Checking out the "real" NP world

I have to admit, as a military FNP, I am a little sheltered from the “real world” of NPs. In our community, FNPs usually work in primary care and, occasionally, pediatrics. We don’t typically specialize in areas such as surgery or dermatology. There are programs in the military for our PA counterparts to branch into specialty practice—most common is surgery or orthopedics—but they are not available to us. Why this is, I cannot answer. I would think it has much to do with the current shortage of primary care providers, but if that is the case, why do PAs occasionally specialize?

Over the last few months, I have met more and more civilian FNPs and am frequently surprised by their ability to specialize. One works in general surgery at the Veterans Administration (VA) facility in town, and prefers to specialize in breast surgery. I was thrilled to hear this because, historically, the VA has been a “man’s world” where there were few services tailored to the female veteran. Another friend works in oncology, both inpatient and outpatient. She talks about how removed she feels from “regular” medicine, and my head spins thinking of all the complicated medication regimens she prescribes.

The one that surprised me the most? A friend who is a women’s health NP recently interviewed for a job in pain management. My first question was, “Can you really do that? Take care of men, too?” And, apparently, she can!

As my time to leave the military slowly approaches—I have just three years left!—it is a little overwhelming to think I will have to go looking for a “real job” and that there are more options than family medicine. I still don’t know that I would choose something else. I enjoy the variety of what I do. But, you never know what door might open when the time comes!

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

Buckle up!

To quote the much-missed Jerry Garcia, “What a long, strange trip it’s been!”

The roller coaster that I call life is still going full speed, with the occasional quick turn and corkscrew thrown in (just to keep me on my toes, I think). In the last month, we moved into our new place, Mom arrived for the summer and I spent a week at the American Academy of Nurse Practitioners (AANP) conference in Vegas. Throw in the last weeks of school and all the programs, typical summer turnover and staffing woes and the day-to-day of sporting events, and I sometimes forget to breathe!

First, the house. It is fantastic! The choice was the right one. The size is great, things are fitting into their places and the cul-de-sac is fantastic! Great neighbors and other kids, as good or better than I had hoped for. The landscaping is moving along, and we should have a back yard within the week. I spent lots of spare time looking for plants to create the low maintenance but enjoyable backyard space it needs to be, and I think we have achieved that.

Now, Mom. What would I do without such great parents?! Both my folks arrived shortly after school ended, then dad returned home after a week. He left mom and her car here to get me though the summer, which is so fantastic! The kids can hang out with friends, go to the pool, attend Vacation Bible School and sports camps, and just relax without going to all-day care, while I rush off to work. And Mom gets to beat the Arizona heat for the summer, which I think she enjoys as well. The three of us as so happy to have her here!

Now, the conference. What a great week! I saw some old friends, both Air Force contacts and friends from graduate school. The lectures were interesting, the Venetian Resort was HUGE—anyone else still getting lost the last day?—and the evenings entertaining. There were some drawbacks to such a large attendance and some things missing I had enjoyed in years past but, all in all, I gleaned some new concepts and ideas to implement in practice.

Since returning to the clinic this last week, there were several times I had to stop and think about lectures I had attended and how to use that new information in practice. I took in the four-hour ECG lecture and, when I did a 12-lead this week, was able to quickly assess for axis deviation and bundle branch blocks. Yes, prior to this I considered them but, after the lecture, they actually made sense!

I have also been working harder to match depression symptoms to medications, considering more dopamine stimulation for those who need it. What I wish I knew more about are herbals, supplements and vitamins. I heard a bit about this, but there does seem to be a connection between some deficiencies and depression, headaches and many other things. It would be nice to be able to support this as an early or additional option for patients. Maybe, a good idea for my next conference choice?

So, summer is off to a roaring start. I am looking forward to some afternoons at the pool, a vacation in August and maybe getting the pictures hung. Oh, and soccer camp, sleepovers, baseball games and can’t forget work. There goes the roller coaster again. Guess I better strap in for the ride!

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

Helicopter parent

I just recently learned the term “helicopter parent” and (small gasp!) think I might on occasion—maybe—hover too much. Take a recent example from my busy week.

It was my girl’s first experience with trying out for a competitive soccer team. She has played for five years or so, thus far on recreational teams that sometimes rock—GO TWISTERS!—and sometimes don’t. In Texas, we were lucky that the team she started with pretty much stayed together, and those girls are still together, still rocking the league. Since arriving in Colorado last year, however, things haven’t been as great.

