What Does A Nurse Practitioner Do All Day?

I get asked this question from many nursing students and thought that I would give you a little peek into my day.

I walk into the back door with a box of charts that I worked on the night before. I can't finish my notes on paper due to my excessive need to talk to my patients and my innate ability to avoid that nasty process. I DETEST paperwork. Thank goodness we are going electronic in a month at the office. The pharmacy will be glad as well.

I head to my office and sigh at the rest of the pile of paperwork that came in the day before when my front desk manager went to check the mail and the fax machine. Take a deep breath, grab my script pad, stethoscope, and first chart of the day and here we go!

Let me tell you right off the bat that I love my job! I always liked being a floor nurse and sometimes worked as a charge nurse but there is nothing better than making my own decisions regarding the patients that I care for. If I am stumped by something, I can always walk around the hallway and consult with my fellow MD who works with me in the office. There are several hours of time that we never lay eyes on each other because we are so busy. Family practice is fun as there is a mix of kids and adults. It's nice to see a smiling face of children who are surprised to see that it's still me that sees them. Often the biggest complaint I get from parents is the fact that too many offices rotate their providers. Kids and adults like consistency.

Most days my mornings are medium to heavy and my afternoons fill up with walkins. I range from a busy day of 24 to a mild day of 13. I prefer around 17-19 to keep the flow going well. Too much idle time makes for a loud and boisterous nursing staff. I don't mind but the doc I work with is used to quiet. Unfortunately, he is outnumbered by women 6 to 1.

Lunch time usually consists of my working on paperwork if I brought something or we got out locally to get away for a little bit.

Afternoons consist of the same flow of patients, phone calls, and paperwork. Sometimes, like today, a patient will show up at the last minute and I will be there for a little longer but I don't mind if it's legitimate.

I often draw labs on the more difficult patients since I have the most hospital experience. I flush porto-caths on some of my patients. The most favorite part of my day is the diagnosis of problems. It's like a detective story every day.

Hope this helps any nurses who might want to go into the nurse practitioner world. Any questions, please leave a comment and I will elaborate on things further.

Including Nurse Practitioners and Physician Assistants In Medical Reform Bills

I recently came across a letter on the Florida Nurse Practitioner Network site that I felt was important enough to pass on to you. Please consider passing it along to your fellow readers and coworkers. If we are not diligent and make sure that we are included in Florida, we will be left behind.

To Whom It May Concern

Florida HB 7107 passed as a Medicaid reform bill during 2011 legislative session. Line 1168 of this bill specifies that enrollees must choose a primary care physician as a primary care agent.

We respectfully request that the word physician be changed to the word provider to legally ensure that Advanced Practice Nurses (ARNPs & Certified Nurse Midwives) as well as Physician assistants are included as a recipient’s primary care provider of record.

This will ensure that enrollees will have a choice in whom their primary provider will be and allow increased access to health care services in their region. Presently, it is estimated that approximately only 5% of physicians accept Medicaid patients.

Currently the managed care contract definition includes advanced registered nurse practitioners (ARNPs) as primary care providers (PCP). As noted here:

Primary Care Provider (PCP) A Health Plan staff or contracted physician practicing as a general or family practitioner, internist, pediatrician, obstetrician, gynecologist, advanced registered nurse practitioner, physician assistant or other specialty approved by the Agency, who furnishes primary care and patient management services to an enrollee.

While neither HB 7107 nor HB 7109 precludes the use of ARNPs as Primary Care Providers, the language in the bill is specific that enrollees MUST choose a primary care PHYSICIAN and does not use the term “Provider”. It is critical for this change to be included in order to expand the access to care as described above

If the current language is NOT changed, a patient may not be able to enroll under a Nurse Practitioner or Nurse Midwife as the provider of choice thus creating further delays in care and widening gaps in healthcare.I feel that it is important to start including nurse practitioners in the wording of these bills because many of my panel are Medicaid patients and they choose me over other physicians. I think that it says a lot about nurse practitioners as a group because it happens all over the State of Florida.

In conclusion, changing the word “physician” to “provider” in HB 7107 line 1168 will increase the efficiency of enrollment, provide increased access and ensure choices for Medicaid recipients when selecting their Medicaid provider.

Thank you for your consideration in this matter.

Please contact me if you have further questions and concerns

Nurse Practitioner Says "Nice To See You But It's My Day Off"

I know that I am your favorite health care provider, but can you please not come up to me in the mall or Walmart and ask me clinical questions? I would think that if I'm in flip flops, a tee shirt and shorts that would tell you that I'm not in a particularly medical frame of mind. Of course, if you are coding, attire is not an issue.
 I shouldn't complain, I know. I am glad that people come to me and trust me to fix all of their health needs that I can. I really love my job! Don't get me wrong!

