4 Most Exotic Places to Practice as a Nurse Practitioner

Posted on December 30, 2011 by Stephen

The places to practice as a Nurse Practitioner are virtually limitless and include some exotic settings. Wherever there are people with health needs, there also needs to be health care providers to care for them. Today, I will share a short list of some of the most exotic places to practice as a Nurse Practitioner.

  1. Cruise Ships – Most of the major cruise lines have a fully staffed infirmary that can treat conditions such as stings and bites on up to gastroenteritis and beyond. The staff usually includes a physician, nurse practitioner and nurses. The medical staff work in shifts and get to enjoy the sites and amenities of the trip on their time off.
  2. Puerto Rico – A commonwealth of the United States; there are practicing nurse practitioners in Puerto Rico. However, these NPs lack the authority to prescribe controlled substances for their patients though they can prescribe other medications and treatments.
  3. Hawaii – Considered by many as ‘paradise,’ nurse practitioners are indeed utilized in Hawaii. These NPs have prescriptive authority for medications (including certain controlled substances) and other treatments. With Hawaii consisting of the islands of Kauai, Oahu, Molokai, Lanai, Maui, and Hawaii’s big island, there should be plenty of opportunities for nurse practitioners.
  4. Australia – You can practice as an NP “down under” in Australia. NPs have been authorized to practice in Australia since 2000. Australia has typicalcities such as Sydney and Melbourne to the more exotic cities of Cairns, Alice Springs, Gold Coast and Broome. For more information about NP Practice in Australia, check out the Australian College of Nurse Practitioners.

The wonderful aspect of being in the health professions are the many opportunities, settings, and locations to care for others. In other parts of the world, NP practice is relatively new and is still being defined in areas such as the Netherlands and Japan while NPs in Canada are being increasingly utilized in NP-run clinics. NPs in all countries have practice barriers to overcome yet one thing is obvious: there is an increasing need, demand, and utilization for NPs as the evidence consistently reveals positive patient outcomes and enhanced utilization of health care resources. Some of those demands may just be in an exotic location!

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The Pros and Cons of Being a Nurse Practitioner

Posted on December 29, 2011 by Stephen

Every profession has its share of pros and cons. Today, I will share my list of pros and cons of being a nurse practitioner.

Pros

Job Outlook: It is generally understood that the NP profession will continue to grow as more uninsured Americans will soon be entering the health system under the Affordable Care Act in the coming years.  This is great job security and underscores the need for clinicians.

The Power to Make a Difference in the Lives of Patients: One of the most satisfying things to me about being a nurse practitioner is the ability to fully care for a patient and develop treatment plans in partnership with them.

Schedule: This one depends on how you view scheduling. Most of the NPs I know work a traditional 5 day, 40 hour/week while others may work three 12 hour shifts per week. The pro here is that there is flexibility in scheduling depending on your setting. Health care is delivered 24 hours a day for 365 days a year and nurse practitioners comprise part of the health care team caring for patients.

Mentor Opportunities – I believe it is a privilege to ultimately help train and educate future NPs within the profession. Mentor and preceptor opportunities are plentiful and desperately needed to teach from the NP perspective.

Practice Settings – Another pro is that there are opportunities to work in many different settings as an NP. For example, as a family nurse practitioner, I have worked in college, correctional, retail, occupational and men’s health. The opportunity to work in different areas within the profession was a very important factor in my choosing to enter nursing.

Income: According to the 2010 Advance for NPs & PAs National Salary Report, the average salary in 2010 for NPs, was $90,770. Obviously, this number varies according to location and practice setting. For example, in the NY metropolitan area where I practice, NP salaries are $100k+.

Cons

Competition: With the popularity of the NP profession, many are choosing this pathway which can make it difficult to get into a program do to the stiff competition. Also, there is a general lack of enough qualified faculty to teach in the NP programs.

Antiquated Regulations & Laws Governing NP Practice: There is much variation regarding NP practice according to the state in which you practice. Some states are much more restrictive in terms of prescriptive authority, collaboration, and autonomy.

