19 May 2014

Dancing between two worlds

This month, I celebrate one full year of nurse practitioner practice and 22 years of professional nursing. It’s quite apropos to pause and reflect on what this year has meant personally and professionally. What do I love? What do I hate? What have I learned? If I had it to do all over again, would I? And if I could, what would I change?

To be a nurse practitioner is to dance between two worlds. In one world, you function within the societal framework of a nurse—read caregiver—and are expected to be available and attentive to the full spectrum of needs presented by the person in front of you. Those needs almost always include a level of psychological comforting and emotional reassurance, inherent in your training but rarely expected of providers in other disciplines. To do what nurses do best—assess, diagnose, plan, intervene, and evaluate—responding to those needs takes time and a degree of emotional availability.

In the world of the NP, you are a provider, expected to be broad in your base of knowledge, swift with your diagnosis, accurate with your treatment, and timely with your follow-up. Patients come to you not to be your friend or have cozy conversations, but for your knowledge of how to cure a condition. In other words, they come to you to get it right. In modern medicine, which follows an airtight business model that requires a certain number of visits per day with built-in cost and overhead controls, the nurse practitioner has minutes—if not seconds—to get the dance right.

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This past year has been a steep learning curve for me. Despite all I know of nursing, there has been the business of medicine and the field of medicine to figure out. The business of medicine involves mastering ICD-9 coding (International Statistical Classification of Diseases and Related Health Problems) and E&M coding (evaluation and management) to ensure that, in addition to diagnosing appropriately and specifically, you are billing accurately, based on what your services are worth for a particular visit. Not only are there legal ramifications for over- and underbilling, there is also the concern of financial insolvency when professional salaries and expenses exceed income. Like it or not, that’s true for all aspects of American health care, with the exception, perhaps, of those whose services fall under charity. A visit for COPD, hypertension management, or follow-up on diabetes is clearly not the same level of service that a nurse practitioner provides to a healthy person who comes in for an allergy-medicine refill or treatment of an uncomplicated sore throat.

This year has also been one of redefining things I thought I knew well, like time management. When I was an ICU and trauma nurse, there were a million tasks to be completed over the course of a 12-hour shift, and, invariably, they always got done. When I worked as a community-health nurse, there was the task of coordinating my care with that provided by other disciplines to which I referred patients, such as social workers, the local pharmacist, physical therapists, and others. As an NP, I have many more irons in the fire, including, but not limited to, test results, medication refills, consult reports from other providers, patients’ phone calls, provider- and insurance-company phone calls, forms to be filled out and signed, and all the ping-pong you can possibly imagine in an eight-, sometimes nine-hour, day. Without strong time-management skills and knowing how or when to turn the clock on and off, many NPs run the risk of burnout before they even get started.

In the past 365 days, I’ve learned what I’m really made of—and what I’m not. In the beginning, it’s easy to crawl under the safe, protective wings of a preceptor and tap into his or her knowledge and strengths. It’s easy to kick the diagnostic can down the road to a specialist to figure out. It’s very tempting to avoid the hard work of figuring out what’s wrong and why. But I’ve learned that the best gift I can ever give myself is honesty. My greatest strength is not what I know, but knowing what I don’t know. In the NP world, there is no place for faking it ‘til you make it. Knowing what I don’t know and asking questions, even at the risk of embarrassment, is a safeguard against making potentially critical mistakes.

Above all else I’ve learned is the rule about rules. Throughout my NP program, emphasis was always placed on knowing and understanding nationally recognized, evidence-based clinical guidelines, and I learned the rules about caring for patients who will present, across the lifespan, with a wide variety of diseases and conditions. What I didn’t know, as a student, is that, in actual clinical practice, I would quickly learn that guidelines are just guidelines—recommendations for practice by experts in a particular area. Sometimes, you stick to them by the letter, and sometimes you simply can’t. In population health, where time, access, and a patient’s insurance plan govern what can and can’t be prescribed or ordered, the nurse practitioner has to have a comprehensive knowledge base of the rules and know when it is safe and reasonable to break them.

In light of the Sisyphean experiences of my first year in practice, the question looms: Would I do it all again? My answer is a resounding yes.

As an advanced practice nurse, I have a much broader range of competencies upon which to position my career. In graduate school, I had the good fortune of working as a graduate teaching assistant, which gave me skills in adult education I did not have previously. With those skills in hand, I received, immediately after obtaining my master’s, an invitation to join the outstanding faculty of my alma mater, Penn State University College of Nursing. Not only is it an honor to teach, but, more specifically, I get to teach on a topic I’m deeply passionate about—family and community health—which is a pleasure.

As an advanced practice nurse working, every day, on the front lines, I am now part of larger discussions that pertain to health care policy and which shape the future of nursing and public health. I have the skills to conduct my own research on issues about which I care deeply, including vulnerable populations, health literacy, cultural competency, food security, and nutrition.

Clinically, I am able to deepen my knowledge in the subject areas I enjoy most: diabetes management and women’s health. What do I love? Simply stated, being an educator to my patients. Every day I get an opportunity to set the record straight. From myths about STDs to misconceptions about colonoscopies and mammograms, every appointment is a living classroom that promotes better health.

What would I change? Nothing at all, because to change any one thing would be to change everything. Every experience I’ve had, in nursing and in life, has been a paving stone leading to this moment.

Every day is different in the life of a nurse practitioner. These differences mold my career into new shapes I’m continually proud of. What will never change is my commitment to being an advocate for my patients, a steady voice for my community, and a teacher for the growing number of nurses coming behind me. What’s next for the coming year? Stay tuned.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. That that promote products or servicds will not be posted.