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.

New NP grad? Some career realities and a little advice

If you live in the northern part of the northern hemisphere, you’re probably ready to pack away anything that comes close to reminding you of winter. Record snowfalls, plummeting temperatures, iced roadways, and closed schools have most of us pining for spring. And if you’re a student nurse practitioner who is coming close to that magical moment of graduation, the urge to pack things up is far greater. It has nothing to do with wanting to hear birds sing or see flowers bloom. It comes down to one simple thing—wanting your life back.

You probably have a countdown app on your smartphone, and every passing day brings you closer to that moment when you can toss those 10-pound textbooks out the window as you pull out of the campus parking lot. There isn’t a night you don’t dream of finally being rid of the preceptor who you’re sure sits up every night thinking of who is the worst possible patient from her caseload she can assign you the next day. You’re reasonably certain you will never, ever want to see your professors again, and, if you do happen to run into them, you’re prepared to put on your best foreign accent and insist they’ve got the wrong person. In a word, you are done, and that official day of completion, with all its pomp and circumstance, can’t come soon enough.

While I agree that navigating a graduate school’s nurse practitioner program is akin to walking a path of burning sand, I often warn those about to exit that path about some hard-to-believe realities they should expect the first year, and I mix that reality check with a little advice.

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1. You will miss being a student.

As a student, you always have new and fresh information coming your way in the form of articles, practice guidelines, and late-breaking research findings that your professor has added to your never-ending syllabus. Until now, you may have carried out doctors’ orders to the letter, reasonably confident of the how but not always clear on the why. Your time as a student, I hope, has changed that. With each article and clinical experience, you’ve gained the tools necessary to determine not only what a symptom means but the pathophysiology behind it, how to diagnose it, and how to treat it. Now, you know which antibiotic to choose (or not choose) for a certain condition, and why. Admittedly, it’s pretty interesting stuff!

Career reality: Learning something new every day will be your responsibility. In the real world, no one is going to show up with a syllabus and a list of learning objectives. You will know what you know, but what you don’t know will show up one patient at a time. Part of your role as a clinician is to stay abreast of new developments—to stay current—so you can provide your patients with the best, evidence-based care possible.

Advice: Always be a student. While you may not have the time for daily scouring of journals to learn about the latest and greatest research, plan to keep up on what’s most important in your clinical specialty. Your first year out, keep a daily journal of clinical issues that arise that may stump you or symptoms that have you scratching your head trying to figure out a diagnosis. Make it your homework to read up on those issues, and make notes for yourself so you’re better prepared the next time they come around. Make a list of topics you least understood in school and, little by little, find a CME, workshop, or conference that address those topics or specialties so you’re more adept when they present.

2. You will miss having a preceptor.

As a student, you lived with the expectation that you could—and would—run out of the exam room in a state of sheer panic, not knowing what to do for that patient in front of you who has a rash you’ve never seen before. After all, “derm” is your least favorite specialty, and you were barely awake during the visiting lecturer’s presentation on common skin disorders. As a student, it was okay not to know what to do. Just when you were sure it was leprosy, there, with years of experience, was your preceptor, ready to save you and remind you of a commonly occurring fungal rash that could be cured with a $5 cream.

Career reality: Depending on where you work for your first job, there may or may not be a person willing to follow you down the hall and confirm your suspicions by taking a look at a rash or peeking inside an ear. To complicate matters even more, figuring out which medications to prescribe for which insurance plans will be your job and yours alone, regardless of what clinical guidelines say are “preferred treatments.” In many environments, your degree and certification translate into the assumption that you know what you’re doing and are safe to be on your own.

Advice: When interviewing for your first job, your first and foremost priority should be to inquire about the availability of precepted orientation. Find out how long the company offers orientation and who will be your resource person to go to for clinical questions that arise during your first few months. During your orientation, be honest about your strengths and weaknesses, and use that time wisely to acquire the resources and knowledge needed to make your transition as smooth as possible. Don’t buy into the media hype that doctors don’t want NPs in their territory. There are many environments where nurse practitioners are highly valued and appreciated. Take time to find a practice where this will be true for you.

