Category: Nursing Types & Specialties

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.

Gail Adcock, MSN, FNP, FAANP, FAAN, and North Carolina state representative, describes herself as "a nurse by grace, a North Carolinian by choice, and a politician by necessity.” Representative Adcock is a nurse practitioner and the Chief Health Officer for a global data analytics company. Despite her busy professional and personal life, Representative Adcock made time to respond to an important call to action.

Per the 2011 Institute of Medicine report "The Future of Nursing: Leading Change, Advancing Health," the call to action is: "Nurses must see policy as something they can shape rather than something that happens to them." This report outlines the vital role, power, and influence of NPs and nurses in the healthcare system.

Why Aren't There More Nurse Practitioners in Political Positions?

The answer is that politics is definitely out of their comfort zone. Busy NPs are often unfamiliar with and intimidated by the political process. However, as patient care champions, NPs also offer a unique view of community and health care needs. Nurse practitioner qualities that translate to health policy include the following:

• Nurse practitioners advocate. Nurse practitioners advocate for patients on a daily basis and advocating health policy and legislation is equally important. An upstream approach to advanced practice, nursing, and health care issues impact communities and patients on a broader scale. 

• Nurse practitioners vote. 89% of NPs vote in national elections, compared to just 69% of the US population (O'Rourke, et al., 2017). Therefore, it's important to encourage both your NP and nurse colleagues to vote.

• Nurse practitioners and nurses are the most trusted profession. For nearly 20 years, Americans have rated nurses as the most trusted professionals. And why wouldn't you want somebody you can trust in office? Honesty and integrity are important assets for holding leadership positions in both community organizations and public office.

• Nurse practitioners are part of the largest sector of the U.S. healthcare workforce. Over 3 million NPs and nurses provide direct care to patients and communities. Nurse practitioners administer care in patient homes, neighborhoods, and health networks, and identify social and healthcare needs in a unique way that is unlike any other health profession.

How Can Nurse Practitioners Respond to This Call to Action?

NPs need to expand outside of their comfort zone, discover their collective voice, spark others, take interest in the legislative process, and translate the patient care experience into action. Remember that it's okay to start small! This seven-step health policy toolkit serves as an NP blueprint for health policy involvement.

1. Learn About the Political Process of Local and State Governments

Investigate local governments and governing bodies in your town and community. Next, learn how laws are introduced and passed in your state. You can find this information through state legislation websites. These websites also allow for bill searches using specific keywords. Search for "nursing" or "health care" to stay up-to-date!

2. Vote

There is strength in numbers for NPs and nurses, and this political strength begins with voting! Aim to include health care policies in your legislative decisions, and discuss these policies with your NP and nurse colleagues.

3. Join Nursing Organizations and Find a Mentor in the Advocacy Group

Professional nursing organizations have expanded from education and certification resource centers to include political advocacy groups. The American Nurses Association (ANA), National Council of State Boards of Nursing (NCSBN), and Campaign for Action are some state and national nursing organizations that offer health policy guidance. Additionally, NP organizations such as the Gerontological Advanced Practice Nurses Association (GNPA) offer health policy resources that are applicable to the specialty NP group.

4. Seek Nursing Leadership Positions

Advancing nurse practitioner responsibilities beyond patient care into policy builds increased public confidence in the NP role and demonstrates that nurse practitioners are educated, trusted, and reliable leaders.

5. Participate in Community Groups

As health professionals, gaining NP input on Parent Teacher Associations, support groups, and fitness and nutrition groups is beneficial. Nurse practitioners can contribute health and safety strategies, assess community needs, and offer valuable health and illness-related guidance.

6. Identify a Bill That You Are Passionate About and Write to Your Legislator for Support

Nurse practitioners are valuable constituents due to their close proximity to stakeholders and community needs. Search your state government website for health care bills, and then research local politicians to ask for support. In your letter, mention your community and how the bill impacts your patients. 

7. Apply for a Health Policy Fellowship

Distinguished programs developed through organizations like the American Association of Colleges of Nursing, National Academy of Medicine, and Robert Wood Johnson Foundation seek nurse practitioner leaders to participate in national policy development. As NPs evolve into policy leaders, these fellowships provide a stepping stone into health policy development positions.

