So You Want to Be a Nurse Practitioner?

So you want to be a Nurse Practitioner?

Part 2.

So, you've been an RN and have tired of the grind. The excessive patient loads and the doctors who need to be hit in the head repeatedly with a Clue By Four. Not to mention money grubbing administrators continually cutting staff and adding even more duties to your job description. You are thinking of making a change and going back to school to broaden your knowledge, make more money (maybe), have more control of your patients, and lower your overall level of stress. Is getting a degree as a Nurse Practitioner really what you want to do? 

That's an internal question you will have to answer on your own. What I am attempting to do is present some general thoughts about the process of getting through school. These are my thoughts and I take responsibility for them. If you make bad decisions based on information I provide it's on your shoulders. If you have ever read an x-ray report you will often see the radiologist print at the bottom of the page. Testing and clinical correlation should be based on patient presentation. Meaning, if I read the x-ray wrong and you based your treatment on my mistake, it's your problem.

What Can I expect in Clinical?

First you have to get to clinical before you can worry about what you are going to get out of it. I wrote in the last piece a little about my tribulations just getting to that point. Let's assume you are there and soon you will be going in and seeing patients.  In a typical program you need the opportunity to treat patients of all ages and medical conditions. But first a Mini Rant.

Mini Rant:

Why is it ok for someone with an associate's degree and 9 months of training in an NP certificate program, to do the same job I am required to have a bachelors and master's degree to do? Even before I went to NP school I had a problem with this line of reasoning. If I need the additional education and training, roughly 23 months more than a certificate NP, then they should not be grandfathered into the existing medical system. Has the human body changed sufficiently from thirty years ago that I need three times the training to care for patients now? I would argue that if I need a master's degree to practice safely (and I believe I do) then the NP's who went through 9 month certificate programs need to be given a sunset deadline. Either complete a bachelor's degree and master's degree or retire. Oh you're so mean.

One of these NP fossils might respond; you see Azygos, back in the dark ages when we were fighting for your right to be an NP, before the role even had a definition, we only had leaches and maggots with which to treat people, and blood letting was reserved to the physicians. So you did not need to have the extensive knowledge base you need now to treat patients, but we know more than you because we have been in practice since the earths crust cooled.

Ok, if you are going to require me to enter practice with a master's degree, how come you can't meet the same standard? This is an ugly double standard that most elderly (notice the PC use of elderly instead of old) NP's hope us younger NP's don't push at the legislative level, limiting the old farts practice. Or, as I think might be the case, is this an attempt by the baby-boomers to control the economic potential of the next generation by making it increasingly difficult to achieve the same income by placing artificial barriers of practice through legislation. Hmmm.

Well I'll let you think about that one. Has the baby-boomer generation consistently raised the bar every time the next generation tried to jump over it? I would argue that is exactly the case when it comes to Nurse Practitioners, and some other professions. The old farts want to keep the monopoly they have and keep competition from entering the profession. Or are you old farts threatened by someone who has a greater level of education than you do?  I'll write more on this in another post. Save your hate mail old ones, I have the fastest delete key in the west.

Simple rules you should already be practicing.

1. Greet your patient and introduce yourself. Hello, I'm Azygos; I'm a N-u-r-s-e P-r-a-c-t-i-t-i-o-n-e-r S-t-u-d-e-n-t. Slowly, clearly and with expert diction. I know a physicians assistant who routinely introduces himself as "Hi, I'm the Physician assistant," with assistant mumbled so the patients can't hear that he is not a physician. Many times I would enter the room after he left and hear the patient say; "The physician just told me such and such." Just to piss off the PA I would say in a clear deliberate voice loud enough for the PA to hear me, "He was not a physician, he is a physician's ASSISTANT." People are very accepting if they know who you are, and sometimes who you aren't.

2. Make sure you have a name badge and it is in type big enough for old (PC- elderly) people to read. I had a badge made up in 18 point type with my name and title. I received many comments from elderly people who liked my badge because they could read it. People get frustrated easily when they can't figure out the players. Remember to wear it!

