Breaking Down the Differential Diagnosis for the New NP

Breaking Down the Differential Diagnosis for the New NP

Posted on March 24, 2021 | by Julie Scott | Leave a Comment

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.

What I Wish I Had Known as a New NP

Posted on March 6, 2021 | by Julie Scott | Leave a Comment

From excitement and elation to fear and anxiety, a brand new nurse practitioner (NP) is likely to experience a wide range of emotions. Transitioning from the role of a seasoned nurse to a novice NP can be particularly stress-inducing. Although the past few years of formal schooling and practicum experiences have certainly been valuable, there is no handbook for handling this transition. When I graduated from NP school, I thought I had to know it all. (Spoiler alert—you don't!) From taking board certification exams to landing a job and establishing a new career, here are some of the things that I wish I had known when first starting out as a new NP.

Board Certification

The two certifying bodies for NPs are the American Association of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC). New graduates often wonder if taking a review course for the board certification exam is worth it, as this adds another expense to the already costly process of becoming an NP. In my opinion, a review course is worth every penny. It helped me better organize my study materials, effectively prioritize the most important information, and develop a framework to prepare for the exam. I haven't met one NP who did not find an exam review course to be beneficial.

The Job Hunt

In some cases, practicum experiences in NP school can lead to a job upon graduation. However, this is not always the case. The new NP should start searching for a job when they are comfortable doing so. However, it's important to keep in mind that the process will likely take much longer than applying for and securing a new RN job. Some NPs aim to have a job waiting for them prior to graduation, while others prefer waiting until passing board exams to begin the search. The new NP should have an updated resume that suits their desired job and it should be tailored to each position they apply to. Many resources exist for support with resume writing, and these can be highly valuable tools for the new NP.

Role Transition

Working as an NP involves a different set of tasks and skills than an RN role. However, the critical thinking skills developed while practicing as an RN will serve as a foundation for future NPs. These new skills will continue to build and advance—even many years into practice. Particularly when working in the same location, the line from RN to NP can be a tough one to cross. It can be challenging for others to see you take a new role with different expectations. Give yourself the grace to acknowledge that it's okay to not know everything and gaining confidence in this new position will take time.

Ask Questions

It's normal to have many questions as a new NP. Never be afraid to ask them, as this is how learning continues after graduation. Particularly during COVID times, practicum experiences may have had limited clinical opportunities. When starting out, a new NP will have unfamiliar experiences or situations daily. Understanding everything from the very beginning should never be expected.

Find Resources

Whether working in primary care or a specialty, a variety of invaluable resources are available for NPs to refer to. As a medical oncology NP, UpToDate and the National Comprehensive Cancer Network (NCCN) are resources that I continue to use daily— even 10 years into my career. Finding the most useful tools and bookmarking them for future reference will make practice much easier. As time goes on, a great deal of information will be committed to memory.

Collaboration

Serving as a crucial piece of providing excellent patient care, collaboration lies at the heart of the NP role. This includes teaming up with patients, RNs, and other staff members. In addition, the relationship with the collaborating physician should be strong. While some states offer full independent practice opportunities for NPs, many require some level of collaboration with a physician. The new NP needs to work alongside someone that they feel comfortable with and can turn to with questions without feeling judged. Furthermore, the NP should believe that the collaborating physician does a good job in their role. There may be a period of time where the new NP feels that they have to earn their trust and prove themselves. However, the physician also needs to earn the trust of the NP. Having a poor relationship with a collaborating provider can lead to significant job dissatisfaction. Even if working completely independently, establishing a strong dynamic with a more experienced healthcare provider can be invaluable.

***

All experienced NPs will be able to recall some things that they wish they knew when first starting out. It's important for new NPs to remember that they will never be expected to know everything immediately and should embrace opportunities to work in positive environments that promote ongoing collaboration. Additionally, keep in mind that the first job after graduation may not be a perfect position. However, it will certainly offer much to learn from.

4 Tips to Succeed in Nurse Practitioner Clinical Rotations

Posted on March 5, 2021 | by Amy Quynh L.N. Tran, FNP-C | Leave a Comment

Prior to enrolling in the nurse practitioner (NP) program, all students are registered nurses who typically already have experience in various clinical settings. However, the NP program can still present additional challenges, particularly as it pertains to the clinical rotation portion of the curriculum. Becoming a lifelong learner is part of being a successful nurse, but for an RN with prior clinical experience, it can be hard to take on these NP opportunities with fresh eyes. Here are four tips to maximize your NP learning experience.