Bias Against the Profession: There are some individuals who believe that NPs shouldn’t practice in the way that we do. Therefore, we sometimes come across these individuals who are looking for us to fail.

On-Call: Depending on the practice setting, there may be on-call expectations that may or may not be compensated. I am not the biggest fan of being tied to a pager/cell-phone.

Landing that First Job: Despite the many opportunities for NPs, it can sometimes be difficult to land your first NP job. Many employers look for experienced providers. The more diverse your background is, the better the chances of finding that first job with little to no experience.

Lack of Formal Residency Programs: Unlike Federally funded residency programs for physicians, NP students must rely on clinical placements to satisfy program and licensing requirements. While most placements are good learning environments, some are not. Lacking a paid and formal residency program means that it could prove more difficult to get the required meaningful clinical experience.

I believe the pros outweigh the cons for choosing the NP profession and many will find it a rewarding and fulfilling career!

 

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Nurse Practitioners: Don’t Forget to Take THIS Course

Posted on December 22, 2011 by Stephen

No, I’m not referring to advanced pharmacology, health evaluation, pathophysiology, or even evidence based practice (presumably you’ve already taken those courses!)

The important course to take is clinical/health informatics. Why is informatics so important? I’m glad you asked!

Ultimately as clinicians, we are managing data. Data exists is in the form of laboratory results, diagnostic imaging, vital sign logs, and medication lists. The sheer amount of data has made it nearly impossible to  track this information manually. That’s where health informatics comes in. Health informatics encompasses the use of technology to manage all of this data. It is widely assumed (and is beginning to be proved with evidence) that using information technology improves the quality of care and reduces the waste and duplication that is perverse in health care today.

For example, a patient can walk into an emergency department in anytown USA and complain of a severe headache. Certainly a CT scan would be in order to rule out a hemorrhage or clot. The patient undergoes the CT scan and finds out the results are normal. Not feeling satisfied, the patient leaves that emergency department and travels to the next town over and presents to a different ER with the same headache and fails to mention that a CT scan (and work-up) was already done. Thus, another CT and workup is initiated. Had there been interoperable information systems, the clinicians at the second facility would have been able to see the results of the prior CT and any pertinent results. The patient (and the system) would have been spared from undergoing another costly diagnostic test and additional exposure to radiation.

Informatics doesn’t stop there. Think about your primary care visits and patients coming in with their blood glucose logs. In a paper-based system, the logs will be glanced over for any obvious peaks or troughs, and medications would be adjusted accordingly. But think about the ability to have this data, electronically imported into your electronic health record. Now the data can be manipulated to see if any trends are apparent over time. This makes so much more effective use of that information. Patients are already using updated glucose monitors and equipment to send point of care data to their clinicians and this mobile health (mHealth) trend is continued to explode in the coming years.

Critics may claim they don’t want computers “telling me how to treat a patient.” I would whole-heartedly agree! We must remember that computers and information systems are only another tool and resource to use at our disposable to ultimately care for patients. The potential of clinical decision support, will also aid in the provision of care and ultimately improved health outcomes. Critics may also counter that these advantages are not worth the cost. Fortunately, some of the cost is offset by the American Recovery and Reinvestment Act of 2009′s HITECH appropriations. There is also a wonderful new resource website that was set up to help prepare clinicians for the transition from paper to electronic called, HealthIT.gov.

Again, why is THIS course or information so important? It’s because informatics presents a complete change in work flow and this typically isn’t taught as part of the NP curriculum. NPs and other clinicians must be schooled on this technology and using it to it’s full potential. No one will be expected to write computer programs or get wrapped up with computer jargon. This is about the effective and maximized use of clinical data management.

Informatics in health care is largely in its infancy. Now is a great time to get involved so that we can take advantage of this technology and better care for our patients.

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5 Nurse Practitioners to Follow on Twitter in 2012

Posted on December 19, 2011 by Stephen

The mircoblogging site, Twitter, has continued to grow in popularity due in part to its simplicity and ability to rapidly disseminate information to large networks of followers. I previously blogged about nurse practitioners and social media and reasons for NPs to start your own blog. 2012 is right around the corner so why not start with jumping right in, setting up a Twitter account and following these 5 Nurse Practitioners/Nurse Practitioners to be! There are many NPs on Twitter and the small list below (in no particular order) represents some of the more frequent NP users of Twitter.