3. You will miss your classmates.

As a student—part of a cohort—you have come to know one another in ways that you likely take for granted. You have seen each other during moments of extreme stress and gotten by with little or no sleep while consuming dangerous amounts of caffeine, hardly a set of images any of you would want showing up on Facebook later on in life. For some of you, there have been painful divorces and difficult breakups; children have eaten more take-out meals than you care to admit; and friends and family have long given up on you as missing without a trace. You and members of your cohort have studied together, cried together, and supported one another with words of comfort during a very difficult time. It’s an experience that only another person who has traveled the same path can understand.

Career reality: Your new colleagues can relate to some of what you have endured, but will never really understand what you’ve gone through. It is impossible for them to know and, honestly, it would be unprofessional of you to rattle off all your past miseries to people you’ve just met. You’re no longer a student and, early on, it’s important that you establish a confident and professional presence in your new environment.

Advice: Do your best to maintain friendships developed in your cohort. Your first year out of your program will offer a full range of challenges with people you don’t yet know. Having a circle of support is critical to strengthening both your knowledge base and your confidence level. As new graduates, you can network with one another on a pretty even playing field, sharing resources about potential jobs, starting salaries, educational conferences, and a vast array of other opportunities that come along.

4. You will miss having a schedule.

As a student, you always had somewhere you had to be and something you had to do by a certain time. There were exams to prepare for, papers to turn in, and clinical rotations that required you to be on deck and ready to go by a certain time every day—no excuses. Even in the midst of what seemed chaotic, there was order. You set goals for yourself and, to achieve the prized goals of graduation and a degree, you learned to prioritize your time and manage your resources.

Career reality: Prioritizing time and resources will be just as critical in your new career as it was in school, except now there won’t be anyone standing by—red pen in hand—holding you accountable and checking off what you did or didn’t accomplish. Years will pass quickly, and the vision you once held for your new career can quickly turn to dust and disappointment.

Advice: Ask yourself where you want to be in one year, three years, five and 10. Set goals for yourself, and work from Day One to achieve them. Take time to find the right “first job”—one that supports your goals and leaves sufficient time to work toward them. If your goal is to have your doctorate, start your own business, or even retire, it’s important that you have a map and a timeline to help you get there. Through frequent check-ins, that circle of friendships you’re continuing to nurture can provide support by holding you accountable.

5. You will miss a professor or two.

As a student, you were certain all of your professors were out for blood—specifically, yours. In the beginning, you took everything that was taught as unparalleled gospel, questioning little—if anything—and hoping one day to be so brilliant. What you’ve learned, over time, is not what to think but how to think. It was never the intention of your professors—really—to force-feed information to you but, rather, to give you the tools to decipher facts and apply knowledge to practice. You now realize the truth in the maxim that what doesn’t kill you makes you stronger.

Career reality: You will find that much of what your professors taught you was true but not absolute. Health care is both a science and an art. No two people practice health care the same way, and you will have to develop a style that works for you. There are thousands of guidelines and algorithms for clinical practice, but how to implement the guidelines in a way that is safe, efficient, and cost-effective for each patient is a skill that comes with time. Your professors have developed their own style of practice, based on experience, and now it is time for you to take the knowledge you’ve gained to develop your own.

Advice: See your professors as colleagues. Stay in touch with the ones you feel most strongly supported your goals as a student and helped you overcome challenges. Ask for suggestions on professional-practice issues, such as getting through the first interview, negotiating collaborative practice agreements, and deciding which professional organizations to join. For those in clinical practice, make a list, and refer your patients accordingly. Tap into their knowledge about certain specialty areas and conditions in which you are not as well versed as they.

In a few weeks, you will join the wonderful world of advanced practice nursing, deserving every gift you receive to honor your accomplishment. But the best gift you can give yourself is a moment to pause and absorb your last few days as a student.

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

So you want to be an NP?

No pessimist ever discovered the secrets of the stars, or sailed to an uncharted land, or opened a new heaven to the human spirit.  — Helen Keller

“I want to be a nurse practitioner. I’m going back to school!” As soon as I spoke the words, I felt their weight and intensity.

We were a group of night-shift nurses—weekend warriors, we called ourselves—commiserating over all that seemed to be missing, not only on our unit but in our careers. We were a mixed bunch. Some, fresh out of nursing school, were dismayed by their new reality, an overwhelming set of responsibilities that hardly matched the “Grey’s Anatomy” image of nursing. There were no organized Code Reds with a well-scrubbed physician yelling “Stat,” nor was there a faculty preceptor to lean on. Some, much older, reminisced about the “good old days,” when nursing didn’t involve complicated EMR systems, committee meetings and unit-based research projects.

