Category: Nurse Practitioner

The demand from the healthcare system on providers such as nurse practitioners appears to be growing daily. Whether it's driven by increasing patient volumes or the heightened requirements for insurance reimbursement, it can seem like an ongoing game of catch-up. While the ultimate goal of a healthcare system is to create high-quality and high-value care for its consumers, most of the responsibility ultimately falls on the physicians, nurse practitioners, physician assistants, nurses, and support staff. With ever-changing technology advancements and the continuous evolution of health disparities, it is critical to avoid the "it's always worked, so why change it now?" mentality. At the same time, attempting to achieve these goals without a proper plan can be exhausting, expensive, and inefficient. Therefore, it is important to understand the purpose of quality improvement and how to effectively execute performance improvement programs.

RELATED: Keeping Your Sanity: How to Prevent Nurse Practitioner Burnout

Purpose of Quality Improvement

Some people question why providers, clinics, and hospital systems even worry about quality improvement, as they perceive it as "fixing what isn't broken." However, that is far from the truth. There are several reasons why quality improvement should be at the forefront of healthcare providers' radar, as it is imperative in the following:

• Improving the health of the population
• Enhancing the patient experience and outcomes
• Improving the provider experience
• Reducing the per capita cost of care

How to Design a Project

Designing an improvement project is a relatively simple process, and several factors should be considered beforehand.

• Clinical Setting: What is the available timeline? Which strategy for performance improvement is appropriate for this particular clinical setting?
• Current Performance: Are there any easily identifiable areas of improvement? Which performance aspect should be prioritized? 
• Patient Population: What are the major features of the clinic's patient population (i.e. age, race, gender, health disparities)? Which intervention will have the most positive impact on the majority of the population?
• Institutional Commitment: Who will be at the forefront of the project? Who are the key stakeholders? Will this require a financial commitment?

RELATED: New Graduate Nurse Practitioners: Keep Learning to Build Confidence

Plan-Do-Study-Act

A classic approach to the design and implementation of a quality improvement project is the Plan Do Study Act approach. This multistep process systematically breaks down the process and allows for proper monitoring of progress:

PLAN The first step of quality improvement is to identify a gap in care and define the goals for improving the performance. Quantify the desired improvement and set a timeframe to achieve the goal.

DO Complete the plan based on the defined time frame, ensuring that the duration is long enough to collect an apt amount of data.

STUDY Monitor the progress of performance improvement and compare the results to the goal that was set during the planning stage.

ACT Depending on whether the performance improvement was achieved, move forward with fully implementing, modifying, or resigning the program.

Ideas to Implement Into Daily Workflow

Primary care NPs can take the following steps to make concrete quality improvements in their offices:

1. Improving Annual Screenings in Wellness Exams: An annual screening can be time-consuming to complete, and time is not readily available in the medical world. However, continuously screening patients is imperative. Depending on the Electronic Health Record capabilities, patients may receive a request via online portal, email, or physical mail to complete and return by their appointment time. 

2. Improving Slot Utilization in Primary Care: Effectively utilizing all available appointment slots is important to providing quality care and access to a patient population. One approach to improving slot utilization is to create a plan that schedules patients as close to the desired time as possible, rather than several days or weeks in the future and sending reminders. Additionally, in the case of cancellations, it is imperative to prioritize patients who were scheduled further out than clinically appropriate.

3. Increasing the Consistency and Efficiency of Medicare Annual Wellness Exams: Annual Medicare wellness exams are often lengthy, tedious, and time-consuming. However, they are pertinent for the geriatric patient population. To ensure that all patient appointments are consistent and efficient, a clinic may choose certain staff members to serve as the cardinal staff members who manage these appointments. Additionally, creating a checklist or flowsheet for these visits can keep them organized and boost the efficiency of each appointment. 