  1. Nurse Barb (@NurseBarbDehn) – Barb is a nurse practitioner, author and frequently appears in the media commenting on health topics.
  2. SalliePorter (@NurseSallie) – Sallie is a PhD prepared pediatric nurse practitioner and DNP candidiate.
  3. Donna Petko (@DonnaPetko) – Donna is a MSN/FNP student and posts frequently about nursing, research, education.
  4. Nancy Onyett, FNP-C (@pyramidmedicine) – Nancy is a FNP and owner of Pyramid Preventative Medicine. She posts timely health information from around the web.
  5. Johnetta Miner, NP (@JohnettaMiner) – Johnetta is a nurse practitioner and life coach.

There you have it. Make it a New Year’s Resolution to start following these fabulous nurse practitioners on Twitter in 2012. You will be glad that you did.

As a personal plug, you can also follow me on Twitter @StephenNP. I would love to connect with you and share health-related information – especially if its having to do with policy and/or technology!

Finally, all nurse practitioners and nurse practitioner students are invited to join us on Twitter on Sunday evenings at 7 pm EST for the #APRNChat. We’ve had some wonderful discussions over the last few weeks including mobile apps for clinical practice, the DNP, and professional NP associations. You can also check out the transcripts from prior chats here.   There is a Facebook page here where you can “like” and also suggest topics for future chats. The chat will be on a brief hiatus for the Holiday season but will resume on January 8, 2012. Again, I look forward to connecting with you on Twitter.

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Billing, Coding, & Documentation – Oh My

Posted on December 14, 2011 by Stephen

Everything that health providers do must be documented in some way with the ultimate goals of reimbursement, accurate tracking of diagnosis to study population health, and for continuity of care. Today, I will very briefly discuss coding for visits. As a disclaimer, I am not a billing expert and wanted to just review some common terminology. Always check with your institution’s resources regard billing practices and specifics.

Evaluation and Management codes (E&M) were established by the Centers of Medicare and Medicaid Services in 1994 in partnership with the American Medical Association. Currently, guidelines used are in the form of 1995 and 1997.

Visit Codes generally range from 1 – 5 depending on level of complexity/severity

9920x – New Office Visit

9921x – Established Patient Office Visit

9925x – Hospital Consultation

9924x – Office Consultation

9928x – Emergency Department

9930x – Nursing Facility

9932x – Domiciliary (Rest home, custodial care)

There are 3 parts of an E&M Code:

  1. History
  2. ExaminaMedical
  3. Decision Making

What comes next is a fairly complex process of proper documentation ensuring that you satisfy the necessary requirements within those 3 parts.

A valuable document to review put out by CMS is their Evaluation and Management Services Guide.

There are also ICD-9 (International Classification of Diseases) and CPT (Current Procedural Terminology developed by the AMA for billing) codes that comprise part of the billing process.

Fortunately, many of the electronic health records (EHRs) systems of today takes most of the guesswork out of billing and coding and automate many of these processes based on the information and fields that you complete. This alone is a major incentive to have an EHR as part of your practice.

Finally, there are some new significant updates that are on the horizon that you should be aware of.

HIPAA Version 5010 – should be in place by January 2012. This is an upgrade to the system of how insurance companies and providers exchange information and sets new standards for the data exchange. This also makes way for ICD-10.

ICD-10 are scheduled to become the standard on October 1, 2013. The main difference from 9 to 10 is that the 10 codes are more robust and descriptive that will better allow to accurately classify patients with their conditions rather than using a global diagnosis code that may not really truly convey a patient’s condition.

There are many websites that go into much further detail for billing and coding that you can find by placing “billing and coding” into your favorite search engine. Many organizations/institutions have classes dedicated to learning this process and employ teams of individuals to ensure proper coding, documentation and reimbursement.