The team was full of wonderful girls and nice families (which is actually more important than winning) but only a couple girls stayed through two seasons, and the coach basically had to start all over, which led to a pretty dismal record. Since my daughter is now eligible for the U11 age bracket, the start of the competitive track in many clubs, the decision was made to change clubs and actually try out. She was a little nervous, but apparently did one of her signature moves. (Using her backside to block her opponent, she stole the ball and then ran it down the field.) She was quickly moved to a more advanced group of girls. Parents were informed that, if a coach saw something that he or she liked, a phone call would be made if your girl were chosen for a team. No phone call? Come back Thursday, and try again. So we waited, but no phone call came and, on Thursday, off we went to try again.

Now, knowing that my girl is awesome, I was a) a little disappointed we were not called and b) a little frustrated by her performance on Night Two. She seemed more content to visit with the other girls and stand around playing with her “penny” than chasing down balls. It took all my limited restraint to not pull her off to the side when she was rotated out and explain that she needed to go to the ball and visit with the girls later. (So, maybe I’m not a helicopter parent, after all?! I did restrain myself!)

Long story somewhat short. The coach apparently was excited when she learned my girl’s name, as they had tried to call but, somehow, the number didn’t work (maybe confused by the out-of-state cell?) and, now, two coaches wanted her for their teams! I could have done a cartwheel, I was so proud of my girl! Yes, I am sure there will be some complaining as this gets underway, as this is a year-round commitment, will cost more than the furniture I am currently coveting for my new kitchen and will involve travel to distant towns. (Grand Junction is a possibility. I hope that trip comes before the snow starts in the fall!) But it is a great opportunity for her to get some quality coaching and flesh out her skills a little more.

Then, it hit me. Are we nurses more prone to being helicopter parents? Is this a new term for micromanaging? In a conversation I had recently with a colleague, we discussed that, as nurses, we tend to lean toward micromanagement. We are taught from Day One to “micromanage” the care of our sick patients, who are hooked to complicated machines that, if left to others, could result in negative outcomes. It is so ingrained in us to maintain control that many of us have a hard time letting go of things we feel are our. We are also taught to manage the minutiae because, if we stay on top of the little things, we prevent the big things.

I try to remember this when I feel squeezed at work. When I feel like a playing card in someone’s obscure game that doesn’t make sense to me, or when my schedule is scrutinized down to the second, I have to remember some are more prone to being helicopters than others!

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

A REAL doctor!

I had one of those experiences last week that I know is not specific to military medicine. I am sure it happens to our civilian counterparts, to other NPs and PAs. And I know it happens on a near daily basis at military treatment facilities worldwide. As I walked into the exam room and introduced myself as a nurse practitioner, the patient announced she was “forced” to come to our clinic and “wasn't allowed to see a real doctor” downtown. I was slightly taken aback. Here I was, running on time, in a pretty good mood and ready to assess and treat to the best of my abilities, and then WHAM. I took a deep breath and realized she wasn’t slamming NPs; she had a grudge against military providers, regardless of education background.

Some people think we are on active duty because we can’t cut it in the “real world,” that we are somehow subpar when compared to our civilian peers. And, people do sense a lack of control, since they have to enroll with a provider at a military clinic, requirements put in place by TRICARE (basically, our military HMO/PPO/insurance provider, depending on current terminology). In reality, we are all credentialed and/or certified in our specialty and really have two specialties to maintain, our civilian requirements and our military ones. I honestly believe military medicine should be it’s own specialty, since we have to know how various military-specific careers affect disease processes. And don’t even get me started on deployment medicine—who needs malaria prophylaxis, who is more resilient and able to tolerate the stress of deployment, etc. I could go on and on!

So, what did I say to that patient that day? Basically, a toned-down version of the above. That she is actually lucky, that we are a unified practice of providers all credentialed in our fields, who “get” the difficulties of being a military family. Then I asked, “What can I do for you today?” and we progressed on with the visit. I hope it was a positive experience for her and she won’t be so opposed to military providers in the future. Time will tell.

As NPs, that is all we can do; try to show the world—a patient at a time—what we bring to the table and what we have to offer. And, to hope that, over time, the response won’t be, “I wasn’t able to see a real doctor” but that patients become more accepting and some will even prefer to see us for what we have to offer!

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

Patient Centered Medical Home

If you stick around the military long enough, you will experience change, which may come as a surprise to people, since we are known as one of the biggest bureaucracies in the world! Since I have been on active duty, we have changed the names of our units (remember Strategic Air Command?), added new units (Space Command is a great example) and closed multiple bases. In the medical service, we have tried multiple ways to provide consistent, quality care to our patients (Primary Care Optimization and Primary Care Management, to name two) and now, we are changing again.

A few years ago, we started hearing more about something termed Family Health Initiative (FHI), and most of us feared it was just another attempt at putting a shine on what was quickly becoming a failing mission. We were undermanned, overdeployed and, in many cases, overenrolled. A case in point, before leaving Texas for Afghanistan, I was assigned more than 2,000 patients, well over the suggested cap of 1,500. But, we had a couple unfilled provider positions, and the patients needed a provider, so we muddled through as best we could. And, when I deployed, the sole primary-care physician who remained carried a load two to three times that until replacements arrived.