Please let me get my nails done or shop for food or clothing on my day off... I need the mental break. I cannot remember every detail of your condition and I don't want to appear stupid when I can't remember them all.

Deep down though, I do enjoy the attention. It's like being a rock star..

Continuing Education Conferences Relevant To Nurse Practitioners

I just finished attending the Fourth Clinician's Network Educational Conference in Orlando. The focus of the conference was on developing a culture of quality throughout the health center. Being that I work in a rural health center, it is relevant to my practice.

Often we are fixated on seeing the right amount of patients in order to meet our quotas, but are we really giving them quality health care? How many people are we missing that need screenings for breast and colon cancers? UDS information is collected from random charts and is sometimes really surprising. I don't agree with random pulls of charts because I have such a diverse population of patients and I think that the true statistics will be accurate once the total numbers are seen. I knew that darn statistics class would rear it's ugly head some time!

We are still on paper charting but will soon start electronic charting which, I hope, will help with some of these issues. The system on the computer will flag us when something is on the outliers. Alerts will show us when there are trends in blood sugars and will tell us that an A1C is due or when a patient's blood pressure is above established parameters. These will be good things to keep us on track. It was also brought up at the conference that we should be on the watch for "alert fatigue" which can make us ignore them due to the constant pop ups.

One of the presenters was a gastroenterologist that didn't get his own screening and found himself with stage four colon cancer. It makes one take a closer look at themselves when it comes to taking care of ourselves instead of focusing on everyone else for a change. How many of you have had your colonoscopy done or your mammograms? I can say that I have had both!

Until the next time, be well and take better care of yourselves Because Your Nurse Practitioner Says So!

Nurse Practitioners Should Be Able To Determine That A Person Is Dead Or Not

Read the below information and then if you agree, contact your Florida Senator and your Congressmen/women and let them know that you are fed up with Nurse Practitioners not being able to practice according to our full abilities. Come on! Don't you think that I can't figure out if someone is dead? It doesn't take a rocket scientist to know when a patient's heart has stopped beating and that they have stopped breathing. Of course, in ICU settings, brain waves can be checked. 


"Talking Points for ARNP’s to Sign Florida Death Certificates
Support of HB 1067/ SB 1544
* Relating to Death and Fetal Death Registration *
Representative Mayfield/Senator Jones
· This legislation gives Licensed Advanced Registered Nurse Practitioner (ARNP) the authority and responsibility to complete and sign a death certificate unless there is a non-natural cause of death. In the case of a non-natural death, a physician is required to sign the death certificate.
· Currently, only physicians, medical examiners and coroners have the authority and responsibility in Florida. This legislation will require Licensed ARNPs to have been in charge of the deceased patient’s care, and to have completed a special training course regarding the completion of a death certificate.
· ARNPs are registered nurses who have advanced graduate and doctoral education, clinical preparation to provide acute and primary care, diagnose and treat acute and chronic illnesses in a variety of specialties. Under current law, they are able to pronounce death, ascertain the cause of death and provide the medical information required by the death certificate, but by Florida law, they are not authorized to sign the death certificate.
· This legislation stems from combined efforts to get certification done promptly and correctly to ensure timely completion in the final act of patient care and alleviate the burden of a loved one who must wait for a death certificate to be signed. As many of you may know from personal experience with the death of a loved one, the death certificate serves many purposes for the survivors of the deceased.
· There are nearly 15,000 licensed and certified Advanced Practice Nurses in the state of Florida, capable of accurately and completely certifying the cause of death, recognizing natural versus unnatural death, and referring deaths to the medical examiner when appropriate.
· Allowing ARNPs to sign death certificates, including the cause of death section will strengthen the accuracy of vital statistic information required by the state and federal government to guide public health efforts. According to a recent study in the American Journal of Forensic Medicine and Pathology (2010; vol 31(3), 232-5), 48% (N=371) of death certificates issued from Broward County had at least 1 of the 5 types of errors in the cause of death section. ARNPs can help reduce errors as
they are actively involved in the health status of the patient at time of death.
· In Hospice care, The ARNP is designated as the “Attending Physician” and is responsible for care until death and maybe the only licensed provider to examine and care for the individual. Hospice care addresses not only physical, emotional, and spiritual suffering, but provides support to families during the final months of life and in the bereavement period after death.
Allowing the ARNP the authority to sign the death certificate, reduces delays, eases the hardship and strain on the family bereavement process. Some rural communities of Florida, where there is a shortage of physicians, rely on ARNPs to care for thousands of patients.
· Nurse practitioners are often the last caregiver in attendance when a patient dies. If the state deems them qualified to diagnose and treat a person while they are living, it is also logical to grant these qualified and capable health care professionals authority to complete the certificate of death.
· Currently Advanced Registered Nurse Practitioners (ARNPs) are authorized to sign death certificates in Arizona, Connecticut, Iowa (introduced 3/9/11), Maine, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New Mexico, North Dakota, Oregon, South Carolina, South Dakota, Utah (introduced in 2011) and Washington.
· Since death certificates must be signed within a specific period of time after death, ARNPs would be able to facilitate the delivery of appropriate and timely postmortem care and help ease the impact of death on a patient's family.
· Certified and Licensed Nurse Midwives have long been authorized to sign Florida fetal death who expired during or immediately following birthing.
· The bill is also expected to help reduce patient, estate and state costs by avoiding unnecessary referral to doctors and/or unnecessary autopsies if deemed coroner cases because of inability to locate a physician to sign the death certificate in a timely manner, while remaining sensitive and responsive to the needs of families and loved ones at the time of death."

