Above and Beyond

Doctorally-Prepared Nurses Making an Impact

Anyone in the world of nursing knows it is a continuously evolving profession.  As patient needs become more complex and health care reform overhauls take shape, who in the profession will lead the way?  Many believe the answer is:  doctorally-prepared nurses.

The problem is that fewer than 1 percent of all nurses hold a doctorate degree, whether it be research-focused or practice-focused.  The good news is that institutions like Vanderbilt University School of Nursing offer the two most in-demand degrees, the Doctor of Philosophy (PhD) and the Doctor of Nursing Practice (DNP), and both programs are growing.

“Our profession desperately needs both,” said Linda Norman, DSN, RN, senior associate dean for Academics.  “We need nursing researchers equipped with their PhD education and big questions to make full investigations using higher-level statistics and theoretical models and develop guidelines.  We also need nurses with their DNPs to take that evidence-based research and apply it to their own practice on a consistent basis with methods to evaluate effectiveness.”

This fall, both VUSN doctoral programs welcomed their largest number of incoming students in the school’s history.  The 12 new PhD students are preparing for a four-year journey toward becoming nurse scientists.  The 65 new DNP students are looking to achieve the highest level possible in nursing practice to translate into their own clinical environments.

Solving Complex Problems
Quality improvement is practically Susie Leming-Lee’s middle name.  This nursing administrator and 2011 DNP graduate was interested in quality improvement before it was a commonplace term in health care.

While she was pursuing her master’s degree in the VUSN bridge program in the late 1980s, she job shadowed with an executive at the Hospital Corporation of America (HCA).  “He told me about this new thing called ‘quality improvement’ and said it would be spreading everywhere and would become part of daily life in health care,” she said.

Susie Leming-Lee, DNP. Photo by John Russell.

That was her first of many experiences in the field of quality improvement.   After earning her master’s degree, she worked at Vanderbilt then ventured out to learn about other organizations.  She moved to HCA and then came back to Vanderbilt in 1998, joining the Center for Clinical Improvement, and has worked in Perioperative Services since 2004.

“You come to a point in your career and life when you feel you need to move to the next level and enrich your knowledge,” said Leming-Lee.  “I’m a life learner.  I love the idea of exchange and knowledge, and when I heard about the DNP, it was like they designed it just for me.”

Vanderbilt’s DNP program requires incoming students to have a scholarly project area to develop during the program.  For Leming-Lee, it was applying the quality improvement system known as the Toyota Production System (TPS) Lean model, to the operating rooms in her division.  This model is designed to identify and reduce eight types of waste – things like motion, delays, inventory and transportation – that add cost but not value.  Lean is viewed as an innovative approach to improve safety, efficiency and effectiveness in the health care environment.

She saw the DNP as an opportunity to take her idea from conception through fruition, and perhaps figure out a relatively simple solution to some complex health care problems.  Specifically, she wanted to improve surgical site infections rates in neurosurgery patients by reorganizing the environment and processes in five operating rooms at Vanderbilt University Hospital.

The approach included getting buy-in from multidisciplinary teams and ongoing training regarding the Lean methodology.  Following the Toyota principles, the team simplified, cleaned and standardized everything in each operating room.  Foot traffic patterns were redesigned to develop more effective pathways that would not encroach, for instance, on the sterile fields.  The location of equipment was an important issue and re-worked many times over to ensure proper placement for frequency of use.

All of her work with the support of the surgical team members has helped significantly drop operating room infection rates and surgical complications.

“People think of innovations as big and disruptive, but sometimes it’s the small innovations that can make the difference,” she said.  “An idea grows and it begins to change the culture, as it did within the Neurosurgery team.”

Leming-Lee confesses that she prefers to be in the middle of the work rather than watching from the sidelines.  Her DNP has helped solidify her role on her team and win the ongoing support of her supervisor and colleagues.
“The DNP takes you to a different level of thinking, how you view nursing, how you view improvements,” she said.