With that kind of workload, we had very little control over schedules, and a frequent complaint was the feeling of “running on a hamster wheel,” as we tried to meet the rising demands. I don’t think this was an issue specific to our little corner of the world; it was a frustration voiced by providers at many military treatment facilities and likely echoed the struggles of our civilian counterparts, who experience their own provider shortages.

So, we spent a few days last week learning more about FHI (now renamed Patient Centered Medical Home) and making plans for implementing this philosophy over the next few months. This is not a military-specific patient care theory, but a model being executed in the civilian community in an effort to maximize available providers and contain health care costs. For us, it will involve a change in staffing ratios and a decrease in maximum enrollment numbers. We will be shifted into teams of eight, composed of a physician, a mid-level (a term I still don’t love), a nurse and five medical technicians. (That’s the ideal composition. When we continue to deploy and our staffing is already below expectations, we will aim for three technicians per team.) We will be responsible for 2,500 patients (1,250 per provider) and be given more freedom to creatively meet patient demand through improved template management.

I honestly can’t yet say that I am 100 percent on board with the change. Part of me still sees it as a name change with lots of empty promises. One concern: Even though there is a strict cap placed on enrollment, as well as “cross booking” between providers, there are still requirements to see patients who are promised care and, after dividing those between our available providers, we are again back to 1,500 patients each. Also, there is an expectation to meet the needs of our patients on a daily basis. So, if there is a spike in viral illness and a need for more acute or walk-in visits, we are expected to do it. This can wreak havoc when my leaving work on time is necessary to make our usually maxed-out, kid-centered evenings work as planned! Between homework and sports, there is little room for overtime at work!

I would love to become a convert to anything that will provide consistent care to our patients. I know they are tired of seeing a new provider every visit and “starting over” every time. Rumor has it that, after the first few months of working out the kinks, most providers really enjoy the new model. I’ll keep you posted on the transition.

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

Some nurses still eating their young

First of all, somehow, in just two months, I’ve managed to precept an adult health NP student for more than 135 hours! It was her first semester, and it reminded me so much of how things were five years ago when I did my first adult health rotation!

I attended graduate school at Uniformed Services University of the Health Sciences (USU). The military’s own graduate-level university, USU has both medical and nursing programs. USU Graduate School of Nursing offers a doctoral program as well as master’s degrees for family nurse practitioner, anesthesia and perioperative clinical nurse specialist.

Within the first few days, six of us gravitated toward each other and we were just as tight when we graduated two years later. We studied together, laughed together—sometimes cried together—and, in our free time, got our families together. We were an incredible support group for each other, and we all stay in contact today. Four of us are still on active duty, one has left the Air Force to start medical school and one, fulfilling a lifelong dream, is is providing health care in India.

I remember those first few days, thinking I knew so much, then walking into clinical, terrified, trying to just remember my own name. Now, five years later, it was a great experience to support another NP through those first scary patient interactions. First, we would talk about the questions to ask and the assessment to do, and then I would turn her loose. She quickly took to the whole process and I watched her confidence grow as she formulated her own style in the exam room. Simply talking through disease processes and looking up current research has done much to reinvigorate my own practice. I look forward to spending more time together over the next year as she works through her program.

Contrast that with another experience I’ve had recently. I conducted a medical legal review for a pending case against another practitioner. I won’t go into details, but it was interesting to read the case files and to read the detailed notes made by the specialist reviewer. She even went so far as to conduct a literature review of the standard of care that was in evidence 10 years ago when the initial incident occurred! My frustration? Another NP reviwer, in seeking to build a case against the person in question, used research that wasn’t even published 10 years ago. It frustrated me that, as nurses, we sometimes still have the “eat our young” mentality.

I wonder if there is any way to remove that from our collective culture. Maybe in precepting a new generation of practitioners, we can take away this outdated belief that we have to step on each other to get ahead. I think there are enough opportunities in this world for all of us to succeed without using our peers as stepping stones!

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

I love vacation

I love vacation, even the vacations when I never leave town. I think it
has more to do with not having to work than visions of exotic locales.
I do like my job but, some days, the demands pile up and my patience
falls desperately short of the expectations. So, after a week of
feeling like the bug who loses to the windshield, we headed off to
sunny Arizona and Southern California for a week of being spoiled by my parents and time for the kids with their cousins.

We took in a spring training game. The Reds won.

We played at the beach.

And stayed to see the sun set.

We even visited Knott's Berry Farm, where my mom had been more than 50 years ago! We kept asking her if it looked familiar!
The time was much needed for all of us, and my previous stressful week was quickly forgotten (at least until I returned to work today). Time with family just makes it all worth it!