4. Maximizing Patient and Provider Experiences by Improving Appointment Agendas: Creating appointment agendas can be an effective way to keep appointment times on-track and in turn allow a provider to see a larger patient load. A typical agenda design includes:
   • Asking the patient to list their concerns
   • Planning the visit by prioritizing immediate issues and saving the other concerns for a follow-up appointment
   • Reiterating the plan with the patient
   • Concluding visit and discussing follow-up

Continual monitoring of primary care workflow leads to efficient patient appointments and potentially better patient outcomes. Appropriate workflows can also reduce the incidence of provider burnout, as providers know what to expect for the workday and can prepare accordingly. If you already have a great workflow in your clinic, check out this list of other performance improvement projects.

Kesha Walton, DNP, RN, FNP-C is a practicing family nurse practitioner who also serves as an officer in an NP professional organization. During a recent meeting, the members discussed the noticeable decline in membership. This conversation alerted Dr. Walton to a professional concern and sparked an idea for her DNP evidence-based capstone project. Research for the capstone project revealed the following reasons for low participation in NP professional organizations:

• Personal and professional time constraints 
• Cost of membership
• Working too much
• Lack of understanding around the nature of the organization

Are any of these reasons keeping you from joining an NP professional organization?

What Is a Nurse Practitioner Organization?

While many organizations exist, the national group that represents all NPs is the American Association of Nurse Practitioners (AANP). The AANP charges one affordable annual membership fee that connects the NP to one of eleven regions. Each AANP region has their own regional director and state representatives. Many other specialty NP organizations exist in conjunction with the AANP. All professional organizations share similar benefits:

• The ability to enjoy discounts on education and board certifications 
• Access to practice and career support services
• The opportunity to engage in political advocacy
• The chance to collaborate through networking events

Acknowledging the professional expectation of membership, many NPs will pay the membership fee and take advantage of a few discounts and services. Identifying the unique value that you offer the organization is critical to accessing additional perks that are only known by those who participate in the group. NPs who are willing to actively engage in the organization are able to experience these unforeseen benefits.

Top Perks of Joining a Nurse Practitioner Organization

1. Discover a New Arena to Demonstrate Skills and Expertise

Finding like-minded professionals to support NP efforts and exchange ideas about current and future healthcare challenges is the key to staying engaged in your patient care practice. Taking an active role in subgroups of a professional organization showcases your value and unique perspective.

2. Increase Your Social Acumen

Social acumen refers to making the most of every moment you have with others. This means becoming comfortable with the "meet and greet" moments and other social rituals we use to connect with each other. You will develop a sense of confidence in making your first impression, which is critical to establishing memorable relationships and serving as a notable presence in the organization.

3. Find New Resources and Best Practices

Expanding your network of NPs and healthcare leaders will expose you to creative changes in your own environment. NPs who are excited to share novel projects, initiatives, and successes with their networks are a great source of support for making positive adjustments in your own practice.

4. Discover New Career Directions or Make a Job Change

A shared environment is a great place to hear what other NPs are doing, learn about jobs, and let others know that you are interested in new opportunities. Policy is a critical element of nursing. As the highest employment group in healthcare, it's important that nursing has representation in the government to guide lawmakers in patient protection and healthcare law. Ask to represent NPs on national committees or take part in research and data gathering to help legislators advance the NP role. You can also consider taking part in the Multi-state Reimbursement Alliance, an organization that tackles NP insurance reimbursement and credentialing. Additionally, the field of healthcare informatics requires educated professional users to participate in discussions about future needs and patient protection in the current internet age.

RELATED: Tips and Tricks for Nurse Practitioner Networking

5. Gain Recognition for Your Accomplishments

Many professional organizations offer fellowships and mentorship connections, which showcase accomplishments and guide industry contributions. Review award nominations and set professional goals for future consideration. Inform other NPs that you're interested in the awards and adding to NP professional contributions. Speak up and never apologize for it – NPs are educated, communicative leaders who deserve recognition for their accomplishments. Your success will inspire others, leading to future mentorship and a respected position in healthcare.

The Bottom Line: Become an Active Member of Your NP Organization

Joining a professional group offers an opportunity to develop relationships, share ideas, and expand your network. Being an active member provides you with a venue to maximize your strengths and improve on weaknesses. Active membership is about more than paying an annual fee and taking advantage of a few discounts. Consider investigating current policy initiatives and notifying members through emails or phone calls. You can also write articles for the organization's blog, suggest ways to increase membership, or participate in different committees. When people see your work, they will have a better idea about your competence and reliability—two aspects of NP life that are highly trusted and valued. Active membership allows you to gain recognition for your contributions, which ultimately leads to personal and professional growth.

