So You Want to be a Nurse Practitioner?

Tips, hints and personal pitfalls I have encountered in my pursuit of becoming a Nurse Practitioner.

I sat down across the table from the interviewer to discuss my goals. Yes, I piped up, with as much energy and enthusiasm as I could generate. You see, I have the personality of a Pet Rock and really have to work on acting excited and interested. But this was not the interview to get into a Nurse Practitioner program. This was the interview to get into Nursing School.

It was a goal of mine to become a Nurse Practitioner even before I became a Nurse. I already had a Bachelors degree, and most of the people I knew would ask; why don’t you just go to medical school? I did think about it briefly and read about several of the local Medical schools, but that is not what I wanted to do. Nurses are different, talented, caring, committed, educated (well some of us) sarcastic, caustic, toxic, and rude. I have since worked as a Nursing Instructor at a Community College and watched colleagues treat students in the most abusive fashion. That is another topic which I may tackle in the future.

So here I was at my second Christian University getting ready to do the school thing again. It wasn’t scary; I’d just finished my first degree the year before and couldn’t pay someone to let me work for them. It seems funny now because my first degree was in electronics. Had I a talent for programming computers instead of taking them apart and fixing them I would probably be a multimillionaire now. Enter the old Wayback machine: It was the mid-eighties; King Ronald was in the White House pushing for rich people to get richer. He quietly pushed through a $50 billion tax increase for the middle class and a tax cut for the rich. He also slashed public health funding and closed Veterans hospitals nationwide. It's great to have a strong military as long as you don't have to care for them as they age.

In the electronics industry, Texas Instruments and IBM laid off a combined 300,000 people in the same month. It just happened to be the month I graduated from college with a degree in electronics. God has always had a sense of humor that way.

So off I went in search of a job. In the process I worked as a gravedigger and other fun occupations. Actually, gravedigger was my first health care job. Although that’s another story also.

Ok, fast forward to Nurse Practitioner School. I found a local NP School that didn’t require the ridiculous GRE to get into the program. I applied and was accepted into the program on the first round. I had been working in ERs and ICU’s as a nurse for the past 11 years at the time I started NP School. The first day of class was an eye opener. The Assistant Dean of the program talked with us the entire first day. She knew her stuff because had we truly a clue about what we were about to do we would have bolted from the room and chucked cookies in the hallway. The other thing about the first day of the program was the intimidation factor provided by the other students. Half the 15 people already had a Masters degree. All but one student had either a Masters degree or two Bachelor degrees. These were not just smart people, they were very smart people, as I would come to find out as I worked my way through the program.

Now, I found nothing about the NP program to be intellectually insurmountable. It did take study, hard work, and lots and lots of hours on the computer sifting through the dregs of electronic stacks to find the information I needed for the classes. In many of the classes I never bought the book. Really you say? Yes, I never bought the book. I either had similar texts at home already or found the information online, freshly printed or published, and just waiting for little old NP student me, to dig it up. My wife is currently in the same NP program and keeps asking me for the book I used for such and such a class. She gets frustrated when I tell her I never bought the book for that class. That does not mean there aren’t classes for which you must purchase a book, there are. Now, is that awkward enough? There are classes you will need to purchase books for or you will have a very hard time passing the class. Is that better?

Ok you really want to be an NP. Take a deep breath and repeat the mantra;

I won’t have a life for 2 ½ to 3 years. I won’t have a life for 2 ½ to 3 years.

Repeat that over and over about 10,000 times.

Tip #1. Don’t piss off anyone.

That’s a real easy one and should be practiced on a daily basis. Why? The simple answer is that nursing is a small, petty vindictive world ruled by Hitler-like women with Short-Woman Syndrome. You’ll have to meet me in person for specifics on certain people as I don’t want to get sued for saying unpleasant things about ghastly people.

