Full Practice Authority for APRNs in the U.S. Veteran’s Administration

December 21, 2016 / Peggy L Chinn / 1 Comment

On December 14, 2016 the U.S. Department of Veteran’s Affairs issued a final ruling authorizing full practice authority of Certified Nurse Practitioners (CNP), Clinical Nurse Specialists (CNS), or Certified Nurse-Midwifes (CNM) in the VA system. This final ruling does aprn-scales_lg not include Certified Registered Nurse Anesthetists (CRNA), but is inviting commentary on “on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.” This is a huge victory – one that serves the interests of the patients who receive care through the V.A. As stated in the ruling:

This rulemaking increases veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians, and it permits VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA. (https://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses)

Various physician groups, including the American Medical Association, have registered strong opposition to this ruling, which in part is responsible for the exclusion of CRNAs (see Forbes report here). Part of the objection from some physicians is the claim that full practice authority for APRNs (i.e. APRNs can practice without physician supervision within the scope of APRN practice) is that physician-nurse collaboration is undermined. Those of us who follow the politics of this relationship recognize the absurdity of this claim, but nonetheless, this very current situation reminds us that we still have a long road ahead in establishing nursing’s sovereignty over our own practice. For more about the long-standing physician opposition to initiatives such as this, see the excellent 2012 report on the ‘Truth About Nursing”

If you are inclined to comment on the exclusion of CRNAs from this ruling, you must do so by January 13, 2017. Here are details about how to comment:

Written comments may be submitted: Through http://www.Regulations.gov; by mail or hand-delivery to Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; by fax to (202) 273-9026. Comments should indicate that they are submitted in response to “RIN 2900-AP44-Advanced Practice Registered Nurses.” Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1068, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Call (202) 461-4902 for an appointment. (This is not a toll-free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at http://www.Regulations.gov.

Making a list – of ways to support health, equality and justice for all

November 30, 2016November 30, 2016 / Peggy L Chinn / Leave a comment

A couple of days ago I received an email from Elizabeth Berrey, who is one of this project’s leaders, in response to my post of November 15, “Grieving for my country.” Her message inspired me to think quite specifically about the list of things that I will do over the coming months to participate in action to resist the dangers that are becoming more and more clear in the US and world-wide, threatening the health and well-being of world citizens everywhere. After all, his is the time of year that our children are making lists in anticipation of the December holidays, At the same time, the notion of “lists” in and of itself raises a specter of danger for many – for example, there is now a website recruiting names of “liberal professors” (see report here and here).

So let’s be clear – making a list of ways we can act and be involved can serve to inspire others, particularly those who are tempted to give up in despair given what is happening around us. But the list must also lead to action – and this is what is so inspiring about Elizabeth’s message. We may not agree about the specific ways to act, and we can certainly have a discussion about the race, class and economic implications of any action we choose to raise awareness in the quest for finding the best and most effective avenues. But unless we act, and support those who are choosing different paths than our own, we in fact support the forces of injustice.

Elizabeth has given me permission to post her message here – so here it is, lightly edited, in the hope that the actions she is taking will inspire you to go beyond a mere list – to find your own ways to get involved!

Hi Peggy,
I have now read your post & sent it to my kids, some nurses, & other non-nurses. I especially like that you said that we must be ready at a moment’s notice. I also read the replies to date. Thx so much for clarifying to the person who wrote that we should stand with Trump & give him a chance.
I have been wearing, & will continue to wear, my safety pin – a large one in the top hole of my left ear. I brought safety pins to our NMOLOC (New Mexico Old Lesbians Organizing for Change) Gathering this month, & explained what it means to the old Lesbians gathered. Our Unitarian church handed them out the 2 Sundays after the elections, with explanations for the whole congregation & especially the children.
As I think that I told you, I am working here in NM to get our state legislatures to sign onto the National Popular Vote Interstate Compact. Nurses across the country could do this, too! They could certainly activate their nursing associations to lobby their state legislators to sign onto this compact. This is the 2nd time that the electoral college has overturned the majority vote in this country since the turn of this century, for heavenssakes! As someone on the Laurence O’Donnell show said a couple of wks ago, “What we call the popular vote here in the US is called the vote in the rest of the world!”
We are organizing our NMOLOC chapter to show up in Santa Fe for the Million Women March (our state’s version). We’ll have our old Lesbian banner, of course!
We are planning training in resistance in our NMOLOC chapter for the coming yr — reminding us all of what we learned, and practiced, so many yrs ago. As you say, we must be ready!