Patients With Abnormal Labs And No Insurance?

One of the biggest problems that I face as a Primary Care nurse practitioner is when I see abnormal labs on a patient that has no insurance. The main worry is whether or not I am missing a bad diagnosis. Many of my patients barely have the ten dollars to get the tests done to begin with, let alone do anything about it if it comes back badly.

We have little resources out here in "rural health land". Most do not have gas money to drive anywhere to be seen by whatever specialist that might do a favor for me. Having Medicaid isn't much better. I can do just about any testing that I want but God forbid that I need a Urologist to do a prostate biopsy or take care of a woman's incontinence issues.

What happened to the medical profession that used to care for their patients instead of the almighty dollar? I understand the whole overhead issue. It's hard to maintain an office and pay your employees and try to make some money, but where is some compassion for your fellow man?

Please remember one day you or a loved one may be on the other side of the medical glass door looking in and needing help.

Who Pays When Medical Providers Step Outside Of The Box Of Medicine?

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Below is part of a recent post that I found on Kevin MD and written by Dr. Kelly over at Mothers in Medicine:

“Fast forward then to my first job out of residency. I was in a small rural community in a group practice with a nurse practitioner whose husband was her supervising physician. After a few months of working there, I started becoming really incensed at some of the practices she had, which to me, were questionable in some instances, and in others, outright harmful. They were not supported by any kind of scientific evidence, and in some cases, even actively discouraged by the evidence. I printed out guidelines and papers for this nurse practitioner to review, and in return, she gave me a book written by a layman which supported her practices. Feeling helpless and outraged, I vented to other staff members and was ultimately confronted by her husband, who called me rigid and inflexible for not being able to accept that there were different ways to practice medicine. They threatened to fire me, and “demoted” me to a separate office location in another part of the medical building.

I did apologize to the nurse practitioner just to make peace, but have always maintained that her practices are wrong and detrimental to patients. I have even contemplated reporting her to the board of nursing and him to the medical board, but have been afraid of repercussions (which is a separate discussion in and of itself). I established my own patient base and kept my practice separate from hers. With that separation, I was able to regain a sense of sanity.”

My reply was the following to which I was also responding to Fam Med Doc’s reply:

While I agree that we should all be allowed to think outside of the box at times due to individualized patient care, I do think that the Nurse Practitioner was wrong not to follow standard practice. I would have welcomed any printouts or constructive criticisms and learned from them. I am sorry that you felt that you had to pull patients into “your” practice in order to feel more comfortable. It’s hard having to work in a group setting especially when you are the “low man on the totem pole” and don’t want to make waves. I don’t however agree that “all” NPs are inadequately trained. That’s too much of a generalization. Great post!

I found it odd and coincidental that the same scenario has been playing out at the office I work in. My collaborating MD and I have a differing opinion on a particular topic of which I can’t elaborate because he would probably recognize it. Needless to say, we’ve had a few conversations weighing the pros and cons and our boss has stopped by to put in his 50 cents worth that the MD doesn’t understand is akin to a probable strike two. He’ll learn.. I figure that there is no one way to do things as long as the patients are not paying the price.

Welcome to Because Your Nurse Practitioner Says So!

Welcome! Here is the place for nurse practitioners to vent about practice issues, including ones that keep patients from being healthy. One of the issues that I have is non-compliance which is causing all kinds of chaos! Is this happening to you in your practice? Do your patients continue to show up at the office with uncontrolled blood pressures and blood glucose levels over 200s?
How do you deal with these problems? Chime in and let's get the conversation started!