Category: Nursing Types & Specialties

Before becoming a nurse practitioner, I worked as an emergency department (ED) and flight nurse. Most days, I was excited to go to work. I enjoyed learning and experiencing new patient adventures with the support of my "work family," which encompassed my colleagues, ED technicians, registration personnel, physicians, and other staff members. We knew that we all played a role in keeping the department flow organized, creating a positive experience, and ultimately providing the best possible care to patients.

When I transitioned to a nurse practitioner role, this team-centered dynamic changed with it. Working in a different department and new position, I began to feel somewhat isolated from the rest of the team. While finding my place took a level of trust and relationship-building, it allowed me to successfully redefine my professional goals. Career development requires a practitioner to work among strangers, gaining familiarity with an unknown culture and establishing trust with a different "work family." However, NP evolutions also offer the opportunity to create a new team leader.

Benefits of Patient Care Teams

Nurse practitioners are able to create and lead patient care teams. Essential to delivering patient-centered care, these teams offer the following benefits:

• Improved coordination of patient care
• Enhanced patient satisfaction
• More efficient use of healthcare services
• Shorter and fewer hospitalizations
• Reduced medical errors
• Better patient treatment compliance

Patient care teams consist of at least two people interacting in a dynamic and interdependent relationship. They engage in effective communication and share the common goal of providing the best care for patients. Although a shared level of responsibility is understood and routinely practiced in healthcare, the absence of high-quality teamwork leads to poor patient outcomes, medical errors, provider burnout, and increased healthcare costs.

Personal Values of Team Members

NPs must establish effective patient care teams in their practice. Before doing so, there are five personal values to consider. The Institute of Medicine identifies the following personal values as integral to high-level patient care team success.

• Honesty: Team members strongly value effective communication within the team. This includes continuous transparency around aims, decisions, uncertainty, and mistakes. Honesty is critical for ongoing improvement and maintaining the necessary mutual trust for a high-functioning team.
• Discipline: Team members carry out their roles and responsibilities with discipline— even when it seems inconvenient. Similarly, members seek out and share new information to enhance individual and team functioning—despite potential discomfort. This level of discipline allows teams to develop and abide by their standards and protocols while finding ways to improve.
• Creativity: Team members are excited about the possibility of tackling new or emerging problems in a creative manner. They also view errors and unanticipated negative outcomes as valuable learning opportunities.
• Humility: Team members recognize differences in training, but do not believe that one type or perspective is superior to another. They also acknowledge that they are human and mistakes are inevitable. A fundamental value of working in a team is the opportunity to rely on each other and help avoid failures—regardless of where they are in the hierarchy.
• Curiosity: Team members reflect on the lessons learned in their daily activities and use these insights to continuously improve their individual work and the functioning of the team as a whole.

Principles of High-Level Patient Care Teams

After identifying these personal values in colleagues, the NP can move forward with developing a team.

The principles of high-level patient care teams include:

1. Defined leadership– Effective leaders must facilitate, coach, and model effective communication skills.
2. Shared goals– All members are involved in defining the team's purpose. This encompasses patient and family goals, as well as shared interest and ownership.
3. Clear roles– Each team member has a clearly defined expectation of their role, responsibility, and accountability.
4. Mutual trust and respect– Team members earn each other's trust and respect, allowing for diversity in opinions and continuous open-mindedness in reaching consensus.
5. Effective communication– High-functioning teams make communication a priority and consistently seek ways to improve these skills among all members.
6. Measurable processes and outcomes– Team members participate in a timely review and feedback of successes and failures. An impartial review enables process improvement and identifies any educational needs.

Studies show that healthcare teams are associated with the following professional advantages:

• increased job satisfaction
• more productivity
• decreased stress levels
• enhanced support for inexperienced workers

Creating a "work family" is a key priority for NPs. These tools allow NPs to lead, develop a strong team, and engage in effective communication. Leading to provider longevity, forming high-level patient care teams ultimately saves patients by improving the healthcare workforce.

A differential diagnosis is a list of potential conditions a patient may have. Through my experience as an instructor, I have found that NP students often struggle with this difficult task. However, this is an incredibly important skill to master, as it is a foundation for providing excellent patient care. Adopting a systematic way of thinking can help organize an NP's thoughts.