My personal preference is for the badge to say "Nurse Practitioner Student." I know it's a mouthful and some want a better title for us but this is what we currently have. The school did provide badges to us, thank you. The badges said "Student Nurse Practitioner." I know there is a subtle distinction between the two but I found that the schools badge caused confusion. People would only read as far as the "Student Nurse" and wonder if they were really getting an appropriately trained provider. After I got the new badge much of the confusion went away.

Also, I would remind the patients that I was already a nurse with many years of experience and that I was pursuing a graduate degree to expand my knowledge and expertise. This falls into the category of teaching patients who we are and what we do. Here in Arizona we are not required to be supervised by a physician. We may open an independent practice and collaborate just as physicians do.

3. Dress the part. You are a professional now and need to dress like one. Always try to dress better than your preceptor. I realize this can sometimes be difficult but people will respect you if you are dressed professionally, even if you're the biggest idiot on the planet. Try to avoid scrubs even if they say it's ok to wear them. People, especially old people, don't like to be taken care of by people in wrinkled pajamas. Ironed shirts/blouses, business pants/slacks, and men- wear a tie. I know that it is the most idiotic piece of clothing but it presents a professional image. Also, in the course of your clinicals you will come into contact with other physicians you may want to interview with after you graduate. You need to present a professional image to these potential jobs. Remember rule #1; don't piss off anyone! Bad dress will definitely leave you out in the cold as far as making a good impression.

4. Grab opportunities to show what we can do as nurse practitioners. I had the opportunity to spend time with an Internal Medicine doctor for whom I have the greatest respect. This physician was willing to give some of his valuable time to me and teach me his peculiar aspects of patient care. The first question he asked me is "where is your lab coat?" Keep in mind I was in Phoenix in the summer. Satan leaves here in the summer to find a place to cool off. The doctor was used to having osteopathic students and had never had an NP student. As politely as possible I told him I don't wear a lab coat because I get overheated very easily (translation; I'm fat and sweat easily). I offered to forgo the experience with him as PC and graciously as I could muster. He informed me he was not used to NP students and did not know what to expect. DO students were required to wear short lab coats. Only actual Doctors could wear long lab coats. He was totally unprepared for no lab coat. I was his first. Flustered he said I could stay, and I thanked him.

My partner that day was a third year DO student. He was totally clueless but it wasn't his fault. I had taken care of 50,000 plus patients in my nursing career and was used to encountering new situations. The DO student and I went into a patient's room and interviewed the patient. I let the DO student go first. After about 10 minutes he had finished interviewing the patient and asked me if I had any questions. I told the DO student no and we left the room to get the doctor.

The patient was a diabetic having problems with the Somogyi effect. The patient was trying to be too good with his diet. After the doctor explained this the doctor got up and started to leave the room. I stayed put and told the doctor I wanted to do some teaching on how to use the BS monitor and how to use the lancet. I went through the process the patient should use to test his blood sugar and left the room. That's when the doctor said to the DO student "See, that's the difference between a PA and an NP, the NP knows how to teach patients the necessities and intricacies of their illness, the PA does not."

5. Any good provider will tell you if you don't know what's wrong with the patient by the time you have taken their history, your not taking a good enough history. Go back and ask more questions. Patients will tell you what is wrong with them and the diagnosis if you really listen to them.

6. Why do patients like Nurse Practitioners better than physicians? Because we don't interrupt them after 18 seconds. Eighteen seconds you say? Yes, an old study had researchers watch and record physicians in the process of patient visits. They timed the physicians to find out how long they listened before interrupting the patient. Eighteen seconds was the physician's attention span before interrupting the patient. Not that nurses were that much better. I think nurses interrupted after 45 seconds. As nurse practitioners we should have the manners to listen to the patient's complaints and direct the conversation to relevant information with a minimum of interruptions. Remember what your mother said- Shut up and listen!!! Or was it "get out of the bathroom and give someone else a chance." Either way its good advice.