RELATED: A 7 Step Health Policy Toolkit to Flex Your Political Muscle as a Nurse Practitioner

"If you want one year of prosperity, grow grain. If you want ten years of prosperity, grow trees. If you want one hundred years of prosperity, grow people."

This Chinese Proverb is a testament to the magic of networking with other professionals in a similar field. In fact, a survey conducted in 2016 revealed that 85% of jobs were fulfilled through networking. So why are nurse practitioners not actively practicing this method? It is not stressed in school, since our profession is not a sales-driven community. However, networking may land you in a top working environment, or provide you with connections that can continue to benefit you as you transform your professional identity.

Networking Tip #1: Offer Incentive

I am not suggesting you pay for your network, but sometimes it can help if you offer to treat your prospective referral with a coffee or lunch date. The life of a nurse practitioner is busy; work-life balance is an entire topic in itself. It’s courteous to offer to pay for a meal or coffee in exchange for picking their brain a little on their current career position. Suggest that they pick the best time and date for their schedule, so they are more willing to proceed with the meeting. During these unprecedented pandemic times, it may be harder to meet in person due to social distancing. This may work out in your favor for those who are busy! Familiarize yourself with Zoom, and suggest a quick Zoom call to check in and catch up. If you can't offer coffee or dinner, offer your help in some other way, such as promoting their practice or suggesting a referral program.

Networking Tip #2: Rehearse Your Questions and Conversation Starters

Consider your networking event like a very casual interview. Although you will most likely be conversing in a friendlier atmosphere, it is always a possibility a job may come from your networking experience. Write out a few points to make sure you cover during your meeting, and highlight any questions you have for your resource. It is also a good idea to have a quick, thirty second "elevator pitch" about yourself and your current job situation.

RELATED: New Graduate Nurse Practitioners: Keep Learning to Build Confidence

Networking Tip #3: Scroll Through Your Rolodex

Not many people actually have a Rolodex anymore, but you understand the concept! The good news about obtaining a nurse practitioner degree is that you are required to have clinical time with other nurses, and this gives you an automatic contact list. These former classmates of yours may be working for employers who are looking for new providers, and they will be able to vouch for you first-hand and speak to your work and school ethic. Don't forget about the friends you made in nursing school, too! Many of them may have become NPs or advanced practice providers as well, and you can pick their brains about where they stand now. Sometimes it can feel awkward to message someone out of the blue, but more often than not your former schoolmate will be excited to reminisce and catch up. If you don't have their number, try messaging them on a social media platform.

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

Networking Tip #4: Join a Facebook Group and Tidy Up Your LinkedIn Account

Facebook is a great tool to use for networking; the entire premise of the application is to mingle with other like-minded individuals. There are many local and statewide Facebook groups that pertain particularly to nurse practitioners and advanced practice providers, and they can be a great networking tool! The groups highlight many job postings, volunteer opportunities, and educational resources. This may also be an easy way to initiate a prospective in-person meeting, where you can have face-to-face contact with other NPs in your area. LinkedIn is a prime tool for networking – it is literally a network of millions. Update your profile picture, provide some links to your page, and ask some of your connections to endorse you and your skills.

“Networking is a lot like nutrition and fitness: we know what to do, the hard part is making it a top priority.”

– Herminia Ibarra

There is an art to networking, and these tips only brush the surface. It can sometimes feel uncomfortable approaching someone that you do not know very well, but most professions run entirely off of networking. Although the healthcare field does not rely solely on mingling to make business run, if you break your comfort zone a little and make the right connection, you may find yourself in your dream job that would not have been possible previously by a sea of online applications.