READ MORE: Nurse Practitioner Practice Authority

Nurse practitioners can answer this call to action in various ways, and every little bit helps! By following the simple actions included in the toolkit, even the busiest NPs can begin the path to understanding and participating in health policy.

From insurance reimbursement and billing to coding and audits, these responsibilities can leave any healthcare provider with goosebumps – especially those who work in or own their own private practice. The most stressful part, in relation to insurance reimbursement, is that most healthcare providers like nurse practitioners are not formally trained in billing and coding and work in a clinical setting or facility with no certified billing and coding specialists. Luckily, there are a wide variety of resources available to help decode this unfamiliar territory.

Coding Basics

Accurate coding is critical for insurance reimbursement, succinct documentation, and identifying clinical care gaps. The Healthcare Common Procedure Coding System (HCPCS) codes and International Classification of Diseases, 10th Revision (ICD-10) codes serve as the building blocks of medical coding.

• HCPCS Level I codes: These codes are used to describe medical, surgical, diagnostic, and other types of medical services. In addition, there are modifiers that help identify alterations to HCPCS codes.
  • Category I: Common procedures
  • Category II: Performance measurements
  • Category III: Emerging technologies
• HCPCS Level II codes: These codes are used to describe products, supplies, and services provided during an encounter.
• ICD-10 codes: These codes are used to describe the reason for a patient encounter or outline a patient's characteristics, and are essential for identifying common diagnoses in a medical practice. They notify the insurance payer of the medical necessity of the visit.

Evaluation/Management Coding

Evaluation/Management (E/M) coding is the core of healthcare billing and insurance reimbursement. Understanding E/M coding can help maximize the insurance reimbursement of a practice and reduce stress levels during audits. These codes are based on several factors:

• The patient's history
• The patient's physical exam
• The provider's medical decision making
• The appointment time, specifically if the provider spent 50% of the visit coordinating care or counseling

There are different levels for the aforementioned factors, which decipher which E/M code to use.

1. History
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
2. Physical Exam
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
3. Medical Decision Making
   1. Straightforward
   2. Low complexity
   3. Moderate complexity
   4. High complexity

The level of complexity related to medical decision making depends on the number of diagnoses and management options, the complexity of the patient data that was reviewed, and the risk of complications or morbidity/mortality.

Transition of Care Billing and Coding

Transition of care visits are an efficient way to support the continuity of care after a patient is discharged from a skilled nursing facility/nursing facility, long-term acute care hospital, rehabilitation hospital, acute care hospital, or observation stay in a hospital. A transition of care visit can only be billed one time per patient in a 30-day timeframe, and can be billed for both new and established patients at a particular clinic.

Transition of care visits can be billed using two different codes.

• 99495-This code can only be used if the patient has been contacted within two business days of their discharge, the medical decision making is of moderate complexity, and there is an in-person clinic visit within 14 days of the discharge.
• 99496- This code is used if the patient has been contacted within two business days of their discharge, the medical decision making is of high complexity, and there is an in-person clinic visit within seven days of the discharge.

Medicare Wellness Coding and Billing

Medicare wellness exams go beyond a typical annual adult wellness examination. In addition to focusing on a patient's wellness, these exams involve a thorough screening centered around disease prevention. The exam also takes a more comprehensive look at the patient's vital signs, medical/family history, and health risk assessments including their emotional and psychological well-being to develop a personalized prevention plan. Many types of healthcare providers can complete these wellness exams, including:

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Registered dietitians
• A team of medical professionals with an overseeing physician

RELATED: Complete Guide to the Adult-Gerontology Nurse Practitioner Specialty

Pediatric Coding and Billing

Accurate coding for the pediatric population is similar to the process for the adult population with several additional considerations including behavior screenings, developmental screenings, and vaccine administration. Another complication is that not all of these screenings and vaccines are completed at every age. Each well child examination typically has different screenings and different vaccine administrations or they may not have any vaccines at all. That's why it is important to follow the recommendations of Bright Futures, which establishes guidelines that insurances follow.

RELATED: Complete Guide to the Pediatric Nurse Practitioner Specialty

Initially, the billing and coding world can be daunting and confusing. Luckily, there are a variety of resources available to help providers make sense of this information. In addition to online resources, there are several textbooks and conferences that can strengthen a provider's knowledge of accurate billing and coding. Accessing the right resources can help providers boost their understanding, which leads to more efficient documentation, increased reimbursement, and decreased stress during chart audits.

