Let's Raise the Bar!

When I first graduated from my master's program as an NNP my 'dream job' wasn't available so I took a position at a Level 1 nursery.  The hospital was interested in becoming a Level II Special Care Nursery and hired me to cover the delivery room and care for the newborns whose pediatricians didn't have privileges at the hospital.  My hours were Monday through Friday 8am to 5pm. 

I held the position for one-year, and it was one of the coolest jobs I ever had.  Some of the clinical highlights included managing the care of an infant with a sub-galeal hemorrhage, a newborn with an undiagnosed diaphragmatic hernia, a baby with a neck mass I discovered during my discharge physical examination, not to mention the numerous deliveries I attended which enabled me to hone my intubations skills 😷.


Besides the adrenaline rush of these clinical emergencies, I also got to educate and mentor an amazing team of nurses.  These guys were so thirsty for new knowledge and the autonomy that new knowledge brings to clinical practice.  Even though I was hired for Monday through Friday I made myself available for off-duty hours as a back-up when there were clinical emergencies and built an amazing rapport with the off-duty pedi team.  I was experiencing true joy in my work :-)

Unfortunately, the hospital was denied a Level II nursery designation and my position was dissolved. I was not discouraged! This was a great job and I could clearly see the benefit of having an NNP on service in a Level 1 setting.  My role benefited the patients, the families, the nurses and the organization.  I needed to replicate this experience.

This was when I created APNA (Advanced Practice Nurse Associates) and I actually got a contract with a local Level 1 nursery, I was on my way.  My dreams of being a primary care provider in an inpatient setting were all coming true. I was an entrepreneur - this was AMAZING!  Until I was summoned to the Department of Public Health to meet with the Perinatal Advisory Committee.  The committee was comprised of neonatologists and pediatricians from across the state who were concerned about my business plan.

Now, just to let you know, before I embarked on the creation of APNA I combed through the Commonwealth of Massachusetts Regulations governing advanced practice nursing in the state.  I was in the clear, there was no language that restricted this practice model, however the Perinatal Advisory Board thought differently.


Their argument was that since there was no language sanctioning the model, they would not allow it to move forward.  They were concerned that embarking on this practice model created a 'slippery slope'.  Although they felt confident that I would provide safe, quality care, what guarantees were there that another NNP would provide the same level of service excellence. 

I did mention that any other NNP would be required to meet all the necessary requirements of an advanced practice nurse in this setting, to include board certification, just like any physician.  Nope, the idea was too innovative, to 'outside the box' - bye bye APNA.

The point of this story is the 'slippery slope' comment.  Currently our educational preparation for nurses and doctors ensures that minimum performance expectations are met.  But it appears that minimum performance expectations may not cut the mustard.  What do they call the person who graduates at the top of their medical school class and the person who passes by the skin of their teeth?  They call that person: 'Doctor' (and the same thing goes for nursing).

Sure, you have to pass your board exams, but is that really all it takes to be in service to people who are at their most vulnerable and most fragile?  Is it enough to know anatomy and physiology inside out and backwards? Is that truly all a patient needs, a good body mechanic?


Have you heard of the term 'top of license' performer?  On first pass I thought this sounds pretty cool, I want to be a 'top of license' performer. But when I started really thinking about it, if there is a 'top of license' performer then there is a 'bottom of license' performer, right?

What does a 'bottom of license' performer look like?  They have a license, so they legally can practice their art, but I guess the question is, should they?  Should that 'bottom of license' performer really be interacting with vulnerable and fragile human beings - where is the bar set?

I believe very strongly it's time to RAISE THE BAR!  Raise the bar on education, clinical practice, and human caring.  Those 'top of license' qualifiers should be the minimum requirements for graduation, board certification and employment in the healthcare industry. 

Why am I so emphatic about this?  Because I know what 'bottom of license' looks like (and I believe you do too).  This level of service must not be tolerated.  And you know what, I think the 'bottom of license' professionals don't even know there is a bar, I mean after all they graduated along with their peers, they passed their boards, wasn't that the bar?

Establishing minimum performance expectations at the low end of the bar leaves a huge margin of concern for quality and patient safety. Folks don't know what they don't know.  But systems know.

For example, how much more research do we need to demonstrate that entry level nursing begins with a baccalaureate degree.  When I was in nursing school back in the day, the plan was that a BSN would be required as entry level into nursing by 1982! 

That's a long time ago and even today there is no consensus on what is required for entry level into nursing.  The system needs a shake up and that can only happen when we put our foot down and say enough is enough!  Our patients and their families deserve so much more!


I expect ALL nurses to not only know their way around the human body but to know their way around the human heart, the human psyche, and the human soul.  I want ALL nurses to feel confident and competent to advocate for their patients and the patient's family.  Challenge the status quo and champion the change that is long overdue in healthcare!

It starts with raising the bar on undergraduate education and is sustained through lifelong learning and professional development. But we need skills in order to effect change.  We need confidence and competence to become successful change-makers. 

Transformation is a journey and a movement!

I invite you to take the leap and join the movement!  Learn how you can become an effective and successful change-maker. 

Take a moment and listen to what Nancy has to share about her journey to becoming a successful change-maker!

I can't do this alone, will you help?

Take care and care well,


P.S.  To learn more about the Quantum Leap program download the program flyer HERE and schedule your Transformation Call TODAY

Using breakthrough, evidence-based strategies Caring Essentials helps you achieve clarity, build congruence, and challenges you, your colleagues, and your organization to become a center of excellence in trauma-informed nurturing care.

The babies and families are waiting!

P.P.S. Here is your quote for the week!

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P.P.P.S. When my daughter read this blog post she commented:

“I really don’t understand how doctors require so much schooling, yet nurses who interact so much more with patients only need a BS”.

I don’t understand either.