7. Make sure you have tools available while you are in clinical.  Reference books, stethoscope, small ruler with metric system, tuning fork, percussion hammer. I use a PDA and have 5 books loaded into it. Griffiths 5 Minute Clinical Consult, ABC's of lab data by Paul Bakerman. (gives you differential diagnosis along with why the test is useful), Tabers (I'm a terrible speller), Harriet lane, and Epocrates (although I can't ever get the formulary version to load). You can also get PDR for the PDA from PDR.Net. You can usually get it free by calling and registering with them. Depends on which clerk is answering the phone that day. Some will add students, some won't.

The more patients you treat the better equipped you will be to enter practice. There is not one perfect practice setting for you to learn the basics of patient care. I come from a background of emergency and acute care nursing. The first time I walked into a room to take care of a child with a rash, I was stumped.  I'd never done rashes. I realized this and scheduled myself to spend additional time in a pediatric office. I still don't like rashes, feet, noses, or anything ending is ostomy.

What might you look for in clinical situations?

Well, if you want to work in cardiology after you graduate you may want to find an NP in a cardiology office with whom to spend time. In general, if you want to work in a specialty area when you graduate you probably need to spend some clinical time in that area, duh. You still need to get all your basic clinical time in also, because your first job may not be in the area you want to work. If you spend a great deal of time in a specialty area while in school and don't spend enough time in family practice, you may suffer. Trust me on this one too.

As I wrote before, I had a difficult time as a student getting into a family practice clinical setting. I ended up spending a great deal of time in cardiology (which I liked very much) but I could have used more time in FP where I now work. There are basic things I did not learn in clinical that I should have learned. Thank God I work with the kindest and most supportive physicians or I would be out of a job.

What are some of the other things I should have learned but didn't?

During my time in the ICU and ER I took care of many diabetics. I taught nursing students about diabetes and assisted them during hospital clinicals. DKA, sure I can do that in my sleep. How about a newly diagnosed diabetic? What medicines do you start the patient on? What dose? Do I go directly to a thiazolidinediones or start with a sulfonylurea? What dose? And what is the NP or doc I'm with in clinical going to do that I would do differently because I just went and heard the latest thoughts on treatment from the guy who wrote the guidelines? Will the insurance pay for it?

Sometimes these are easy questions because the insurance will only let you do stepped therapy. I have to do A before I do B. If B does not work then the insurance will let me do C. But what if that's not the case? So the doctor agrees that diabeta needs to be sent to the Smithsonian and never used again. You start them on Glucophage. What dose? How long do you leave them on one pill a day before you increase it? Do you really need to max them on the milligrams to get the best benefit from the drug?

How about you get a glucose tolerance test back (3 hour) that shows 1+  spilling of urine glucose for all 3 hours, a 1 hour glucose of 152, a 3 hour glucose of 55. Ok now what do I do? Is the patient diabetic? Hyperinsulinemia? Hypoglycemic episodes? Is it ok to order an A1C and will the insurance pay for it? You see that's the key. Will the insurance pay for it? The above patient was diagnosed as not having diabetes by the physician until I showed him the A1C of 8.4. The doc didn't know I ordered it. Insurance paid for it because it was abnormal but was not going to pay for it unless it was abnormal.

Ok, you know about diabetes and are comfortable with meds, changes etc. What do you do when you send a diabetic to endocrinology because they are totally out of control and two weeks later you get a letter from the endocrinologist who put the patient back on the exact regimen that you took the patient off of because it wasn't working. You switched his meds and insulin because what he was using is absolutely not working. What do you do now? Do you say oh well what the hell and let the patient crash into the side of the mountain? Or do you call the patient and ask him if he was behind the push to return to his previous regimen? Was it the patient's idea or the doc's?