Whether you're a newly graduated nurse practitioner or an experienced NP, contract negotiation can be intimidating to even the most confident people. Poor salary negotiation doesn't only affect you – it reflects on our profession and sets a precedent for NPs interviewing behind you. If you accept less, then the NPs below you will be offered less as well.

Why Is Contract Negotiation Difficult for NPs?

Negotiating goes against a nurse's nature. The best qualities of nurses – caring and empathy – work against us during negotiation. Place these traits aside and bring your communication capabilities, attention to detail, and leadership skills to the forefront.

There is a gender gap in negotiating. Men earn almost 25% more money than women because they negotiate more aggressively. Traditional gender roles and the nature of nursing ultimately compound the gender gap. Nurses – and women in general – are often expected to be accommodating, considerate of others, and relationship-oriented. These traits can make it difficult for women to be assertive negotiators. In contrast, the societal expectation of male nurses – and men in general – involves a competitive, profit-oriented, and aggressive personality. As a result, men are more comfortable negotiating pay and benefits.

Nurse practitioners are more needed and valued than ever! According to the 2011 Institute of Medicine report "The Future of Nursing: Leading Change, Advancing Health," NPs will lead the country in caring for aging baby boomers, serve as champions in primary care, and continue to be a part of the largest health care workforce in the U.S. A fair salary is essential to reflect the value of NPs, and reasonable salary negotiations benefit the profession as a whole.

Confidently Negotiate Your Contract by Following These Four Steps

1. Prepare For the Conversation

a. Research NP salaries. In the U.S., this can vary by location and hospital network. An online search can help, but the best resources will be your NP peers. Call previous clinical preceptors or ask professors what salary to expect after graduation.

b. Gather background information about the practice. What is the community and patient population? How many physicians and providers are in the practice?

c. Practice confidence! Perfect your body language by sitting up straight and avoiding fidgeting. Keep your tone of voice pleasant and maintain eye contact throughout the conversation.

2. Say No To The First Offer

If the first salary offer seems below average or is not where you’d hoped it would be, it may be a low-ball number. So how do you know what to counter offer?

a. Aim to add at least 10% to the initial proposal. It’s also a good idea to research the market rate for the position in your area, taking into account your education and experience level, and calculate your counter offer accordingly.

b. Be prepared with reasons as to why you are requesting more. Do you hold additional credentials or certifications? Do you have extensive niche experience? If an employer wants to know why you are counter-offering with a higher salary figure, be sure to highlight why you are worth it.

3. Annual Salary Isn't the Only Consideration – Be Prepared to Address Additional Perks

a. Negotiate orientation time – An appropriate mentored orientation time – especially for a new graduate – is three to six months. Make sure to include this orientation time in the contract, as informally-discussed orientation times can end up shorter than agreed upon.

b. Are you taking after-hours calls? Get paid for it. In some practices, after-hours and weekend call time is a regular part of employment. Expect additional pay for on-call hours.

c. Negotiate your contract yearly. It's not unusual for an employment agreement to automatically renew annually. Holding a yearly review of your work and a discussion for new contract terms is standard and allows you to renegotiate salary and other contract terms.

d. Remove any restrictive covenants. A restrictive covenant (or a non-compete clause) is set to prevent you from working within a specific area (usually within 25 miles) of the practice and can be in place for one to five years after your employment ends. Never agree to sign a contract with a restrictive covenant. These restrictions force NPs to move or commute long distances and if you leave the organization for any reason, the restrictive covenant still stands.

e. Termination. Both parties should share the same terms to end the employment agreement. Health care providers give three months notice when they resign and conversely, the practice should be required to provide the NP with the same three months notice of termination. It takes 90 days or more to find another job and complete the credentialing process.

f. Negotiate a bonus. It is possible to receive an annual bonus based on performance and practice success. Sometimes, Relative Value Units (RVU) determine bonus pay. RVU, used by insurance companies to pay providers, is based on the extent of the provider's work, necessary resources, and expertise in providing patient care. Physician partners receive year-end rewards and so should you!