Tip #1: Get to Know Your Clinical Preceptor, Staff, and the Community

Arrive early on the first day to clarify expectations and preferences with your preceptor.

Address the following questions:

How should the NP student present themselves at each patient visit?
Will the preceptor come in and see the patient first, with you seeing them afterward? Or will you and the preceptor come in at the same time?
What are the preceptor's preferences for case presentations?
Do you only observe on the first day, and can you take notes? Should you ask questions while seeing the patients, or wait until you are out of the room? Also, see tip #4.

Learn the names and roles of the clinical staff and consult with them as appropriate. Be sure to say "thank you" often!

Regarding the community, proactively ask about the patient's age, gender, ethnicity, socioeconomic status, and typical conditions seen in their population. You should also know how to locate all nearby ER, labs, hospitals, pharmacies, and specialists. Do a drive-by to explore the housing conditions, demographics, neighborhood safety, and environmental hazards. This will give you a sufficient understanding of your patient's experiences.

Tip #2: Prioritize a Patient's List of Concerns at Every Visit

Many patients will have a long list of active medical diagnoses. While you should be knowledgeable about these conditions, you might not be able to address everything in one single visit. Therefore, it is important to prioritize and shape patient expectations. You may start with asking the patient, "What brought you in today?" It is critical to avoid missing new and potentially serious concerns while still addressing key management goals of chronic conditions. It may be helpful to set an agenda with the patients. Try saying, "There are a lot of important concerns. Let's focus on your new onset of heart palpitations and hypothyroidism management today. We will discuss your diabetes, gout, and chronic back pain management at the next visit since we only have 15 minutes for today, okay?"

Tip #3: Learn to Communicate Well with the Patient

Prior to seeing the patient, aim to review charts, look up conditions as needed, and formulate a tentative plan. When seeing the patient, introduce yourself while maintaining good eye contact, listen carefully, and establish the agenda and expectations. It is imperative that you ask for permission before laying hands on your patient's body. Additionally, as you perform your physical exam maneuvers, make sure to communicate your findings and clarify what you are looking for to ease your patient's comfort.

Tip #4: Learn to Give a Well Thought-Out Patient Presentation to the Preceptor

Check with your preceptor to determine the process for presenting new and established patients. Keep a go-to template to adjust as needed to suit your preceptor's preferences. Here is an example:

TEMPLATE: Patient's name, sex, age, presenting concerns, list of medical diagnoses, current medications, and newest lab results.

Concern #1: Chronological history of present illness. Relevant physical exam findings. Treatment plan. Questions for the preceptor.

Concern #2: Same as above.

Other concerns: Follow-up plan.

CASE EXAMPLE: Mrs. Jane Doe, 63-year-old female, is here for a new onset of chest palpitations. History of hypertension and hyperlipidemia, diabetes, and hypothyroidism. On Metformin 500mg BID, Atorvastatin 20mg QD, Levothyroxine 100 mcg QD. Latest lab results from 3 months ago at annual visit include HbA1C at 7.1, TSH at 2.8, Lipid panels (list lab values), CBC (list lab values), CMP (list lab values).

Chest palpitations. She noticed the chest palpitations about two months ago. It occurs abruptly while at rest at a frequency of approximately once a week and a few seconds at a time. No other associating symptoms such as tingling in the arms, shortness of breath, or dizziness. Heart rate and rhythm normal with pulse at 88, 12-lead EKG shows normal sinus rhythm. Because she has hypothyroidism, her Levothyroxine may not be at the therapeutic level, causing the palpitations. My plan is to re-check the TSH level. Could there be other explanations and treatment plans for her concern?

Hypothyroidism. She has had hypothyroidism for one year and it is currently well-controlled. Her Levothyroxine dosage was increased to 100mcg from 75mcg at the annual visit three months ago. During the exam, skin is warm, dry, and intact with no lesions; thyroid is not palpable. I would like to re-check her TSH lab level due to a recent increase in dosage and the new onset of palpitations. Is there anything else I should be checking?

Other concerns. We did not discuss her diabetes today. I would like to schedule an appointment in two weeks to address this.

***

With a few tips like this in your back pocket, you can rest assured that your NP clinical rotations will help prepare you for a long and rewarding career.