Again, this was by no means meant to be an exhaustive overview of billing and coding. However, I wanted to share some terminology and background. The use of EHRs are so vital for easing the burden of documentation and billing so that clinicians can better use data to care for patients rather than spending so much time writing about it.

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NP Career Option: College Health

Posted on December 9, 2011 by Stephen

One of the most enjoyable nurse practitioner positions that I held was as Associate Director of student health services at a large private university. College Health today is much different than college health of even 20 years ago. Today, depending on the college/university, health centers range from a solo clinician taking walk-ins to a full service primary/urgent care center that takes care of all of the health needs of students.

College is a particularly stressful time for first-time students and being away from home presents many challenges - particularly regarding their health. In essence, this may be the first time that students are caring for themselves without parents nearby scheduling their appointments.

I really enjoyed the health education opportunity that I incorporated into each visit with the students. This was a captive audience and were thirsty for age and situational appropriate health information.

So what can a nurse practitioner in college health expect to see? There were plenty of upper respiratory infections/otitis media/sinusitis to go around. We managed some chronic conditions including asthma, diabetes and hypertension. We performed many pre-participation athletic physicals. We counseled and treated sexually transmitted infections. We also saw many students with mental illness including depression, anxiety, attention deficit disorder and worked with students with anorexia and bulimia.

Staffing a student health center is usually lean. That is, don’t expect many support staff and clinicians are usually collecting their own labs/testing. We had a small formulary of pre-packaged pharmaceuticals that we would prescribe and dispense where appropriate. In addition, many point of care tests including, rapid strep, rapid mono, rapid flu, pregnancy testing, and urine dipsticks were performed.

The billing/pricing structure is interesting. Some colleges and universities charge an annual health fee to all students which grants students access to the health services with little to no out of pocket expenses. Some student health centers are set up to be in network with many major insurance carriers and therefore bill the students insurance (this sometimes proves difficult especially when dealing with out of state insurance carriers).

There is a wonderful resource for college health that I recommend checking out – the American College Health Association. They have an annual conference which is greatly attended and I even got to present there a few times (on performing pre-participation athletic physicals and on pharyngitis/mono).

To sum, working as a nurse practitioner in college health was a great experience. One downside is that the salary isn’t usually as high as a hospital or private practice. However, there was plenty of time off and many schools allow you and your immediate family members to take undergraduate courses for no charge. That alone may be worth it to be a great job opportunity to many clinicians.

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Preparing for the Job Search, Part II

Posted on December 6, 2011 by Stephen

In my last post, I offered some tips on searching for a nurse practitioner job. In today’s post, I will offer some tips on preparing for the interview and the follow-up required to land that position.

Now that you have worked on your resume or CV, it is advisable to work on the interview. The employer by now, had the chance to review your resume/CV and they determined that your education and background meets their requirements. The interview is your opportunity to prove to them why you are the best candidate for the position beyond what your resume/CV states.

You can expect to be asked questions regarding past work experiences. These are the easy questions since you already know the answers! The more difficult ones are the opened ended questions that are asked to determine how you might respond to a particular situation. These questions include: “Describe a time when you went the extra mile for a patient. What did you do?,” or “How would you respond to someone demanding antibiotics for what you feel is clearly a viral illness?” or “Describe things that frustrate you at work and how do you manage these things?”

Other questions that I have been asked multiple times on interviews (and have asked to applicants myself) are asking to describe your strengths and weaknesses. Also, expect to answer questions regarding your goals and aspirations. These may sound so cliche but it provides a nice snapshot of how reflective a candidate is. Please think of these and how you would respond and be sure to name three things if that’s what they ask.

Finally, be sure to do research as much as you can about the particular job, institution,  or person that you will be interviewing with. (Undoubtedly, they are doing the same to you. Now would be a good time to check your privacy controls on your social media outlets and remove anything that may be damaging to landing that position).

Try not to memorize any answers but have a general idea of what you would like to discuss. It goes without saying, (but I will say it anyway) be sure to dress professionally, show up on-time, and to follow-up your meeting with the interviewers with a timely e-mail(s) (ask for their business cards). Ask them what their timeline is for filling the position and what the next step would be in the interview process.