– Kathy Rivers

Improving Health in Rural Communities
Alane O’Connor, FNP, who graduated from VUSN’s first DNP class in 2010, is using her degree to make a difference in her small community of Belgrade Lakes, Maine (population 1,000). She’s combining her interest in rural health with the knowledge obtained from her degree to help make her community a better place. On the faculty of Maine Dartmouth Family Medicine Residency, much of O’Connor’s work is devoted to treating opioid-dependent patients, including pregnant women.

Alane O’Connor, DNP. Photo by Kevin Wellenius.

Surprisingly, Maine leads the nation in the percentage of residents being treated for addiction to painkillers.

“Maine has eight times the national average,” O’Connor said, adding there may be many causes, but the amount of narcotics available on the street and the failure to implement protocols that assure patients are taking their medications appropriately are both contributing factors.

O’Connor treats non-pregnant opioid-dependent patients with buprenorphine, an alternative to the synthetic narcotic methadone.

“The work logically extended into working with pregnant patients since women of childbearing age are not immune to addiction.”

Her practice includes 12 resident physicians and 10 other faculty members including physicians, nurse practitioners and physician assistants. She sees patients individually and has also developed a group medical visit that has been used as a model by other practices. O’Connor, an instructor in Community and Family Medicine at Dartmouth Medical School, teaches medical students and residents in both a one-on-one setting with patients and in larger lecture formats.

“People often have strong opinions about patients with addictions – particularly those who are pregnant – and I think that the vast majority of these women are doing the very best they can for both themselves and their babies,” she said.

O’Connor’s scholarly inquiry in the DNP program at Vanderbilt centered on chronic disease in rural areas and showed that people who live in rural environments are more likely to be diagnosed with diabetes and coronary heart disease than those from urban areas – probably because many of the common risk factors for these conditions, including poverty, obesity and tobacco use, are more prevalent in rural communities.

Having a DNP degree has made it possible for O’Connor, the mother of two sons, 2 years and 7 months, to better balance career and family.

“My challenge right now is not a lack of opportunities to make a contribution, but a lack of time since it’s really important for me to spend time with my children,” she said. “Having the DNP offers more flexibility since I can work on research and quality improvement projects on my own timetable.”

She is currently working on identifying whether breastfeeding is related to the severity or duration of neonatal abstinence syndrome, when newborns are exposed to addictive, illegal or prescription drugs while in the mother’s womb.

“The DNP was perfect for me since I wanted to acquire the skills necessary to be a better clinician and public health advocate. You really need a multidisciplinary education and experience to have an impact on this increasingly complex health care system,” she said.

And O’Connor is definitely having an impact.  She is part of a multidisciplinary task force drafting statewide guidelines for the treatment of opioid-dependent pregnant women and their infants and  recently published a health policy paper focusing on how existing federal legislation potentially limits access to treatment for these patients.

Belgrade Lakes is only slightly larger than the rural Maine town in which O’Connor was raised. It had a population of 800. “I always knew that I wanted to settle in rural Maine and raise my family here,” she said. “I am deeply committed to the health and well-being of the people of Maine.”

– Nancy Humphrey

Fighting Childhood Obesity
Some say you can’t go home again. Sharon Karp’s decision to return to her Middle Tennessee roots to continue her education at Vanderbilt has made all the difference.

Karp grew up in Franklin, Tenn., and always thought she wanted to be a veterinarian.  In high school, as she began to talk with her family about career plans, she learned there was a long history of nurses in her family and began to consider the opportunities of this profession.

Sharon Karp, PhD. Photo by John Russell.

“I had an interest in science and helping people. As I looked into nursing, I realized it was a good fit for my interests and an excellent foundation for many opportunities.”

She attended Xavier University and earned her BSN. Early on in her nursing education she realized she wanted to be a nurse practitioner to have “more tools in my belt.”

She entered Vanderbilt’s School of Nursing pediatric nurse practitioner program, earned her master’s degree and immediately went to work with a pediatrician in private practice in Georgia.  While she enjoyed the continuity of a small practice, she began to feel frustrated by a disturbing trend she was observing.

