionary nature of new programs, there is a need for continuous rapid adjustment of the DNP curriculum. Ideas presented here have evolved with student, faculty, and agency input. Many elements of DNP curricula represent a shared world view of faculty across the county. However, consensus about the DNP project has not been reached and is urgently needed to promote acceptance of the DNP-prepared advanced practice registered nurse. The DNP project allows synthesis of the American Association of Colleges of Nursing DNP Essentials through "real world" translation of evidence into practice. This article proposes that DNP projects be defined as practice improvement partnerships between academia and community agencies. This "win-win" collaboration can improve care while preparing the next generation of nurses for the demands of increasingly complex healthcare environments.

APRN expertise: the Collaborative Health Management Model.

The Collaborative Health Management Model fosters teamwork between nurse practitioners and physicians based on an egalitarian partnership. It serves to operationalize the "Future of Nursing's" call for Advanced Practice Registered Nurses to deliver high-quality chronic disease management using their full abilities: a unique professional lens, expertise in team-based care, and patient partnerships.

Faculty perspectives about the DNP: a study of advocacy, ambivalence, & antagonism.

This article describes research about faculty perspectives at the time of and 2 years after the Doctor of Nursing Practice program was launched at the University of Washington School of Nursing.

Nurse practitioner practice patterns for exercise counseling.

PURPOSE: To describe nurse practitioner (NP) practice patterns for exercise counseling for adults. DATA SOURCES: Using a cross-sectional design, participants completed a self-administered questionnaire that ascertained barriers and facilitators encountered when providing exercise counseling. Participants included 398 NPs, who averaged 11 years in practice (SD = 7.9) and worked in a variety of practice areas. CONCLUSIONS: In a given week, about half (48%) of the NPs counseled more than 50% of their patients for exercise. The majority of participants (84%) agreed that exercise counseling is as valuable an intervention as prescribed medication. More than half (59%) of the participants exercised regularly. Barriers and facilitators to exercise counseling were predominantly a patient's lack of interest and the length of the patient visit. Specific strategies were identified for older adults and individuals residing in rural areas who may require more tailored exercise counseling. Participants demonstrated strong values about exercise counseling and observed that exercise had clear benefits for their patients. NP respondents offered recommendations focused on safety and adherence that can be used to improve exercise counseling. CLINICAL IMPLICATIONS: Exercise is a crucial component of preventative health care. Studies have shown that healthcare provider recommendations can be effective in helping patients increase their exercise and activity.

The transition of nurse practitioners to changes in prescriptive authority.

PURPOSE: To understand nurse practitioners' (NPs) decisions about whether to obtain prescriptive authority for controlled substances, to describe NPs' experiences with providing or prescribing controlled substances, and to describe the relationship between perceived autonomy and prescriptive authority for controlled substances. DESIGN AND METHODS: Twelve focus groups were conducted with approximately 100 NPs who attended continuing education conferences. Discussions were audiotaped and transcribed verbatim. Grounded theory approaches were used for data collection and analysis. FINDINGS: A core category of Letting go and taking hold characterized Washington State NPs' experience of the transition to prescribing schedule II-IV medications. Three dimensions of the NPs' transition were Resisting change, Ambivalent about change, and Embracing change. CONCLUSIONS: The core category, Letting go and taking hold, indicated how transition to a new scope of practice extended beyond successful passage of legislation, the importance of examining the nature of professional transition that accompanies successful legislative change, and role development as an ongoing process throughout one's career in response to changes in scope of practice. NPs need preparation for a new scope of practice long before legislation actually passes. Revealing and examining this process can facilitate the goal of achieving fully autonomous NP practice.

Advancing practice inquiry: research foundations of the practice doctorate in nursing.

The University of Washington Doctor of Nursing Practice program entails 3 curricular dimensions: advanced practice, leadership, and practice inquiry. In this article, the practice inquiry dimension is discussed and defined as a type of clinical investigation that closely aligns with the realities and complexities of everyday practice by advanced practice nurses (APNs). The advancement of APNs' practice inquiry competencies is timely for its interfaces with the national scientific agenda's emphasis on translating science to clinical practice, health care delivery systems and policy. A framework for conceptualizing a practice inquiry curriculum and competencies is proposed. In addition, the divergent and convergent comparisons with Doctor of Philosophy (PhD) nursing programs are discussed, with emphasis placed on potential collaborative clinical research endeavors.

Enhancing women's mood and energy: a research-based program for subthreshold depression using light, exercise, and vitamins.

The prevalence and clinical significance of subthreshold forms of depression with sequelae comparable to major depression have been recently described in the literature; however, research on effective treatment is rare. A new intervention program that combines a specific regimen of light, exercise, and vitamins is effective in improving women's mood and overall sense of well-being. This program is well suited to many patients who present with somatic and psychological symptoms consistent with subthreshold depression.