There is nothing more frustrating for a job searcher than to never hear a word back following a 1 – 2 hour interview. You may have this happen to you. Try not to get discouraged and keep on searching. The way I view this lack of communication is, it could be very telling as to how responsive (or not) that person or institution is if you are an employee. Therefore, it may not be the worst thing if you don’t hear back despite your desire for the position.

Good luck with your job search!

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Preparing for the Job Search

Posted on December 2, 2011 by Stephen

As one school semester is rapidly drawing to a close, some nurse practitioner students will be graduating soon. The next step (after licensing and certification requirements are fulfilled) is to land your first nurse practitioner job. The job market for NPs is frequently expanding. I have never come across as many job listings for NP positions as I see today and many expect the job market to continue to flourish. This is primarily a result of NPs being recognized as part of the solution to the shortage of primary care providers as more people will be seeking care as they gain health insurance coverage. We know, however, that doesn’t automatically mean that the offer letters will be rolling in. In this two-part series, I will share some tips with your search and what to expect once you start interviewing.

Resume or Curriculum Viate & Cover Letter: A well-polished resume or curriculum vitae (CV) are a must. You definitely want to keep them concise and easy to read. Try to avoid overly complicated fonts and graphics and decide if you want to go the CV or resume route. Each has it’s advantages and disadvantages and in fact, it may be wise to have them both and use your discretion for sending it out according to the posted position. In a prior job where I was responsible for hiring NPs, I reviewed many resumes. Make your prior positions stand out with noting some key accomplishments. For example, don’t waste valuable space listing all the duties you performed while working in the ED as a staff RN. Most people reviewing the resume already know those duties are. Did you undertake or assist with an evidence based quality improvement initiative in your work? Did you identify a process improvement that was implemented? These are the items that should be highlighted on your resume.

A nicely worded and concise cover letter is also mandatory when sending out your resume. You can basically use the same one for each job that you apply to but be sure to tailor it to the specific job/institution you are applying to.

Networking: It’s true that many jobs out there are never “posted” to a website or made public. You must network and take advantage of any connections that you have. Get on Linked In and Facebook and join some of the groups on the respective sites. Send requests on Linked In to local recruiters and headhunters. Utilize the search features on the site to find them and they will soon be contacting you. Think of your Linked In profile as your resume/CV (as noted above).  This would also be a great time to become actively involved in your state’s professional NP organization/coalition to speak with other NPs who may know of upcoming available jobs in their institutions.

Job Boards: You have a few options on the job boards: submit your resume to the site for recruiters to review and/or selectively apply to certain listings that fit your intentions. I still get the occasional random e-mail from recruiters from when I posted my resume over 5 years ago when I was looking for a new opportunity. The major websites that I found useful are Monster, Indeed, and Craigslist. Be sure to set up “alerts” with key words (such as “nurse practitioner” and “school health” etc) that you specify on the sites so that you get notified immediately as its posted on the Web.

Cold E-Mailing/Mailing: I don’t believe this method is very effective but it certainly doesn’t hurt if you are not making any progress. You can send your resume to local private practices, hospitals, and health centers for example. If you are snail mailing, use resume stock paper so that it stands out. Your timing may work out if someone is looking for an NP but has been too busy to post a job.

Those are some initial tips on the job search. In my next installment, I will review what to expect on a typical interview.

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One Step Ahead, Two Steps Back

Posted on November 30, 2011 by Stephen

There has been some interesting NP-related content in the news over the last few weeks regarding utilization of NPs and how adding NPs to the care team reduces unnecessary emergency department visits. And with the good, comes the bad. That is, the negative backlash of comments filling blogs across the blogosphere and attempts to minimize NP practice. I wonder if other professions endure the baseless attacks and seemingly distrust that NPs do. I’ve learned to ignore the unprofessionalism and be one of the ones writing our own story from a positive perspective.