Unwritten rule here. Never, Never, Never speak badly about a physician in the presence of another physician. It will come back to bite you in the butt. Remember rule #1 Don't piss off anyone. Even if the physician you work with is having a temper tantrum about another physician stay out of it. I'm using this diabetic patient as an example because I don't want you to make this mistake. What did I do about this real life patient with out of control diabetes? Well, I sent him to the endocrinologist and he put him on the regimen he feels is best for the patient. He is the expert in diabetes, I'm not. Could the patient suffer harm from mismanagement? Possibly, but he's overweight, drinks ETOH, doesn't exercise, has a bad diet, and is not trying to lose weight. The patient has some responsibility to try to take care of himself.

How about anything else I should have learned and didn't? Woman's health. I had the best OB/GYN preceptor any one could ask for. The problem I had was being able to get enough hours and pelvic exams in to feel comfortable doing them on my own. It's a moot point now because I do more pelvic exams in the office than any of the other providers. Every single time I worry I am not going to be able to find the cervix. Just wait, you'll find out.  You know it's in there but you can't find the darn thing. I did the absolute minimum number of pelvic exams (25). It used to be 100 but none of the FNP students could get that many done in a 45 hour clinical. Do as many pelvic exams as you are allowed to do. Even if you think you are going to work in a specialty that will never require you to do them. You may get stuck in FP like me and find you need to know how to do them.

Hint- if you can't find the cervix using the speculum, do a manual first and feel for which direction the thing is pointing. Then you will know where/which direction to look for the cervix. Keep in mind the KY Jelly may interfere with any cultures. My first pelvic was on a 350lb female nurse practitioner who brought her own speculum. I still have night terrors!!

Should I have a Physician or an NP as a preceptor?

Easy question to ask, difficult to answer. My first thought is that you need an NP for your first few clinicals. There are many physicians who are excellent teachers and provide NP's with outstanding clinical experiences, but, nurses are not physicians or physician assistants. We learn from a different model, a different theory of patient care. Physicians use a medical model while nursing is generally taught along a holistic model (touchy-feely crap will only get you so far). That is a very broad generalization and does not take into account osteopathic physicians who also historically practice a holistic patient model.

The above statements should not be taken as negative in any way towards the medical model or physicians in general. Medicine is an art not a science. Those who would approach medicine and patient care only as a scientific endeavor are bound to make serious errors because of the complexity and dynamics of human development.

I think having an NP as a preceptor is important. Overall, physicians simply don't understand nurses, our idiosyncrasies, education, background, and how previous experience can fit into current clinical practice. A good NP will have a better idea what it is you need to learn to become a good clinician. It's not that physicians can't teach you but the approach may be entirely different. It might help to understand where physicians come from by looking at small part of the process.

Nurses are not taught to do a primary and secondary survey. What are you talking about you say? Paramedics use a medical model of patient evaluation. Dr. Nancy Caroline, the god of Para-medicine, taught a system of primary and secondary physical assessment. She is no longer with us and we should remember her with awe, respect, and reverence. The world owes her a debt of gratitude for her work in bringing Para-medicine into daily action. Her work has saved thousands if not millions of lives.

Anyway, a primary survey evaluates the patient's airway, breathing, and circulation. Sound familiar? A secondary survey is just that, a second look at the patient from head to toe after you make sure that the ABC's have been addressed. Nurses do the same thing but it's not taught this way and is not broken down this way in nursing school (although I think it should be). We waste more time in touchy-feely crap we could have spent in learning patient pathophysiology. It's criminal. As a nurse practitioner you will have to alter your philosophy of patient care to include the mental steps of deciding on a medical plan of care. Differential diagnosis is going to become your best friend. This doesn't mean all you touchy-feely do gooders out there can't incorporate some of that psych gobble-de-goop into your practice as a nurse practitioner, but you may quickly find the dollar more important to your employer than molly-coddling the patients with a primary diagnosis of monosynapsis. (This is a simplistic description of primary and secondary survey so please hold the e-mails)

Clinical

I did say that I would get to this topic at some point.