Differential Diagnosis Challenges:

• It is impossible to know every symptom for every single disease
• The process can take a lot of time and research
• Patients won't always be honest or tell the whole story
• There is no "one size fits all" approach

Steps to Completing a Differential Diagnosis

Following these steps will help new NPs develop a comprehensive differential diagnosis.

1. Taking a Good History

The first step in conducting a differential diagnosis is completing and reviewing an accurate and thorough evaluation of a patient's medical, surgical, social, and family history. An accurate medication list is important as well. These areas often include details that will be helpful to refer to later on.

2. Physical Exam

A great deal of information about a patient can be discovered without using a stethoscope. Watching posture, breathing, and other behaviors can provide a wealth of information. While a meticulous physical exam is critical, never discount the non-verbal clues displayed by the patient.

3. Diagnostics

A thorough review of a patient's available labs and diagnostic imaging is another important aspect. Tests will often definitively result in a diagnosis, but not always. In these cases, combining diagnostic results with the physical exam findings and patient history will be necessary for the diagnosis. Sometimes, testing will need to be ordered. Beginning to think about potential conditions can help determine which types of tests may lead to a diagnosis.

4. Thinking Process

Compiling a patient's history, physical exam, and diagnostic test findings requires the ability to synthesize the information. This is a skill that will not be learned immediately, but will instead develop over time.

An Experienced NP's Process

Here are the steps I take when developing a differential diagnosis. At this point in my career, I am able to do this in my head without writing it down. However, I would advise new NPs to take notes, as information can be overwhelming when clicking through charts.

Review

Review the patient chart (if available) and chief complaint of the visit before the patient arrives. Here, I can start to develop a potential list of causes for their symptoms. It is important to not let any bias cloud judgment, as keeping an open eye and mind is critical

Confirm

During the visit, confirm the patient's full and accurate history and perform a physical exam.

Data

Review any previous imaging or laboratory data that may be relevant to the patient's current presentation.

Question

Ask the patient many questions and most importantly, listen to their answers! Using the OLDCARTS system works best for me (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

Think

During the above steps, I will be going through a list of possible causes based on experiences with past patients. I also draw on what I have learned or read previously over the years. The main question I keep asking is "what could this be?"

System-based thinking is a helpful way to organize my thoughts. For example, if shortness of breath is a presenting symptom, I would think of all potential causes and compare them with the patient's exam findings and history to arrive at a list of differentials. Once I have a few differential diagnoses, I will review them, determine what fits best at the moment, and treat them appropriately. I include a list of the differentials in my documentation for easy reference by myself or another provider who may see the patient in the future.

Keep in mind that common diagnoses are frequent, and not every patient will have a rare illness that nobody has ever seen before. It does happen occasionally though!

Follow Up

Shortly after providing a diagnosis, I follow up with the patient to make sure there has been a resolution of their symptoms. If not, I begin looking into other causes.

Collaborate

If I don't know the answer or am unsure of what to do, I collaborate with another provider and ask questions. It is absolutely OK to not have all of the answers, and transparency with the patient is important. Letting a patient know that I don't have the answer but will do my best to find it will help put them at ease.

***

The process reviewed above is just one way to develop a differential diagnosis. As the new NP settles into practice, they will determine what works best for them. While obtaining a differential diagnosis is a critical skill for NPs, it will take time to fully master. Therefore, never hesitate to ask for support or collaborate with another provider. With enough time and experience, this will become much easier to accomplish.

Although the recent job landscape has felt uncertain, employers are still hiring nurse practitioners with an increased reliance on virtual interviews. Even recruiters are hopping on the videoconferencing trend for evaluating candidates.

As a nurse practitioner, you may be more used to communicating with patients, hospital administrators, and other healthcare team members in person. Wondering how to stand out from the crowd while behind a screen? Here are some tips.

If you haven't already done so, be sure to create a professional-sounding username for all programs and applications that you intend to use for virtual interviews.

This confirms your true identity and displays a sense of professionalism, giving your potential employer nothing to raise an eyebrow at. After all, could you imagine holding an interview with someone whose username is in_jail_out_soon?