The summary from the utilization of NP data performed by the CDC (2011), “…suggest that PAs or APNs continue to provide a critical health care function by providing care in settings with fewer physicians, such as rural locations, small hospitals, and nonteaching hospitals.” This certainly validates the positions NPs (and physician assistants) are finding ourselves in. The trend suggests that there will be increased utilization of these two professions across the health care spectrum. In fact, a recent “Hottest Jobs” list puts NPs as the number 1 hottest job with a 22% 10-year job growth projection.

The other newsworthy item was a study on NPs reducing emergency department visits, conducted at Loyola (2011), found that “…the nurse practitioner reduced ED visits by improving the continuity of care and troubleshooting problems for patients.” In addition, a result of using NPs, “…improved use of resources and financial benefits for the health system.” The NP worked closely with surgeons and post-operative patients and was able to anticipate and act on patient needs and increase communication to reduce unnecessary visits to the ED.

As mentioned, this emerging data validates what NPs have been doing for more than 40 years. That is, providing high quality, cost-effective, and cultural congruent care to our patients. Some vocal opponents of NP practice (and of the DNP) believe we have an ulterior motive to “take over” health care. (Unfortunately, the article that I am referring to doesn’t allow access to the full discussion since it is a “physician-only” discussion area.) Our health care system cannot afford this bickering. Despite all the studies completed to date showing the effectiveness of NP utilization, there are still some who believe that the evidence is lacking for NPs providing primary care.

As a profession, NPs must continue providing high-quality care to the hundreds of thousands of patients encountered every day. We should continue gathering evidence on new treatment modalities and innovations in care to increase quality while reducing costs. The only wars in health care should be about battling the inefficiencies of the system and treating chronic disease – I’m sure that is something that most of us can agree on.

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Alternative Models of Practice

Posted on November 27, 2011 by Stephen

As the health system evolves out of necessity, we are seeing new and innovative models of practice popping up. In fact, you may find yourself working in one of these models. Below are some examples.

Retail/Convenient Care: These clinics are located within an existing retail location such as pharmacies, grocery stores, and big box retailers. They are usually staff by a single clinician and handle common episodic illnesses such as strep throat, ear infections, and bronchitis. Since a lot of the conditions treated in these clinics are seasonal, retail clinic operators are beginning to offer monitoring of chronic conditions such as hypertension and diabetes. Most clinics operators are in-network with major health insurance carriers and therefore just collect the copay. For those out of network, costs for the episodic visits range from $60-$80. In addition, the clinics offer immunizations including influenza, tetanus and pneumonia vaccines.

Urgent care: These are free standing mini-emergency rooms without the hospital attached. Clinicians at these locations treat episodic illnesses but also can suture lacerations and x-ray equipment is on-site to help diagnose musculoskeletal fractures and sprains. There is usually a robust clinical staff including clinicians, nurses, technicians as clerical. Many urgent care centers are also in-network with the major insurance carriers but bills can quickly run up if a patient is without insurance and requires advanced diagnosis.

Tele/Video Medicine: There are websites are offering diagnostic and treatment services for common illnesses without you having to leave your computer. For a fee, a patient will answer questions on-line and submit them to the site. A local clinician will review the questionnaire, ask additional questions (if necessary) and make a diagnosis and prescribe medication as appropriate. These visits are not covered by insurance but are usually priced below $30.

Micropractice: These practices are very lean because the clinician is the sole person in the office (there may be minimal clerical support). Clinicians have adopted this model because it allows them to spend more time with patients and have extremely low overhead costs. Access is a main priority of micropractices and clinicians usually give out their direct mobile number for patients to contact them if necessary. An integrated electronic health record (EHR) is a must for these practices to run efficiently.

House Calls: There is a resurgence in the “house call” practice model as clinicians are grabbing their black bags and tablet computers and coming to a patient near you. The majority of patients seen in a house call practice is home bound. However, other patients are finding the convenience of a house call to be advantageous and are opting to have their providers come to them for routine and chronic visit care. Clinicians are usually in-network with private insurance carriers, as well as, Medicare.

We are likely to see more of these models emerge as the health care system changes to become more efficient and patient-centric.

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