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.

Michael Jung/iStock/Thinkstock

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.

Nurse practitioners and the pursuit of social justice

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Martin Luther King Jr.

If there’s one question every nurse practitioner is familiar with, regardless of geography, specialty, or number of years in practice, it’s the one that sounds something like this: So, are you a doctor or still a nurse?

I was two months out of my graduate nursing program when an elderly patient posed that question to me. She had come in expecting to see the physician for a routine, post-hospital follow-up visit that quickly became not so routine. Slightly overweight, she presented with the common triad of chronic conditions I was becoming adept at managing—diabetes, hypertension, high cholesterol. Added to that were depression, anxiety, COPD, GERD, and arthritic knee pain. Her scribbled list of medications spanned the alphabet: amlodipine, clonidine, Cymbalta, furosemide, gabapentin, hydrochlorothiazide, K-Lor, lisinopril, Lantus, pantaprazole, Senekot, sliding-scale insulin, Symbicort, and tramadol. After determining that the physician was unavailable, she settled, albeit reluctantly, into seeing me that day, her slightly raised brow indicating lack of confidence in my capability.

We began by reviewing the most obvious: her hospital discharge summary, the list of medications she was supposed to stop taking, those she was supposed to start taking, and, with regard to the latter, a quick but subtle quiz on why she was taking each one. Her answers revealed little to no knowledge of the purpose of the medications, correct dosages, and, least of all but most importantly, potential side effects.

We proceeded into what is known as the ROS, or review of systems, a quick query from head to toe about important systems and any symptoms that may be present. Given her conditions, I asked if she was monitoring her blood pressure at home (Yeah, sometimes it’s as high as 170, 180); if she was monitoring her blood sugar (Not really. I can’t figure out how to work all those buttons); and how often she was using her inhaler (What inhaler? I don’t have an inhaler). I also asked about pain and how much pain medication she had been taking (That stuff never works, so I just sit for most of the day to keep from hurting so bad).

From there we proceeded to her physical assessment, which underscored the majority of her story. Her blood pressure was indeed high, her knees were indeed crackling, and the wheezing in her lungs could be heard without even lifting the stethoscope. I went on to ask how many of the medications she actually had at home, only to discover that she was still waiting for the pharmacy to deliver nearly half of them. From there, the plot thickened even more.

Truth was she lived alone, depended on an untimely cab service to get to and from appointments, had children who, for one reason or another, could not help and had given up on trying to figure out whom else to call. Her funds were limited and, more often than not, she took only half the dose of insulin to “stretch” her supply until the next Social Security check came in. After purchasing food from the corner market (which was as far as she could reasonably walk without getting too tired) and paying the gas bill, she would buy her medicines, if she bought them at all.

Some say it isn’t the primary-care provider’s job to get involved with social issues, such as transportation, food, finances, and physical access to needed services and educational supports. That some individuals live in what we now know as food deserts—communities without access to nutritious, healthy foods—is a personal problem, they say, one beyond our control. Certainly, there are social workers who are better suited—and have the time—to address these issues, and there’s no argument that our payors will not reimburse us for helping individuals find transportation or locate family members to help. But to ignore the social determinants of health—defined by both the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health as the range of personal, social, economic, and environmental factors that influence health status—is to contribute directly to the very health inequities that our care is supposed to eliminate.

The role of the primary-care nurse practitioner—who, yes, is still a nurse—is multifaceted, with good reason for being so. Certainly, he or she is credentialed to provide the same level of care that a physician would provide in the primary-care setting. We can describe, ad nauseum, to our patients and to the world the educational preparation that enables us to do so. We can attain doctorates, perform and publish research, and gain the skill sets needed to perform a number of advanced, highly technical clinical procedures. But, at the end of the day, what matters most is the actual delivery and fulfillment of the work for which our role was created in the first place—the equitable and efficient delivery of comprehensive health care with a focus on health education and disease prevention.

In truth, the foundational premise of our role dates as far back as the 1870s, a time of severe postwar food shortage, rampant spread of contagious disease, and a medical infrastructure inadequate to care for returning wounded soldiers across the rural South. Our role dates back to the early 19th century, a time marked by racial segregation and African-American families migrating to northern cities in search of better living conditions and employment opportunities—only to find themselves in overcrowded, often vermin-infested tenements where unsanitary water supply, high infant mortality, and poor childhood nutrition were the order of the day.

And our role now, in the most contemporary sense, will be defined and shaped by the uncertainties of health care policy reform amidst a struggling economy, a growing demographic of aging, medically underserved citizens and of whole immigrant communities lacking access to the most basic preventive care. In truth, medical care is what we deliver, but social justice and eradication of health inequities are, and always have been, our foundation.

In meeting with that patient that day, the focus was not on my credentials and the myriad differences between my physician colleague, whom I respect and admire, and me. My focus was on doing what I’ve always tried to do best: provide patient-centered, age-appropriate, culturally competent care.

For patients who ask, “But are you still a nurse?” the answer should be evident in the work we do: simplifying medication regimens by eliminating or combining medicines where feasible, thereby reducing costs and the risks associated with polypharmacy; securing home-care referrals for medication teaching, diabetes education and blood-pressure monitoring; collaborating with community pharmacists to find efficacious drugs, particularly those offering financial benefit for the medically underserved; and speaking out wherever and whenever we can for those most vulnerable in our society—the elderly and the young. The nurse and nurse practitioner as continual advocates of social justice, health equity, and comprehensive health care are roles that we should defend and be proud of.