Student Loan Forgiveness: 4 Options for Nurse Practitioners

Posted on February 23, 2021 | by Rebecca Brunelle | Leave a Comment

Are you a nurse practitioner who is saddled with student loan debt? If so, you're not alone!

For many nurse practitioners, the financial burden of getting their degree is the only downside to the profession. With a nurse practitioner degree costing up to $100,000, it is not surprising that many nurse practitioners take out student loans. In fact, according to the American Association of Colleges of Nursing, the average nursing student loan debt is between $40,000 and $54,999.

The good news is there are multiple student loan forgiveness programs to help ease this financial strain. There are strict guidelines to qualify for the programs, but for those who meet the requirements, they are certainly worth applying for.

Federal student loan forgiveness programs available to nurse practitioners include:

Nurse Corp Loan Repayment Program (NCLRP)
Indian Health Services Loan Repayment Program (IHS)
Public Service Loan Forgiveness (PSLF)

Nurse Corp Loan Repayment Program (NCLRP)

The Nurse Corp Loan Repayment Program is an excellent option for nurse practitioners who want to work in under-served communities or in academics. The program repays up to 85% of student loan debt for nurse practitioners who work in a Critical Shortage Facility (CSF) or who work as faculty for eligible nursing schools.

Eligibility Requirements For Nurse Practitioners

Applicants must be U.S. citizens or lawful permanent U.S. residents.
Nurse practitioners must work full-time, which is a minimum of 32 hours per week, at either a CSF or an eligible nursing school.
Applicants must have an active, unencumbered license and have a post-graduate degree from an accredited nurse practitioner program.
There are no income requirements, but priority is given to applicants with the greatest financial need.

Amount of Debt Forgiveness

The baseline loan forgiveness is 60% in exchange for working two years in a CSF or working as a nursing faculty at an eligible nursing school.
After completing the minimum two year requirement, nurse practitioners have the option of working a third year in their approved practice location to earn an extra 25% reduction, for a total of 85% loan repayment.

How to Apply

Nurse practitioners interested in the program may apply online using the Health Resources & Service Administration (HRSA) loan repayment application portal .
For questions about using the portal or the application process, applicants can call 1-800-221-9393.

Indian Health Services (IHS) Loan Repayment Program

The Indian Health Services (IHS) Loan Repayment Program pays a maximum of $40,000 in student loan debt of eligible healthcare professionals in exchange for working two years in healthcare facilities serving American Indian and Alaska Native communities. After the initial two-year commitment, providers may continue to work with IHS until their student loans are paid off in full.

Eligibility Requirements for Nurse Practitioners

Applicants must be U.S. Citizens.
In order to apply, applicants must have an unencumbered license or be in the final year of a postgraduate nurse practitioner degree program. Applicants must be licensed prior to starting employment.
Priority is given to American Indians and Alaskan Natives, but any nurse practitioner who is committed to working at IHS facilities is encouraged to apply.

How to Apply

Nurse practitioners must have an IHS web account in order to apply and it can be created online here.

Public Service Loan Forgiveness (PSLF)

Public Service Loan Forgiveness (PSLF) is an excellent option for nurse practitioners who have worked at least ten years for a qualified employer and still have student loan debt. In order to be eligible for the program, nurse practitioners must have made a minimum of 120 student loan payments. Unlike income-based loan repayment programs, repayment from the Public Service Loan Forgiveness Program is not taxable.

Eligibility Requirements for Nurse Practitioners

Applicants must work full-time for a qualified employer, which includes federal, state, or tribal healthcare facilities and non-profit healthcare facilities.
Only Direct Student Loans or student loans that have been consolidated into a Direct Student Loan are eligible for repayment.
Applicants must have made 120 student loan payments while being employed by a qualified employer. Individuals who pay ahead on their student loans will not qualify before the ten-year mark.

How to Apply

Complete the PSLF application and submit it to the US Department of Education via mail, fax, or upload via the MyFedLoan Portal.
The Department of Education recommends that applicants update and submit the PSLF application annually for each year working for a qualified employer.

State Level Loan Forgiveness

Each state offers loan forgiveness opportunities for nurse practitioners in addition to federally sponsored loan forgiveness programs. The requirements, eligibility, and work commitments vary by state. Information for specific state programs can be found on individual state websites.

If you're a nurse practitioner with student loan debt, don't hesitate to apply for a loan forgiveness program. Paying off your debt is the best way to reap the financial benefits of earning your nurse practitioner degree.