“I saw how quickly the diet of infants and toddlers went from healthy to unhealthy.  There was a disconnect between the advice we were giving mothers and what they were doing at home, and this increased their risk for problems like obesity and diabetes,” Karp said.

The desire to find an effective way to promote healthy feeding practices during early childhood is what led her back to the Vanderbilt School of Nursing to earn her PhD and develop her skills as a nurse researcher.

“I wanted the research skills that would help me evaluate our current feeding strategies, use this knowledge to develop new interventions and then test these new strategies in order to really make a difference in the lives of children.”

As a PhD student, Karp immersed herself in the research process as a research assistant on several projects. She also served as  the project coordinator of a five-year clinical trial being conducted by her VUSN research mentor.

“I had the chance to really learn about the processes of a large research project right from the beginning.  I was also able to develop relationships with clinicians and researchers across VU and the country,” she said.

Upon completion of her PhD in Nursing Science, Karp accepted a tenure track position as an assistant professor of Nursing at VUSN.  She balances her time between developing her own program of research related to childhood obesity prevention, being a co-investigator on the clinical trial, working with graduate nursing students, and practicing as a pediatric nurse practitioner in the Division of General Pediatrics.

“The resources to help junior faculty succeed and the opportunity to collaborate with top-notch clinicians and researchers was unmatched at Vanderbilt,” she said.  “It’s the best decision I ever made.”

– Kathy Whitney

A Passion for Children
Two roads diverged in Terrah Foster’s life.  She took the one less traveled, the route to nursing research, and couldn’t be happier.

As an undergraduate, Foster’s life revolved around her biology studies and commitment as a collegiate softball player. She entered VUSN’s pediatric nurse practitioner program to pursue clinical nursing, and with a master’s degree in hand, worked for three years in primary care for a pediatrician who became a clinical mentor.

Terrah Foster, PhD. Photo by John Russell.

“He would sometimes see 50 patients a day,” she said.  “When he moved out of clinical practice into research, I didn’t understand why at first. Then I realized that his research would affect practice and he would end up touching even more lives.

“I held onto that, and wanted to pursue my PhD in Nursing as the gold standard for a research doctorate,” she added.

She completed her PhD at VUSN in three and a half years.

“It was work, but I don’t know I would really call it ‘hard’ because I enjoyed it.  When you have this driving force of a topic that you are passionate about, it makes it easier,” said Foster.

Her dissertation examined associations among continuing bonds, coping and grief in bereaved parents and siblings who had experienced the death of a child to cancer.

“I’ve always had a passion for children at the end of life.  They have joy about life that is different than other kids and it draws me to them,” she said.

Only two years into her research career, Foster’s star is rising.  She quickly secured funding from the Robert Wood Johnson Foundation Nurse Faculty Scholars Program to develop a behavioral intervention for children living with cancer.  Children are helping invent the activity by sharing their ideas for what would help other children in the future.  Children and families are very willing to contribute, and the hope is the new intervention will help enhance life and reduce children’s suffering.

“I had been developing this study for a couple of years, worked on it all throughout my doctoral program, got it funded in September 2010, and then it hit me, ‘I’m going to finally carry this out,’” she said with a smile.

While moving forward on the RWJF grant, she has been doing a couple of simultaneous studies such as a survey of children’s hospitals across the country to explore current legacy-making services offered to pediatric patients with life-threatening conditions and their families.  She admits that part of her mind is always thinking about writing the next grant and the submission process.

She also enjoys teaching in the research and theory series in VUSN’s master’s program and seeing students become interested in research or get a paper submitted for publication.

This pediatric clinician-turned-nurse researcher enjoys her career track and envisions her ultimate purpose.
“At my retirement speech, I would consider myself successful if I could look back and say I had mentored others to fill my role as a nursing scholar, teacher and leader. Then I would know I had made a difference and advanced nursing science,” she said.

– Kathy Rivers