Just trust me on this one. Nursing is a small world and if you are considering becoming an NP you may need all the goodwill and help from every bad manager you have had to work for. Another side to this is that many bad managers become managers of hospital departments that hire NP’s. If you piss off this person, even though they have no clue what we do, you will never get an interview and you may miss out on a great opportunity.

As you get out into the NP world companies will want to talk to former employers to gauge your demeanor under fire. They don’t particularly care about your nursing skills because they don’t mean a rats-patootie to the medical world. They want to find out what kind of person you are. Are you calm, quiet, understanding? Do you ask the doctor when you don’t understand something or do you first look it up in a text book?

Your first employer is looking for a good “fit” not just somebody who has the skills to diagnose epistemological dualism with one ear plugged and both arms tied behind their back.

So- Rule #1- Don’t piss off anyone, you’ll need them in the future.

Tip #2. You have to trust others to help you.

This is a real hard lesson for nurses to learn. You can’t do everything yourself. The program I went through had group projects that I hated with every breath I took. I now see the benefit of group projects. One person, doctor, NP, PA can’t know it all and needs the benefit of and the experience of others to assist in safe patient care. If you run into a provider who never consults anybody else run. Run fast, run hard, but run. Everybody needs someone they can ask questions of without repercussions.

The program I went through required us to develop and obtain our own clinical experiences. This was the single most difficult thing for me to do in the entire program. I sweated blood over this. The city I live in has three medical schools, two PA schools, two NP schools and a third NP school on the way. It was beyond stressful for me to find appropriate clinical agencies and preceptors.

Go back and read Tip #1. Employers are going to interview your clinical preceptors to see what kind of person you are and how you practice. Make sure you get the best trained and respected preceptors you can because your future employment depends not only on your skills, but those of your preceptors. I worked as a Nurse Consultant for an HMO while going to NP school. I went to over 100 offices and spoke to many, many NP’s and doctors about acting as my preceptor. None of the offices I went to would take me on as a student.

Frustrated, I wrote a three sentence one paragraph complaint about the lack of NP’s willing to precept students and posted it on the state NP listserv. I received over 900 angry e-mails in return. Some were posted to the listserv but over 900 came to my inbox directly. I don’t think there are even 900 NP’s in the state? I received one offer of help from an NP four hours away. 900 to 1, those are great odds. Many of the e-mails were so vial and vitriolic I deleted them before I finished the first sentence. Feel the love yet?

I wish I had some magic formula for getting into an office and getting a good preceptor. I really think it’s time for the state to step in and require the school to provide preceptors. The time and stress I spent in trying to set up clinicals was way beyond unreasonable.

How did I finally get preceptors?

1. I chased an NP down the hall of one of the hospitals in which I worked. It turned out he was a fellow alumni who took pity on me. He had had the same problem finding preceptors. I had a great experience in his specialty.

2. My fellow students gave me leads for preceptors, all of which I tracked down. Never let a lead get away. My pediatric and OB/GYN preceptors were a direct result of my fellow students arranging them for me. They said trust me, I can get you into this office or that office and they did. I would not have graduated without their intervention. You have to help each other.

3. I spoke to and wrote to everybody I came into contact with about acting as a preceptor, or who they knew who takes students. I have come to believe letters are a complete waste of time. Busy NP’s and doctors line their bird cages with student letters. You must get face to face or minimum on the phone and speak directly with the potential preceptor. It’s hard to say no to a face, but I heard it over 100 times so be prepared for disappointment. One preceptor was gracious enough to accept me as a student through an e-mail. I would not have completed the program without him.

4. Start very early looking for preceptors. Many offices have contracts with other colleges and are set up to take students 1-2 years in advance. It’s never too early to start setting things up.

5. Tell them you are going to be in the NP program and you are probably going to need a preceptor in blah blah blah month of next year. Keep calling and reminding them about your needs and that you are progressing and will start clinicals in such and such a month. This is important because I did get into several offices where the NP accepted me, but the doctor had arranged for a PA student to be with the NP. How nice huh! I’ll say it again; the doctor arranged for the NP to have a PA student without the NP knowing about it. It would have been nice for the doctor to have the PA student since he arranged it don’t you think.