DNP by 2025? 4 Reasons to Support DNP Entry-to-Practice

Posted on January 26, 2021 | by Fran Fasching, DNP, RN, FNP-BC | Leave a Comment

The Doctor of Nursing Practice (DNP) is a terminal degree that serves as an add-on program to the Master's of Science in Nursing (MSN). Currently, nurse practitioners (NPs) obtain an MSN and then return to complete a DNP program. As a rigorous degree with an emphasis on clinical expertise and leadership skills, the DNP program culminates with an evidence-based practice project. DNPs are prepared to translate evidence into practice, lead patient care teams, evaluate patient outcomes, and promote system change. There are currently over 300 DNP programs in the U.S. with more than 8,000 DNPs, which represents approximately 1% of NPs in the country. DNP programs strengthen the MSN by providing additional education around evidence-based practice, quality improvement, and systems leadership.

Why the DNP?

The value of the DNP models other health professions that transition to doctoral degrees such as physical therapy (DPT), pharmacy (PharmD), Psychology (PsyD), and Audiology (AudD). Doctoral education prepares today's health professionals for the complexity of modern healthcare due to:

The rapid expansion of knowledge underlying practice.

Increased complexity of patient care.

National concerns about the quality of care and patient safety.

Shortages of nursing personnel, which demand a higher level of preparation for leaders who can design and assess care.

Limitations of doctorally-prepared nursing faculty.

Enhanced educational expectations of other members of the healthcare team.

Proposing Change

In 2018, The National Organization of Nurse Practitioner Faculties (NONPF) committed to assisting all entry-level nurse practitioner (NP) programs with shifting to the DNP by 2025. In other words, the MSN exit point will dissolve and the DNP will become the common endpoint. NONPF emphasizes that the addition of curriculum around evidence-based practice, quality improvement, and systems leadership is critical for modern healthcare.

Since 2002, NONPF has promoted a seamless path for obtaining the DNP. In 2004, the American Academy of Colleges of Nursing (AACN) proposed that the DNP should be the entry-level degree for NPs. However, transitional challenges prevented the accomplishment of this goal. In 2006, NONPF announced plans for completing the transition by 2025.

Challenges to Change

Although support for eliminating the MSN varies across academia, there are more concerns outside of the educational realm. The AACN identifies the following barriers of removing the MSN step:

While the MSN continues to be the dominant pathway for APRN entry-into-practice education, there is some limited movement toward replacement with the BSN-to-DNP.

Two tracks toward the DNP will remain, as defined by schools' planning horizons: a single-step process (BSN-to-DNP) and two-step process (BSN-to-MSN followed by an MSN-to-DNP at a later date).

Requirement of the DNP for certification and accreditation is an important factor in schools' decisions to eliminate the MSN degree.

There is no demand for DNP-educated APRNs by employers.

Elimination of the MSN raises costs and budgetary concerns for many schools—particularly those that are not freestanding or autonomous.

Supporting the DNP Entry-to-Practice

Despite the difficulties involved in eliminating the MSN and promoting the DNP as an entry-level NP degree, the advantages are undeniable. In addition to ensuring the best quality care for patients, this degree offers the following benefits for the nursing profession:

Higher income potential. DNP-educated NPs earn approximately $7,000 more per year than MSN-educated NPs. Learn more about NP salaries.

More position choices. More education results in an increased amount of choices. DNPs can explore opportunities in nursing education, nurse leadership, and healthcare administration.

Opportunity for advancement. As DNP knowledge and capabilities become increasingly mainstream, hospital networks have begun promoting individuals in this role to advanced positions. In fact, nurses must participate in shared governance to qualify for Magnet Hospital status. The DNP is an important part of this initiative.

Greater job security. The expansion of nursing in today's healthcare system has led to increased recognition around the importance of DNP knowledge in advanced nursing practice, organizational leadership, and healthcare policy. This creates higher job security for the DNP.

In addition to elevating the position to the doctoral level, the universal DNP helps create an equitable environment among NPs, increase wages across the board, and expand professional opportunities. The DNP is not only an advanced practice provider, but a practice change agent as well. While creative change may be a challenge for academia, support from current DNPs and future NPs will propel professionalism and job satisfaction to new heights.

Acing the Virtual Job Interview: 6 Tips for Nurse Practitioners

Posted on January 4, 2021 | by Julie Nyhus | Leave a Comment

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.

1. Upgrade Your Username

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.

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.

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.