Sociopolitical Knowing: Connecting with hearts, minds, guts, and groins

August 5, 2016August 6, 2016 / Olga F. Jarrín / 7 Comments

[Edited 8/6/16] At a time when many are celebrating the official nomination of Hillary Rodham Clinton I am also acutely aware that many are not. While there are many valid concerns that have been raised, what troubles me most is to hear the contempt and disbelief that anyone could support Trump. It concerns me because it reflects a de-humanizing and de-valuing of many in the white working class.

We expect that our students and coworkers will be sensitive to the values and personal goals our patients and their families. We expect nurses to be non-judgemental towards patients who are living in poverty, suffering from addictions, or making decisions that do not seem based in upper-middle class norms and values. Can we also expect nurses to develop an understanding of how to be respectful and understand what is important to people with different political views.

Sociopolitical Knowing is a core strength of professional nursing. Conceptualized by Jill White in 1995, sociopolitical knowing occurs on two levels:

1) the sociopolitical context of the persons (nurse and patient), and 2) the sociopolitical context of nursing as a practice profession, including both society’s understanding of nursing and nursing’s understanding of society and its politics. [emphasis added]

To start the dialogue, I am circling back to the Spiral Dynamics model that was used to organize the sociopolitical context of nursing in the published Results from the Nurse Manifest 2003 Study: Nurses’ Perspectives on Nursing.

Basics principles of leadership and motivation according to Spiral Dynamics:

identify the specific needs and capacities of individuals and groups, and
calibrate the precise developmental messages that fit each unique situation.

Sociopolitical knowing requires an understanding of how to connect with and motivate people where they are. It means developing an understanding of what messages will be most effective in “pushing someone’s buttons” or eliciting a strong emotional response. The table below highlights the most prevalent value memes in modern society – defined through worldview, core values, and value-based reasons for violence and war.

How Trump connects: From sexual innuendos and vulgar speech to stoking conspiracy theories and racist viewpoints, Trump often makes his connection with people’s minds, guts, and testicles. He has effectively tapped into pent-up frustrations and fears, justifying aggression and intolerance to make America “great again” (red and orange) and “safe again” (blue and green).

How Clinton connects: From It Takes a Village to Hard Choices, Clinton has a long history of speaking to people’s hearts, minds, and ovaries. She has effectively tapped into national pride and hope, focusing on accomplishments that make America “great right now” (red and orange) and safer through unity and tolerance (blue and green).

Both campaigns employ messaging that is strategically targeted at different audiences. The point of this blog entry was not to start a political debate — this is not the place for that. Rather, I am hoping to start a conversation about understanding how we might apply sociopolitical knowing to strengthen our ability to communicate with others. I hope that through application of sociopolitical knowing we can better connect with different communities about the work of nursing, and issues that impact the patient populations and communities we serve.

Please help build the dialogue around sociopolitical knowing, through comments here, and conversations with your coworkers, family, and friends.

References for further reading:

Beck, D. E. Human Capacities in the Integral Age: How Value Systems Shape Organizational Productivity, National Prosperity and Global Transformation

Charen, M. What Hillbilly Elegy Reveals About Trump and America: A harrowing portrait of the plight of the white working class. National Review, July 28, 2016.

Harryman, W. Is Hillary Clinton the First Integral Politician? Integral Options Cafe, November 6, 2005.

Jarrín, O. F. Results from the Nurse Manifest 2003 Study: Nurses’ Perspectives on Nursing. Advances in Nursing Science, 29(2), E74-E85.

Pew Research Center. Few Clinton, Trump Supporters Have Close Friends on the Other Side. August 3, 2016.

Schwartzbach, S. M. Drowned: Nurses Under Water. The Nurse Sonja. July 27, 2016.

Vance, J. D. Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. 2016; HarperCollins: New York, NY.

White, J. Patterns of knowing: review, critique, and update. ANS Adv Nurs Sci. 1995 Jun;17(4):73-86.