Nurse practitioners (NPs) are typically hyper-focused on the health and well-being of their patients, constantly encouraging them to eat nutritiously, exercise regularly, stick to a regular sleep schedule, and participate in stress relief activities. However, when was the last time you practiced what you preached as an NP? With healthcare professionals pulled back and forth between balancing patients and administration at work and family and daily responsibilities at home, it is no wonder that so many providers suffer from burnout without even knowing it. From family care to acute care, burnout does not discriminate in the healthcare field.

While preventing burnout is important in any role, it's especially pertinent when working in healthcare during a pandemic. It has become increasingly crucial for providers like NPs to recognize what burnout looks like, the different causes, and how it can be prevented and treated. This is not only valuable for providers, but for the safety and well-being of patients as well.

Causes of Nurse Practitioner Burnout

Hours

Depending on the employer, providers may or may not have a set schedule for work. However, the scheduled hours are not the extent of the hours worked. NPs could come in early, leave late, or work through lunch, which ultimately cuts into their availability to care for themselves.

Low Control of Daily Pace

In both hospitals and outpatient environments, NPs have little to no control of their patient load and acuity. Providers who work in hospitals or urgent care facilities have no say over who walks in and is admitted to their service. Outpatient providers may have a daily schedule of the patients who they expect to see that day, but it often changes throughout the day.

Time Pressures

Regardless of the employer, there is always an expected number of patients that an NP will care for during a shift. Oftentimes, the allotted time for patient care is not enough to thoroughly examine and address all of the patient's concerns. This can ultimately increase the amount of follow-up appointments, further filling up an already tightly-packed schedule. Alternatively, an NP may try to address all of the patient’s concerns in one visit. However, this approach typically causes delays in other patients' care or scheduled appointments.

RELATED: 5 Must-Have Apps and Tools for Nurse Practitioners

Electronic Health Records (EHR) and Documentation

EHRs are a vital asset for billing, legal liability, and continuity of care. Outside of caring for patients, documentation is the next most important job for providers. This means that everything must be completed accurately and succinctly in a timely manner. However, the real challenge for NPs is finding time to complete this work with no breaks between patients.

Symptoms of Nurse Practitioner Burnout

1. Mental exhaustion
2. Emotional exhaustion
3. Physical exhaustion
4. Depersonalization
5. Insomnia
6. Sadness or irritability
7. Increased vulnerability to illness
8. Decreased sense of personal accomplishment

It is important to understand that the responsibility of preventing and treating burnout does not fall solely on the employer.This process requires some level of effort from the provider as well. Here are some ways to prevent burnout from occurring, or treat it if symptoms have already begun.

Nurse Practitioner Burnout Prevention/Treatment

Schedule 10-30 Minutes of Exercise Daily

Physical activity strengthens the cardiopulmonary and musculoskeletal system and releases endorphins. This boosts both physical and emotional health. With time constraints, squeezing in small exercise breaks may be more feasible than developing one longer exercise routine.

Seek Support

Healthcare burnout is very common, and finding a colleague who may be going through a similar experience can offer a great source of support. Discussing your frustrations and feelings with a counselor or psychologist can also help relieve burnout. These conversations can be conducted in an office or virtually.

Evaluate Work Options

If there are no promising changes after sharing your thoughts on imbalances in expectations, it may be time to start looking for a new job or employer.

RELATED: How to Negotiate Your NP Contract

Staff Meetings to Evaluate Office Flow

Engage in open discussions with support staff to determine what type of patient flow works best in your office or unit, ensuring that it is as optimized as possible. Also, aim to schedule small breaks throughout the day to complete documentation and other administrative tasks.

Streamline EHR Flow

Create smart sets and favorites of orders, diagnosis codes, and patient instructions to streamline the documentation process. Consider the possibility of hiring a scribe to help reduce the strain of documentation.

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Nurses and nurse practitioners are the most trusted professionals in America, but this high honor can lead to a significant amount of pressure. While we should continue to provide the best care possible to our patients, it's important to take notice when it's negatively affecting our physical, mental, and emotional health.

Being a nurse practitioner is so much more than just assessing, diagnosing, and treating patients. Providers are also regularly responsible for breaking bad news, calming frustrated patients, and explaining the complicated world of treatment plans based on accessibility and insurance requirements. This is a daunting task to add to the already demanding world of medicine. So, what are some approaches that can help lighten this burden? Understanding the source of the problem and creating a game plan to ease the situation is key.