Make the Right Decision: Managing Decision Fatigue as a Nurse Practitioner

Posted on December 7, 2020 | by Kelly Coloff, FNP | Leave a Comment

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.

Dear NP Student, From a New Grad NP: Study Tips

Posted on November 13, 2020 | by Michelle Woo, MPH, MS, BSN, RN | Leave a Comment

Whether you are an undergraduate, new graduate, or a seasoned nurse, entering a nurse practitioner (NP) program is an exciting time. However, it can also be a stressful one. In fact, you may discover that NP school will be one of the most difficult academic endeavors you experience. At the end of the day, any advanced practice health provider role requires a great deal of studying and the ability to put complex material into practice.

Despite being a full-time graduate student who was no stranger to hard work, I still remember the stress of my first semester. Luckily, my program provided some insightful resources that helped me recognize the importance of learning how to study to achieve success. Based on my experience, here are some useful strategies for new NP students.

5 Tips for Didactic Study

Most NP programs will begin with one to two semesters of didactics. This means that there are no clinical rotations just yet. Whether they are enrolled part-time or full-time, students will juggle two to three classes at a time. Here are my five tips for success during didactic semesters.

1. Time Management

Prior to beginning the program, reflect on when and where you study best. Also, understand that you need a resting period. Someone once told me that graduate school is like a job and it should be treated like one. When working as a nurse, consider a per diem or part-time schedule to help ease the transition into NP school. Remember that graduate school is not like undergraduate work.

2. Invest In a Tablet

If you have the funds (and that is a big if), a tablet can boost efficiency. You can write, type, download notes, and more, and it is highly portable. While it's not a necessity, having a tablet was beneficial throughout my entire graduate experience.

3. Student-Life Balance

You will likely hear that NP students "have no life." While I had to learn to say no to certain social events, I also knew that life existed outside of school. I would typically study from 8AM to 5PM every day including weekends, reserving evenings for time with family and friends.

4. Know Your Study Style

There is an overwhelming amount of material that NP students are expected to learn. In addition to adjusting to the transition of graduate student life, you're also required to maintain certain grades to stay in the program. My recommendation is to know your study style. Louisiana State University has a great resource with surveys to help you determine your best study methods.

5. Know the Course's Objectives

This is something that I wish I knew sooner. The course's objectives offer incredible insight into what students should focus on when studying. Most of these objectives align with the necessary knowledge for boards. Therefore, be sure to review them in the course syllabi and weekly modules.

Clinical Rotation Study Tips

When you enter the clinical rotations phase, it's important to factor in travel time and patient entries as well as other additional assignments. Both can be time-consuming. Here are some tips to study effectively.

1. Listen to Relevant Podcasts

I often played medical podcasts in the car while driving home. As a Family Nurse Practitioner student, my favorites were American Family Physicians and The CurbSiders Internal Medicine. Many of my colleagues purchased MP3s from multiple board review sources such as APEA and Fitzgerald.

2. Learn in Rotations

Rotations offer an opportunity to apply didactic knowledge in hands-on situations. From suturing cysts to pelvic exams, it's critical to advocate for your participation. Learn how to assess for abnormalities while allowing preceptors to educate you. You will utilize these skills when practicing professionally.

3. Review Material

If there is material that you're unfamiliar with as a student, take the time to review it and gain an understanding of differentials and treatment plans. Even after graduating, it's crucial to become accustomed to reviewing and staying updated on current guidelines for treatment and preventive care. Making this a habit during rotations is important for doing well in clinicals and achieving long-term professional success.

Becoming an NP is a path that can only be understood by those who have experienced it. As a new graduate, I can empathize with the difficult transition to student life and working to pass exams every semester. I hope that new students can learn from my experience and utilize my tips. The journey is tough, but ultimately it is a rewarding one.

What Is the Role of the Nurse Practitioner Student in Clinical Rotations?

Posted on November 7, 2020 | by Amy Quynh L.N. Tran, FNP-C | Leave a Comment

Simply put, the objective of a nurse practitioner (NP) student is to become a competent clinician. Through clinical rotations, he/she will need to develop and implement foundational skills and knowledge for their future clinical practice. To accomplish this, the NP student should be actively and enthusiastically involved in patient care as a member of the diagnosing and treating team—not a scribe or errand-runner. However, the NP student is not an independent practitioner just yet. Therefore, they can only participate in patient care under the guidance and supervision of the authorized preceptor. The NP student should have a clear understanding of their roles and responsibilities to maximize their time during clinical rotations.