As soon as I made my declaration, questions and rapid-fire judgments quickly followed. How? With what resources? Why? Who in their right mind would want to take on student loans, late-night studying, clinical rotations and research papers at this stage in an already established career?

These questions, common for nurses who feel the urge to pursue graduate studies, are surely valid. Graduate school is expensive, requires self-directed study and ongoing individual assessment of learning style and learning needs, and it demands focus if one is to successfully juggle multiple tasks, set priorities, and meet deadlines. More importantly, especially for aspiring nurse practitioners who will incorporate unpaid clinical rotations into their schedules, graduate school usually requires students to reduce their employment workload, which lowers personal income over the course of the program.

Bedside nursing has tremendous perks, not the least of which are shorter workweeks; open and continuous opportunities for overtime; and casual “uniforms,” the cost of which pale in comparison to the professional wardrobe required in corporate settings. However, advanced practice nursing has its own share of perks, including opportunities for leadership, scholarship and management, as well as regular work schedules and potential for independent practice.

The barrage of who, what, where, why and when can lead to doubt, worry, and complete derailment of one’s quest for professional and personal growth. Success requires not only a leap of faith but the parachute of careful planning. The following are five key considerations for the journey to becoming a nurse practitioner.

1. Do your research.

Nurse practitioner programs are not all created equal. Speak directly to program directors and admission counselors about the number of credits required, the average length of time for completion, and graduation rates. Assure that the program holds solid accreditation and sufficient faculty-to-student ratios. Check national ratings for each school and the length of time the program has existed. Investigate the experience levels of the program’s faculty members, to ensure you’ll be learning from experienced nurse practitioners, rather than novices. Beware of new programs “awaiting accreditation” and lacking a track record. Speak with other nurse practitioners you know, to be sure you understand the role and responsibilities of a nurse practitioner. Consider “shadowing” an NP for a day or two, to get a clear picture of what the career path entails.

2. Assess your needs.

Carefully consider your learning style and weigh the options between traditional on-campus programs and those designed for distance learning. While distance learning may offer convenience, it also requires discipline, strong commitment, and strict time management. There is no one to hold you accountable for showing up to class, viewing lectures, reviewing content, and reminding you of deadlines. It is very easy to fall behind or become distracted by everyday life responsibilities, family and work obligations, and unexpected emergencies. Because traditional on-campus programs require a reduced employment workload to accommodate classes, clinical rotations and exams, you may need to line up additional financial resources to replace lost income.

3. Create a financial plan.

Add up all costs for the program, including tuition, books, clinical supplies, fees, parking, and commuting costs. To help offset these costs, investigate existing scholarships, graduate assistantships, grants and nursing education loans. When creating your budget, allow a reasonable amount for unplanned expenses such as car repairs, fluctuating gas and commuting costs, and household repairs that may occur. Realistically decide how many hours you will be able to work each week and compare this figure to current expenses. If attending graduate school requires you to move to another city, fully investigate the complete cost of living in the new location. Will you need a car to get to school and clinical sites? Is reasonably priced, safe housing affordable? What are average costs for utilities? Your NP studies will prove difficult enough. Inadequate income will not only create stress; it will distract from the time and focus needed for your studies.

4. Rally support.

If you have a spouse, significant other, or children, be sure you have their support early on in the decision-making process. In all fairness, these are the people who are going to be most affected by your decision. They will endure your late-night studying, early-morning clinical rotations, and perpetual absence at family events and affairs. Openly and honestly explain the time and financial commitments you’re planning to take on. Be realistic about the time you will need to study and the help that others will need to provide for day-to-day household management. If you are an adult learner with children, be sure to include extended family and friends in these discussions, and ask for their support as needed for carpooling and assistance with after-school activities. Once in the program, be considerate of their time, and remember to thank your “village” for helping you succeed.

5. Make your decision and stick with it.

If everything aligns properly, stick to your decision and move confidently in the direction of your passion. Equipped with your research and careful planning, beware of pessimists and naysayers who lack the insight you now have. No matter which direction the economy turns, graduate education in nursing will always yield a high return, and there will always be room for new nursing leaders who seek out opportunities for professional growth and advancement.

Consider every minute and every dollar spent an investment in yourself. Opportunities for nurse practitioners are endless and include such specialties as clinical research, global health, teaching, consulting, independent practice, and much more. Take your leap of faith with passion and optimism!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.