While you're at it, make a professional email to share with employers and recruiters. You have probably outgrown your ilovehellokitty@yahoo email anyway.

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2. Lights. Camera. Clothing!

As a nurse practitioner, you already know how to dress professionally, but your ensemble is especially on display during virtual interviews. This requires you to take further steps, as the mix of lighting, cameras, and computer monitors can wreak havoc on your wardrobe.

• Avoid wearing clothing that either blends in or clashes with your background. Ensure that your clothing and background choices are not competing with each other. Speaking of background – it’s a good idea to do a sweep of what is visible behind you. Otherwise, you may not realize that your unmade bed or muted TV will show up in the background on-screen until it’s too late to do anything about it.
• Avoid wearing white, all black, or bright-red. Regardless of the lighting in your chosen room, the colors will display differently on your prospective employer's computer screen.
• Wearing white can overexpose your face and add a glow to their screen. Dressing in all black could do the same or worse—make you appear shapeless and blurry. Bright red colors also have the potential to bleed on screen and produce a halo effect for the viewer. All of these will distract the employer from what you really want them to see: your shining character.

3. Avoid the Slouch

In addition to making you look miserable on camera, slouching isn't professional. Instead of hunching over with your shoulders dejected, try the following.

• Sit up straight, make eye contact, and smile
• Rest your hands in your lap rather than crossing them over your chest or clasping them on the tabletop and keep hand gestures to a minimum
• Refrain from fidgeting in your seat or messing with items on your desk
• Avoid touching your hair and face

4. Eye-Opening Insight

Unexplained eye movement is distracting and can undermine the confidence you're aiming to project. Here are three ways to avoid those random eyeball swings:

• Set a focal point near the camera on the screen, and speak directly into the microphone. Pretending that the camera is a person can help you maintain eye contact.
• Print out all supporting documents, instead of having them pulled up on the screen for reference. This will allow you to refer to them with little movement or distraction to the person on the other side of the screen.
• Hide your self-view. Even if it's up in the corner, you will be tempted to look at yourself. Every time your eyes shift away during the interview, it's noticeable.
• Try your best to make sure you are in a quiet space free of noisy distractions such as pets and children. Not only can this interfere with how you hear your interviewers (and how they hear your responses), but constantly taking your attention off the video to tend to these disturbances can make for a disjointed and awkward interview.

5. From Formal to Personal

Virtual interviews have the potential to be stiff and formal, which can be worse than in-person interviews. To bridge the gap, here is a simple way to make a stronger connection.

• At some point early in the videoconference, use the interviewer's name.

• Without overdoing it, a simple and natural-sounding "Hello, Ms. Smith, great to finally meet you" can go a long way. If there are a few people conducting the video interview, remembering who’s who is also helpful – it is much more engaging to give a response such as, "Following up on Dr. Johnson’s question regarding my pediatric care experience, I’d like to go over my certifications.” Creating a personal connection is half the battle— especially when you are hundreds of miles apart. This little trick can help you feel more at ease too.

RELATED: Conquer Uniqueness: 5 Novel Ways to Educate Yourself and Expand Your Advanced Practice Nursing Career

6. Computer Savvy

You already know it's wise to check your internet connection, camera, and microphone well before a virtual interview. It's also important to ensure that you are familiar with the interview platform ahead of time.

But here are two things that you should never do on the day of a virtual interview:

• Don't update your computer's operating system or the program application that you will be using for the interview. Updates can disrupt settings and cause delays, forcing you to uninstall and reinstall the program and potentially lead to additional issues. You don't need the added stress, so save the updates for afterward.
• Never rely on your computer's battery to carry you through the interview. Be sure that you're plugged in ahead of time. Scrambling for a power source in the middle of an interview will make you appear unprepared, and the look of panic on your face won't send a comforting message either.