Find out what time your preceptor wants you there. Be flexible, some want you there long before they start seeing patients, others want you to arrive later in the day so that their charts are done and they can focus on you.

What do you mean their charts are done? Please excuse me if I sound like I am talking down to you. Every test, every lab you order, every letter from another provider must be initialed by the receiving provider (you) before medical records will file the chart. You in turn, need to either call the patient with the test results or write them a letter explaining the result and any necessary plan of care. I did not participate in this decision making process enough in any of the offices I went to as a student. This is entirely my fault. I can tell you it is difficult trying to learn this after graduation. I would recommend that you get to clinical early, go through the charts, and on a separate sheet of paper write up what you will do next with the patient. Any additional tests you may need to order, any referrals you need to make, any drugs you may prescribe, and any change in the patient's drug regimen you may want to make.

This does not mean I was lazy during clinical it just means I did not recognize that I needed to spend more time doing it. It's a 20/20 hindsight sort of thing. It also has to do with how we as nurses spend our time. We spend most of our time in the acute care areas. Even med/surg is an acute area in respect to a family practice office. Your focus is getting the patient well enough and comfortable enough to make it to the first follow-up visit in the FP office and established with a long term plan of care. Think of yourself as the provider in the family practice office now. You are the provider who has to decide what to do next. What are you going to do?

I know I'm repeating myself but try to see the widest variety of patients you can during clinical. The more patients you encounter in clinical the greater degree of comfort you will have when you graduate.

Practice using the correct medical terms to describe what you see and where it is in relation to other body parts. One of the stupidest things I was taught as a nurse was to just describe what you see without diagnosing. I was taught not to use medical terminology to describe what I saw and what the patient was telling me. Don't even get me started on Nursing Diagnoses. 

Learning the correct medical terminology is a long-term project. It takes practice and patience at first. The more you are familiar with the correct medical terms the easier it will be to chart, and your charting will often be shorter.

Example:

1. The nurse's description:

The patient has round red raised lumps ranging in size from dime sized to nickel sized, intermingled with flat semi-circular red patches on his chest. Some of the patches and lumps merge forming one large rash.

2. A medical description:

Nummular maculopapular chest rash, 10mm to 15mm confluent.

It's still better to be able to describe what you see in a clear concise fashion. Even if you don't know the medical term for the condition a good description of the problem is still important. This is not my advice but I have heard some lawyers at legal charting seminars say it's better to use the simplest terms possible to describe a patient's condition. The reasoning they use is that when you get sued the jury may take more kindly to charting they can understand without the need of a medical dictionary. Learning to chart is an ongoing process. For some it helps to read how/what others chart. It can be particularly helpful to read the notes from specialists and what they write.

3. Learn to read x-rays. I was fortunate that I worked in ER's and had had the opportunity to review x-rays on a daily basis. Also try to learn what you can't read from an x-ray. I worked at one hospital where the doctors and NP's said they could tell the difference between bacterial pneumonia and viral pneumonia.

4. Let the MA's and office staff do their jobs. You are the provider now and have more important things to do than nursing duties. I know it's tempting, you're right there and it's almost faster to do it yourself. DON'T. Concentrate on doing what providers do for patients. Go do your charting while the MA gets the EKG.

Why is this important? Because you need to sever the nurse role from the provider role. Every step you take to move into the role of the provider will help your transition. Don't be surprised if you run into problems working as a nurse as you progress through the program. This role confusion is normal. Believe me, I hated working as a nurse in the ER along side the dumbest doctors on the planet. Current hospital excluded. This is another topic that is a volume in itself and might be addressed in another post.

5. Learn to read 12 lead EKG's prior to clinical.

6. Take every opportunity to do anything new. It does not matter what it is, if you have the chance to do it go for it.

7. You are going to run into doctors who are monera. What is a monera? Monera are an essential component of pond scum. I may be insulting pond scum here. When you run into these uptight, insecure, self-serving assclowns just ignore them. Doctors who are sure of their abilities are not threatened by NP's or PA's. Doctors who are insecure, arrogant, self-serving, condescending dildos often are threatened by PA's and NP's.