4. Sleep On It

Don't give an immediate answer. Take at least a day to consider the proposal and decide if the job and contract detail is right for you.

Negotiating the right contract delivers professional satisfaction and respect from practice management, which ultimately benefits the NP profession. Never be afraid to get out of your comfort zone and negotiate!

Prior to becoming a nurse practitioner (NP), you gain experience administering and educating patients about medications and medical conditions as a registered nurse (RN). Now, as an NP trainee or practicing NP, your tool kit is enhanced with an extra layer of complexity due to the responsibility of accurately diagnosing patients presenting clinical symptoms, prescribing the right medications, and managing conditions successfully.

The more practice you have under your belt, the more confident and knowledgeable you will be regarding the process of diagnosing, utilizing diagnostic tools, and selecting the right medical regimens for your patients. Your nurse practitioner education should effectively prepare you for this advanced practice role. It is important to have tools ready at your fingertips to quickly double-check any clinical suspicions or simply look up the right medication for the medical condition you are treating.

While technology makes looking things up much faster and easier than ever before, keep in mind that these tools are for reference only. Make sure to also use your critical thinking and clinical judgment before implementing any recommendations. If you are still unsure, it's recommended that you check with a more experienced clinician and additional trustworthy print or online resources.

1. Medication Look-Up Tool

In cases when the NP is seeing patients back to back, he or she might need to quickly double-check the indications or contraindications, dosing, and adverse effects of a particular medication before prescribing it to a patient.

The Epocrates app serves as a go-to app for many clinicians, offering a free way to lookup medications. It also allows you to check interactions with other drugs by inputting all medications that a patient is taking into the app. Remember to always check for contraindications, interactions, and the patient's history of medication allergies before you prescribe. Additional features such as information on diseases are also available for an additional fee. Find out more at www.epocrates.com.

There are many algorithms, calculators, equations, and guidelines that help the NP with quantitatively measuring his or her clinical suspicion of a presenting symptom, or determining whether it is justifiable to prescribe a medication for a patient. Luckily, most of these are readily available.

The MDCalc app is an excellent tool with many guidelines and calculators that you can utilize in clinical settings. It has all of the common guidelines such as the Ottawa Ankle Rule to reduce unnecessary X-ray ordering and the ASCVD risk algorithm for the NP to determine when to start a patient on anti-cholesterol medications, such as statins meds. It is available both as a smartphone app and online at www.mdcalc.com.

3. Medical Management Tool

In clinical settings, the NP may have a long list of patients to take care of. Therefore, it's important to have a concise tool to efficiently look up the most relevant management for a particular medical condition.

The FPNotebook app is a straightforward and user-friendly app that helps the NP formulate differentials and review common management. You can look up information by diagnoses or symptoms. It is available both as a smartphone app and online at fpnotebook.com. Again, remember to use your clinical judgment in every patient encounter.

4. Pediatrics Dosage Tool

The NP is required to dose prescriptions based on the pediatric patient's weight and/or age. For every medication, there is a recommended dosage per kilogram. For example, the recommended dosage for Acetaminophen for children is 10-15mg/kg/dose. So how much should you give a child of 60lbs?

The PediQuikCalc app is an especially convenient tool. All you need to do is enter the patient's weight. The app will then generate the suggested dose, maximum dose, recommended drug strength, adverse effects, dose frequency, and dispense amount per prescription. Of course, these are only recommendations. Find out more at www.pediquikcalc.com.

Learn more about nurse practitioner practice authority.

5. Antimicrobial Tool

Antibiotics misuse is on the rise, which means that the NP needs to be judicious when prescribing them. Other antimicrobials such as antivirals or antifungals require sensible use as well. So how do you choose the right antimicrobial?

The Sanford Antimicrobial Therapy app has been a long-standing trustworthy authority in the antimicrobials world. You can look up which antimicrobial is recommended based on the particular medical conditions. You can also enter the medication name and retrieve a thorough review on the usage, dosage, pharmacology, and major drug interactions. Although the price is steep for the app at $29.99/year, you can also buy a paperback version and keep it in your lab coat pocket. For more info, visit www.sanfordguide.com.

While there are endless tools that you can keep at your fingertips to enhance your clinical performance, these options are especially ideal if you're in a time crunch and need to retrieve concise information efficiently.