Healthcare providers face a wide variety of job stressors including demanding hours, personal risks, and emotional strains—and nurse practitioners are no exception. All of these factors can lead to burnout, a multifactorial state of physical or mental exhaustion due to job-related stress. One of the most threatening contributors to burnout in nurse practitioners and other healthcare providers is decision fatigue. While most individuals will manage some level of decision fatigue in their daily lives, the process of evaluating, diagnosing, and treating medical issues adds another layer of significant stress for nurse practitioners. In addition to causing burnout, persistent decision fatigue is exhausting and poses serious risks to both NPs and the patients they serve.

Decision Points

Heavy patient loads, short appointment times, and long work hours can all contribute directly to decision fatigue for nurse practitioners. There are many decisions involved in each step of managing health conditions, including evaluating, diagnosing, interpreting test results, implementing treatments, and ensuring follow-up. Evidence-based guidelines are frequently evolving to match emerging scientific advances across the medical field. Incorporating these changes involves another layer of decision-making in the healthcare setting. Nurse practitioners are required to make decisions during individual patient encounters, as well as when reviewing test results days later. In clinical practice, providers often make decisions regarding multiple patients simultaneously.

Provider Risks

Decision fatigue grows significantly over the course of a long or demanding shift, and may lead to a variety of effects on healthcare providers including:

• General fatigue
• Anxiety
• Lack of attention
• Difficulty concentrating

These factors affect providers' physical and emotional ability to care for patients and can impact their overall performance. This ultimately affects the ability to offer consistent quality care. As decision fatigue sets in, providers may inadvertently:

• Overlook important new or presenting symptoms
• Overprescribe antibiotics
• Take longer to make treatment decisions
• Overprescribe high-risk medications including pain medications
• Experience difficulty in resisting inappropriate treatments
• Order unnecessary laboratory, imaging, or diagnostic tests
• Suffer legal consequences related to poor decision-making in diagnosis and treatment

Patient Risks

Each patient deserves the full attention of their healthcare provider. However, the serious consequences of decision fatigue imposed on healthcare providers can extend directly to the patients they treat. These effects include:

• Delayed treatment
• Treatment with inappropriate medications
• Unnecessary diagnostic tests
• Misdiagnosis

Decision Fatigue Prevention

While decision fatigue cannot be eliminated entirely due to the ever-changing healthcare environment and ongoing demands around patient care, there are several important ways that employers and individual providers can prevent and reduce healthcare decision fatigue. This includes:

• Algorithms
• Prescription defaults
• Team-based care

Many excellent resources are available and easily accessible to providers to quickly reference during a patient evaluation. Algorithms, decision trees, and clinical pathways are available for a variety of common and complex illnesses and medical conditions. These tools offer a predictable clinical course based on sequenced interventions that guide clinicians in treating specific medical issues. Nurse practitioners can seek out these tools to guide their decision-making process. Commercially available clinical resource tools, such as Up-To-Date, offer current clinical pathways. Some electronic medical records have built-in decision trees for providers. These tools ensure appropriate care for presenting symptoms, and allow providers to easily and efficiently tailor care based on the specifics of patient symptoms. All of the tools utilize up-to-date, evidence-based guidelines aimed at providing consistent care for all patients. Effective clinical resources are imperative in fighting potential decision fatigue, as they help organize and minimize choices during times of critical decision-making and offer a clear path for treatment and improved patient health.

A key step in preventing and managing decision fatigue is recognizing the signs. Providers can monitor for signals of exhaustion, irritability, and rushing through work in themselves and their colleagues. Providers can also implement specific habits into their own practice to avoid entering a state of decision fatigue. Some simple but effective strategies to reduce day-to-day decision fatigue include:

• Scheduled breaks throughout the day
• Deep breathing
• Healthy snacking
• Brief periods of physical movement
• Re-checking E-scripts prior to sending
• Consultation support with other providers
• Consistent use of decision trees

To stay vigilant in patient care, addressing decision fatigue is more important than ever. Understanding what decision fatigue is, how it presents itself, and effective ways to prevent it will significantly impact the health and job performance of nurse practitioners and ultimately lead to better patient outcomes. By embracing healthy habits and clear clinical pathways, nurse practitioners can effectively minimize overload during critical decision points. By effectively managing decision fatigue in the healthcare space, providers will feel more supported throughout their demanding work days and can fully focus on providing the best possible care for patients.