8. Don't set up cinicals in the same hospital, office, facility in which you work. The other nurses will not be accepting of your new role and it will only cause you grief. One of the ER's I worked in while going to NP school had two charge nurses who were threatened by NP students. There was one other nurse in the same NP program as I and when we worked we were assigned 9 patients each, every time. This started after the charge nurses found out we were obtaining an NP degree. These two charge nurses separately told me that they hated school and would never go back to get another degree. They were both ADN's (Another Dimwitted Nurse).

9. Learn when you can start clinical. We went to class every Friday for 8 hours. The week started on Monday four days before the first day of class. There were times that it would have been helpful to attend clinical even before the classes officially met. Get as many clinical hours completed as soon as possible. You never know when you are going to become sick, have a family member die, pet die, home burn down. All of these things happened during my program, fortunately not all to me. One student had her mother die, home struck by lightening and every electrical appliance and computer fried, and husband get triple bypass surgery all in the same week.

10. Sometimes no matter how carefully you plan it just does not work out. Try to have a plan B. I was finally accepted by a pediatrician as a student. I accomplished this by treating the doctor's kid in the ER. I talked to the doc during the treatment process, she liked my bedside manner and agreed to accept me as a student. I went to the office expecting to be with the physician but was immediately pawned off onto a PA. One day I went to the office and was teamed with a PA. It was apparent from the first second he did not like me. The feeling was mutual. I managed to get through the day and about 3 PM a 9 year old Spanish speaking only girl came for treatment. I did not want to see the patient but the PA's girlfriend (a PA student) showed up and said she would translate. I knew this was a recipe for disaster but went into the room with the PA student. I would ask a question and listen as the PA student and mother would chat back and forth for 5 to 10 minutes. Each and every question went through this routine and I would have to interrupt the PA student and ask "what was the answer to the question?" The PA student would answer Yes or NO. This after a 10 minute discussion with the parent.

Over the course of time I learned the child refused to come home form school when "Uncle Jose" was the only one to watch the children. The child was complaining of vague headaches, stomach aches, and other somatic complaints. It appeared to me the child was being molested by "Uncle Jose." This was the gut feeling I got from the interview and because I dealt with this so many times in the ER.

The child also complained of a left earache. I looked in the ear and saw yellowish pus discharge. I tapped on her sinuses and looked in her throat which were all normal. The PA student asked what I saw so I gave her the otoscope and let her look. She glanced at the ear, pronounced it normal, and went and got her boyfriend. Her boyfriend came in, looked in her left ear, pronounced the child had a sinus infection, wrote a script, and left. He never palpated the sinuses, never spoke to the mother, and totally discounted my assessment. The child was actually scared to leave the office.

The second incident involved a new graduate PA and a 30 day old infant. I was teamed with a PA who had just graduated and had been a shoe salesman or accountant prior to going to PA school. I went in and examined a 30 day old infant. Keep in mind I worked in the ER and handled infants to geriatric patients, often in critical condition. This infant was cyanotic and had a substantial heart murmur. There was no lub-dub. It was squish-squish. I was immediately alarmed by the kids look and even more alarmed by the heart sounds. The PA was totally clueless as to the patient's problems. When you care for enough infants you get a sense of what a normal kid is supposed to look like. This was not a normal kid. I related my concerns to the PA and she blew me off. She wanted me to chart in the official record but only what she believed to be the correct PE. I refused, told her I had an urgent appointment else ware, and left never to return. I never heard what the true diagnosis was for the kid.

If you find yourself in a situation like this remember you are the guest. I brought this concern to the doc and she did not want to listen to me. Not wanting to get called before the board of nursing I removed myself from this clinical site and let the school know what kind of problems I had. The school placed the office on the not-authorized list.

Next Time: Role Confusion, or do I really want to work as a Nurse?

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