What to Expect During an NP Preceptorship

There are several key hands-on duties that NP students are responsible for during their preceptorship.

1. Take Patient History, Perform Physicals, and Propose Differential Diagnoses and Treatment Plans

Depending on the clinical setting, a new patient's history may be collected in one visit (such as in urgent care, the emergency room, and the hospital) or over two or three visits (as done in family or internal medicine, pediatrics, and outpatient clinics). Regardless of the setting, the NP student should begin the visit by introducing themselves and asking the patient what they would like to address.

If the patient has one pressing concern, the NP student should address that acute issue without neglecting other chronic conditions and perform the physical exam that's appropriate for the problem at hand. For example, if the patient presents an aching leg, the exam should be focused on the lower extremities. An exam for the eyes may not be needed, unless there is another reason. Based on the clinical findings, the NP student should learn to formulate three to five differential diagnoses and an appropriate treatment plan.

2. Present Patient Cases to the Preceptor

During the first initial meeting with their preceptor, the NP student should ask about any format preferences for the presentation. Some preceptors prefer abbreviated versions, while others prefer comprehensive formats for teaching purposes. The purpose of the verbal presentation for the preceptor is to convey the problem-oriented essentials of the patient case. This requires more than just a simple reiteration of what the patient and the labs show. A good patient presentation demonstrates the patient's most concerning issues and includes the NP student's clear plan of treatment and critical analysis.

After seeing the patient, the NP student should spend at least a few minutes organizing their thoughts before presenting the case. They should also aim to keep the presentation concise (about three to five minutes for new complex cases), organized (with history in chronological order, pertinent findings, and labs), and well thought-out (three to five differential diagnoses and rationales for each, as well as recommended treatment and follow up). If the NP student is unable to formulate a diagnosis or plan, they should ask for the preceptor's help. This offers an opportunity to conduct further research online or through textbooks, which demonstrates strong enthusiasm and a "self-starter" attitude.

3. Complete Patient Write-Ups

The note that comes from the NP student should demonstrate a comprehensive grasp on the patient's presenting case. It should follow the SOAP format (Subjective, Objective, Assessment, Plan) as learned in NP programs. Since the preceptor is ultimately the person who is legally responsible for the patient's care, the NP student should review the plan with the preceptor first before discussing with the patient. The ‘plan' includes ordering further screening or diagnostic tests, writing prescriptions, and providing patient education. It is important the NP student learns how to write the prescriptions appropriately under the preceptor's guidance. All notes, orders, and prescriptions need to be reviewed and co-signed by the preceptors.

4. Obtain Constructive Feedback from Preceptors

After presenting the case to the preceptor, the NP student may directly request for any suggested improvements to the presentations or write-ups. If the NP student has a specific need for further instructions, they should ask the preceptor if they can go over a certain physical examination such as a cardiac or ankle exam. Additionally, the student should schedule a mid-term evaluation with the preceptor to gauge how they are doing and where they can improve.

5. Read for More Insights

Reading is a great way to expand your understanding of diseases and different patient cases. Before each visit, it's helpful for the NP student to read the patient's charts and pertinent scientific literature to formulate an approach ahead of time. By understanding the patient's primary concern, the student can determine appropriate questions to ask during the history-taking and establish a physical exam to focus on. Proper preparation before seeing the patient will save time during the interaction.

Before the physical exam, an NP student may briefly read over the patient's chart again or their own notes to ensure that the proposed approaches are correct.

In advance of each case presentation, NP students should review their findings to solidify the rationale and clarify any aspects they are unsure about.

Between patient visits, reading critical medical literature that relates to patient cases can improve overall understanding.

Is A ‘Locum Tenens’ Job For You? The Pros and Cons for Nurse Practitioners

Posted on November 3, 2020 | by Julie Nyhus | Leave a Comment

The U.S. Bureau of Labor Statistics expects employment for nurse practitioners (NPs) to grow 45 percent from 2019 to 2029. Therefore, now is the ideal time to consider temporary clinical assignments—better known as ‘locum tenens' jobs, which is Latin for "to hold a place." These assignments cover all medical specialties and practice settings, with durations ranging from days to months.

How Nurse Practitioner Locum Tenens Jobs Work

It's most common for locum tenens NPs to work with healthcare staffing companies, as they play a supportive role in NP licensing, credentialing, relocation, and placement. However, locum tenens nurse practitioners can also work directly for organizations as temporary employees or independent contractors. Here's a basic rundown of NP locum tenens positions.