The Root of the Problem

Difficult patient and family interactions come in a variety of shapes and sizes, and they go beyond bearing bad news or discussing potentially ominous test results. Challenging interactions most frequently stem from discrepancies in expectations, perceptions, and communication. Common real-life challenging interactions include:

• Patients feeling left out of treatment decisions 
• Patients not feeling heard or listened to
• No concrete answers or diagnosis after a workup
• Treatment non-compliance 
• Expensive treatment options
• Delivering bad news

Challenging patient interactions are a multifaceted experience, and these situations aren't only about the provider and patient. In reality, they include a variety of internal and external considerations. Factors that can affect the difficult interactions include:

1. Environment: The office, clinic, or hospital may not always be able to accomodate the ideal privacy and comfort setting for these discussions.
2. Audience: The environment where the interaction occurs may have a larger or smaller audience than the patient would like. Patients may or may not want family present, and additional staff members can occasionally be present as part of their daily role. 
3. Empathy: Long working hours, an increased workload, and the frequency of certain interactions may invoke an unintentional lack of empathy from the healthcare provider. 
4. Resources: A lack of staffing, specialists, and diagnostic testing can lead to long wait times, drawn-out workups, and delays of treatment. 
5. Nonverbal communication: Nonverbal communication is equally as important as verbal communication. However, this form of communication is open for interpretation and can lead to incorrect perceptions.
6. Ambiguous/complicated plans: Treatment plans are not a one-size-fits-all strategy. Sometimes, a full treatment plan cannot be created as it depends on diagnostic results or responses to first-line treatment. These incomplete plans can cause anxiety in patients and families as they do not know what to expect. Overly complex treatment plans can also be overwhelming and confusing to patients and families, potentially encouraging noncompliance. 

While the primary goal of a difficult interaction is to create a positive outcome for the provider and patient, that's not always the case. Potential worst-case scenarios include:

• Consulting "Dr. Google"
• Frustrations that lead to threats of legal action
• Failure to accept the diagnosis
• Lack of trust related to no diagnosis, despite having signs and symptoms
• Noncompliance
• Negative focus on continuing symptoms, as opposed to recognizing progress

RELATED: Nurse Practitioner Practice Authority

Managing Difficult Patient Interactions

Nurse practitioners experience difficult interactions on a regular basis. Unlike the doctors and nurses on television, healthcare providers cannot rely on a writing team to deliver an eloquent, jaw-dropping speech to patients and families. So, what's the best way to manage these situations? Should we just accept that they are bound to occur and we have no control over them? Absolutely not. Managing these situations might take a lot of work on our part, but it will ultimately make our daily practice less stressful. Here are some ways to prevent and control a potentially difficult interaction:

1. Plan your interaction with the patient or family.
2. Consult a colleague or seek additional training before the interaction.
3. Create a comfortable environment by introducing all present parties, sitting with the patient, and maintaining eye contact.
4. Pay attention to your nonverbal communication, as well as the patient and their family. 
5. Ensure everyone's safety and maintain situational control.
6. Use empathy and active listening to encourage a patient's emotional control.
7. Provide multiple options to focus on solutions and resolve areas of disagreement.
8. Avoid using language such as:
   1. "I'm afraid I have bad news."
   2. "This is a terminal disease."
   3. "You are lucky it is only _________."
   4. "There is nothing left for us to do."

After a difficult interaction, it is important to reflect upon the situation – whether it went well or not. If it was a positive discussion, it's helpful to take note of the particular approach and utilize it for future interactions. If the encounter with the patient and family did not go as planned, it's critical to note what didn't go well and develop new approaches for future patient conversations.

Difficult patient interactions will inevitably occur in a nurse practitioner's career. However, it is the NP's responsibility to serve as a trusted resource in their patient's care. Understanding which factors create difficult interactions and customizing the appropriate approach to the patient's needs can help develop a dynamic that fosters the best possible health outcomes.