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

Beyond credentials: Cultivating authentic leadership in uncertain times

“Leadership is lifting a person’s vision to high sights, the raising of a person’s performance to a higher standard, the building of a personality beyond its normal limitations.” – Peter Drucker

Twenty years ago this May, I stood at the far end of a crowded hallway that was alive with students in starched white uniforms, light flashes from clicking cameras, and the collective sighs of relief characteristic of new graduate nurses. There we were in alphabetical order—porcelain nursing lamp in one hand, fresh red rose in the other—anxiously awaiting the moment of pinning that granted us official status as nurses. Ahead was the auditorium, where we would be met by faculty and hear final speeches on leadership and the nobility of the nursing profession. The specifics of the messages offered that evening are long gone, but what remains is my vision of one faculty member, in particular, who embodied authentic leadership without ever speaking a word on what it meant to be a leader.

Angel Shannon, 1993

A young, soft-spoken woman of few words, she balanced a full-time teaching schedule at the junior college with four young children, a husband, and full-time enrollment in a PhD program. Always impeccably groomed, she was known amongst students as a natural mentor in whom you could confide without fear of admonishment or embarrassment. To her, every mistake was forgivable. Indeed, every transgression was an opportunity to learn, even those that others may have considered of sufficient offense to warrant prompt dismissal from the nursing program. She viewed nursing not as a job but a noble profession, and she believed in the philosophy of nursing and the nursing process—ADPIE (more on that later)— as tenets for meeting the challenges of everyday life.

In the clinical setting, she demanded that we be “prepared for anything,” as there is no way to foresee the change or crisis that can completely make void the best laid care plan. From tasks as simple as making a bed to those requiring more critical thinking, every nursing intervention either added to or subtracted from the collective patient experience. The ability to memorize the chemical makeup of a medication was nice, she said, but no more impressive than displaying compassion by wrapping an arm around the shoulders of a grieving mother or inconsolable child. Raised in the Caribbean, this faculty member had a palpable sense of community and lived by the dictum of working together, urging us to study together and draw upon the collective wisdom of our cohort rather than traveling the difficult road alone. In a word, she was the kind of nurse leader many of us aspired to be.

Over the years, much has been written about leadership and timeless questions still remain: Are leaders born, or do they develop over time? Are good leadership skills innate, or can they be taught? In a rapidly shifting economy, in the face of globalization and amidst constant health policy reform, what skill sets do future nursing leaders need? Aside from credentials and long lists of certifications, what are the personal—and sustainable—attributes of great leadership? A few thoughts come to mind when considering these questions.

1. Great leaders are great listeners.

Hearing is not the same as attentive listening. Hearing is simply a neurological response to the presence of sound. Attentive listening evokes memory, conjures up compassion and helps convey the message that the concerns, opinions, and ideas of another are not only heard but understood and valued. Whether engaging an individual or a group, great leaders value the credibility and trust that is gained through paying attention and listening deeply.

2. Great leaders are lifelong students.

The pursuit of a doctoral degree is not for everyone and certainly not necessary for every career path, but education and advancement of skill sets are. Whether through formal higher education or self-paced, continuing education, great leaders teach and lead from their own wellspring of knowledge and experience, driven by the personal satisfaction and fulfillment that comes through sharing knowledge with others.

3. Great leaders are eternal optimists.

Every experience is an opportunity to learn and grow, even suboptimal experiences that we view as contrary to our well-laid plans. The job that went sour, the research proposal that wasn’t funded, the unit project that fell flat despite endless hours of meetings and hard work—all are opportunities to gain new knowledge and refine processes for the next time around. Great leaders learn from the past, operate in the present, and focus on the future to improve the chances of team success and avoid repeating costly mistakes. (It’s a process we nurses know as ADPIE—assess, diagnose, plan, intervene, and evaluate.)

4. Great leaders tap human potential.

Desmond Tutu, one of the greatest leaders of our time, once said, “A person is a person through other persons.” Every member of a group matters and, whether they know it or not, has something of value to contribute. Great leaders learn from others. They tap the sparks and tiny flickers of possibility that burn deep on the inside of every individual, nurturing potential rather than harping on limitations and deficits. As individuals learn and recognize their own strengths, they are better prepared to work collectively, nurturing the strengths and potential of others.

5. Great leaders are resilient.

Resilience, by definition, is the power or ability to return to original form or position after being bent, compressed, or stretched; the ability to recover readily from adversity and the like. In other words, resiliency is the ability to “bounce back.” Great leaders are those who anticipate adversity and accept change as a natural part of living. Great leaders are flexible in the face of uncertainty and ambiguity, recognizing that rigidity to fixed rules negates one’s ability to overcome adversity, obstacles, and setbacks. Always committed to growth, great leaders learn—and teach others—how to “go with the flow.”

The faculty member I’m referring to in this post later earned her PhD in nursing and went on to become a pillar of strength, not only at the junior college but in her community, embodying the kind of authentic leadership skills required of nurses in these uncertain times. For those of us who are advanced practice nurses, it is just as important in this era of rapid change to maintain ownership of our profession and develop vision for the scope of our practice as it is to collect credentials—not only for ourselves, but also for the communities we serve and represent.

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

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.