The Healthcare Staffing Agency

Healthcare staffing companies handle temporary work contracts from hospitals, clinics, and facilities. Reasons healthcare employers use locum tenens can vary. Some need temporary support due to challenges filling permanent positions or covering for leaves of absence. Staffing agencies are actively involved in the NP placement process, ensuring that candidates are experienced and qualified.

The Contract

A quality staffing company will protect the interests of both the nurse practitioner and the hiring facility. Nurse practitioners can expect a legally binding contract outlining the terms of agreement such as the assignment, start and end dates, pay rate, and stipends. The temporary contract varies by location and facility and becomes an important element of the tax-related requirements associated with locum tenens work.

The Travel

For tax purposes, functioning as a locum tenen means temporary and periodic movement away from your tax home. So, how far away is "away from the tax home?" Although the IRS does not state an exact distance, it must be far enough that rest or sleep are required for the NP to perform the work.

The Reimbursement

Often, the NP pay package will contain tax-free reimbursements. The IRS expects tax-free reimbursements to be for expenses—not substitutions for wages. In order to qualify for tax-free reimbursements, the NP must have a legal and established tax home. This means not working too long in one place, or not working in the same area for more than 12 out of 24 consecutive months. The temporary contracts serve as proof of these requirements.

Pros of Locum Tenens Assignments

Nurse practitioners who enjoy the challenge of working in new environments often gravitate toward locum tenens positions. This is also a good arrangement for NPs who don't want to be tied down with a permanent position, or even for those looking for extra work on the side. Other advantages include:

No quotas. Locum tenens are paid hourly or weekly wages. With no productivity quotas, the primary focus is patient care.
Great pay. Reimbursement depends on the specialty and state that you work in, but it is always comparable to market value. NPs should negotiate a competitive hourly or weekly wage, along with travel or lodging expenses that are paid or reimbursed by the agency. Additional benefits may include malpractice insurance or free continuing medical education credits.
Flexibility. Will you work full-time, part-time, or extra shifts? When, where, and how long will they be? You can let the agency's travel team arrange housing and travel accommodations, or find it yourself. It's your choice!
Discover. Traveling involves discovering the culture and tastes of new places. It also means a variety of unique clinical experiences—from serving patients in rural areas to working with front-line technology in leading teaching hospitals. Even if your locum tenens assignment doesn't take you too far from home, exploring a different healthcare organization or part of town can give you a fresh perspective.

Cons of Locum Tenens Assignments

The unpredictable nature of locum tenens jobs is not suited for every nurse practitioner. Before you commit to this type of working arrangement, be sure you are aware of the following:

You will be expected to hit the ground running. You won't need a ton of experience, but you will need to know what you're doing. These positions do not offer long orientations or drawn-out breaking-in periods.
You will need to be alert. Recruiters don't work for you—they exist for their clients. Some staffing agencies will earn commissions on each NP salary. This isn't a bad thing, but it's important to recognize that not every recruiter will have your best interest in mind. The final choice is always yours.
You will need extra advice. Prior to beginning a locum tenen assignment, consult with your tax preparer. Discuss taxation laws, as well as taxable and nontaxable reimbursements in the states you're traveling to (if applicable). Do not depend on the staffing agency to give you tax advice.

How to Get Started As a Locum Tenens Nurse Practitioner

If you've weighed the pros and cons and come to the conclusion that you'd like to try out locum tenens NP positions, the following tips will make your transition much easier:

Know what you want. Do you need benefits, travel, lodging? Will you need a 1099 or W2 for payment? Where do you want to go? How far from home are you willing to travel? What are the practice laws in the states you're traveling to? Ask yourself these questions before you contact a staffing agency.
Make a timeline. If substantial travel is required, getting started means lining up your own travel readiness with the requirements of the state or region you're heading to, and then aligning that with current demand. Maintaining a multi-state RN license in a Nurse Licensure Compact state can help you find work faster while obtaining licensing for other states.
Research agencies. Choose at least four agencies with strong reputations. Good recruiters are those who return calls and follow up. It's not uncommon for NPs to use multiple agencies, depending on their needs.
Gather and organize. Keep all of the documents you need in one place. Make PDFs of licenses, certifications, vaccination records, reference letters, and CEUs so they are ready to email at a moment's notice.