Book of the Year Award – twice!

February 15, 2016February 15, 2016 / Peggy L Chinn / Leave a comment

On September 14, 2014, I posted news of the newly published book “Philosophies and Practices of Emancipatory Nursing: Social Justice as Praxis,” noting its relevance for all NurseManifesters! The book is edited by Paula Kagan, Marlaine Smith, and Peggy Chinn, and contains 22 original chapters by some of the leading nurse scholars in the area of critical inquiry. The book has gained some attention, but in January, it was awarded two AJN “Book of the Year” awards – in the categories of History and Public Policy, and in Professional Issues. You can see the press release about all of the awards here. The link to. the article online is here. The detailed comments of the reviewers are posted on the web as supplementary digital content; you can access this information online as a subscriber, or through your library. The book is available in both paper and electronic formats – here is the Amazon link!

We are thrilled with these awards, not just because we know how important this book it, but because it is amazing for a book of this type to gain this kind of recognition in a “field” that typically focuses on very pragmatic and even “technical” topics. Both of the reviewers who selected the book in their category commented on how accessible the content of the book is, even though much of the focus is on complex philosophic ideas. If you have not yet had a chance to see the book, consider asking your library for a copy, and take some time to browse, and read! Share your comments here about the details you see as particularly important for manifesting nursing!

Courageous Conscience: Engaging in Politics with a Capital “P”

January 13, 2016January 8, 2016 / Adeline Falk-Rafael / 1 Comment

When I began thinking about a topic for this blog last fall, Canada was in the middle of a federal election and the upcoming U.S. presidential election was already making the news daily. I thought about the changes that have occurred in both our countries and globally since neoliberal ideas privileged “the market” over elected governments in the 1980s. Increasingly, policies reflect the interest of big business and the dictates of “the markets” rather than the electorate. And although both countries are arguably now plutocracies/oligarchies, both maintain a semblance of democracy through democratic structures and processes, such as elections. So what does this have to do with nurses and nursing?

The Nursing Manifesto itself answers that question. It is a call to action and one avenue for that action is engagement with political processes. I am reminded of an address Patricia Moccia gave at a conference in the late 1990s in which she used the term “citizen nurse” to remind us of the importance of bringing a nursing voice to the political table. With the percentage of eligible voters who actually vote near record lows – 54.87% in the 2012 presidential election and 61.1% in the 2011 Canadian federal election – one group could significantly shift results. In fact, in the recent 2015 Canadian federal election, the Liberal party made a concerted effort to get out the “youth vote.” The result was not only a change in governments, from Conservative to Liberal, but an increase in voter turnout to 68.3%. Imagine the possibilities if nurses mobilized to vote!

I’m not suggesting that all nurses will vote alike, any more than “the youth” in Canada did! But I am suggesting that increasing the number of nurses who vote has the potential to influence the outcome of an election. What we have in common is commitment to care for people, for promoting health, for social justice. Our work, then, as citizen nurses is to discover which party or candidate most closely aligns with our own values and become as involved as is right for each of us in supporting that party or candidate. It may involve running for office, contributing money, volunteering to work for a particular candidate, or simply but equally importantly, making an informed vote.

Voters, to my mind, are followers in the democratic process. Robert E. Kelley, who has studied followership for more than 30 years, initially characterized followers on 2 dimensions: active engagement and critical thinking. His 5 categories of followers included sheep and yes-people, neither of whom are critically engaged. As voters, sheep would wait for direction on how to vote, perhaps relying on family or community tradition (my family has always voted this way). A yes-person might be more actively involved with a candidate or party but simply accepts the “party-line” without question. Alienated followers, Kelley asserted, think critically but bring much negative energy with them. Voters in this category might spend that energy criticizing the candidates, parties, the system and either spoiling their ballot or loudly proclaiming their refusal to vote. Pragmatics, Kelley’s 4^th category, align themselves with whoever is winning. As voters, they might watch the polls and vote with whoever is leading.

Kelley’s final category is that of effective or “star” followers who are actively engaged critical thinkers with a “courageous conscience” to stand up against illegality and injustice. I think this category of followership exemplifies what being a citizen nurse is about.