Anyway I would get a call about 6:45 AM from the NP telling me not to come to clinical because there was going to be a PA student that day. This happened to me throughout the program and at several different offices. Every time the NP apologized about the PA student, but really the doctor should have been the one to call me since he was the mule’s backside who caused the double booking.

Tip #3. Not everything is as it appears.

I now work in a family practice office. It took me 6 months of full time hunting to get my first job. As it happens I work in an office wholly owned by a Hospital corporation. I did part of my clinical time in a family practice office wholly owned by another Hospital corporation. These hospital owned offices are more used to having students and are slightly easier to get into because the staff is used to having students. One trick is knowing who to speak to and who to call. Also, you have to go through the hospitals HIPAA, fire safety, back safety etc… so give yourself time to get all that stuff done. Six months in advance is cutting it close so don’t wait until the last minute.

Remember you are a guest while you are in clinical. You are also performing a job interview while you are in clinical. I’ll admit I was not as good at this as I should have been. I probably would have had a job sooner after graduation had I spent more time in clinical. I’ll get into more specifics of clinical in another post.

Tip #4. Get all the paperwork for UPIN (Medicare number) AHCCCS (Medicaid for those of you outside Arizona), DEA, prescribing and dispensing, NP certification, done ASAP when you graduate.

Spend the extra money to have things processed faster if necessary. I didn’t and had to wait 3 ½ months just to get my state certificate. The school was the slow horse not the BON. Here in Arizona it took less than one business day for the BON to process my application. Pretty good for government workers. It took forever for the school to process my graduation paperwork- I should have forked over the extra $50 to have it done in one week. Once it’s in the system you can’t decide to spend the $50 for faster processing, because they can’t find your application amongst the 100,000 or so other graduate applications.

Why does any of this matter. As a Nurse Practitioner you need your own UPIN for the billing company to bill for Medicare patients, otherwise its fraud unless the physician also sees the patient. Since I work in a clinic owned by the hospital the physician has to see any Medicare patients first, and establish a diagnosis. I always check what insurance the patient has to make sure we are doing things legally. I worked had to get through school and don’t want to be the HHS whipping boy.

Get you DEA Number ASAP!
Having to run down the hall to have the physician sign a script because you don’t have a DEA number can bring your patient numbers way down. Remember, this is a business and you are the cash generator for that business. You don’t see patients, the company doesn’t make money, and you don’t have a job. Spend the $210 and get a DEA number ASAP. Just as a side note the DEA lost my paperwork twice and the state never sent verification to the DEA that I was a licensed provider. I had to fax my diploma, prescribing and dispensing and NP certificate to the DEA and let them work it through backwards. Is any body surprised by this?

AHCCCS (Medicaid)
You need to get an AHCCCS provider number ASAP so your employer can apply for provider status with the various AHCCCS plans. Some will credential you others will tell you to bill through the doctor. If you are planning to open your own office it’s an entirely different can of worms. I suggest you read the archives of the CAZNAP listserv for a complete discussion of the complexity of this issue. My AHCCCS provider number was processed in less than one week. Again, I was surprised at the swiftness and first-rate job done by the state workers.

Because of budget problems (i.e., the AHCCCS plans are only making millions instead of gazillions of dollars) some of the AHCCCS plans have decided not to pay retroactively for services provided by NP’s, PA’s and doctors. This can make it difficult to get a job if the office can’t get paid for your service. It makes it double difficult for NP’s because AHCCCS refuses to credential NP’s prior to them working for a physician or hospital. They will credential a doctor anytime however. We, NP’s, are being excluded by exception.

Next time: Tips on what to focus on during clinical.

These are my thoughts and experiences and if you disagree with them, Phbttt. I really don't care!