The What, Why, and How of RN to FNP

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When I talk to people outside the medical profession, I often get asked, “so why are you becoming a nurse practitioner? Isn’t that a lot of school to essentially do the same thing you’re doing now?” I smile. I explain. I do my best to educate. But I still wince at that question because many, many people do not understand the difference between a nurse and a nurse practitioner. The tide is slowly moving in the right direction as nurse practitioners become more prevalent but there is still a huge knowledge gap in the public.

With my friends within the healthcare world, the questions are quite different. “Why did you decide to do FNP?” or “How much time do you really need to commit to school?” or “How in the world are you doing that school along with everything else in your life?” All valid questions based on real concerns. Deciding to become a nurse practitioner is a big career move requiring time, support, money and a huge portion of your sanity. This is part of my story along that journey.

Ever since I graduated from nursing school in 2009 I knew that I wanted to eventually get my master’s and become a nurse practitioner, even before I really knew what that entailed.  To be honest, I didn’t have a whole lot of backing behind that desire other than I had always been a “school person” and wanted to say I had a master’s degree. At that time I was nearly as ignorant as most people on the street about the qualifications, the education, the job description. I think I even revealed my professional plans in my “welcome to the unit” profile at my first job (so naive, not the smartest move). I just though it sounded cool and made me look like I had ambitions.

The WHAT: After a few years in the ICU I started to get a handle on where I could go with my career. I could stay in my unit and pursue a management position. I could go to CRNA school and live in the OR. I could stay where I was at as a RN. I could become a nurse practitioner. And a few more options that I never seriously considered.

After ruling out all the other possibilities for one reason or another, I decided on nurse practitioner only to discover that, like nursing, the NP job description varies intensely from position to position and environment to environment. I could become an acute care NP and work nights in the ICU responsible for thirty very sick patients. I could move to a specified clinic like nephrology or neurology and work solely with those patients. I could transition to outpatient and pursue a career in something completely foreign like family practice. And that’s ironically what I chose.

The WHY: Why did I choose family nurse practitioner over the other varieties? The standard reasons are obvious: no holidays, more money, less time on my feet, more responsibility. I wanted a weekday schedule with no weekends and holidays. I have a young family and it’s difficult for me to spend twelve-hour shifts away from my baby plus I’m tired of fearing that I’ll have to work on Christmas. I was also weary working in a job that required so much physical exertion. Turning large male patients, standing on your feet for hours on end, and sometimes not being able to take a lunch break until 3pm are all taxing on your body. I know I just turned thirty, but I could see the future and it was full of back problems and tired feet. I didn’t want all that exertion for the rest of my professional career.

The most professionally motivating reason for my career change was that I wanted more responsibility for patient care. I had finally gotten to the point where I wanted to write the orders instead of take them and felt that I had enough experience to take that step. I had always been afraid of such great responsibility (and rightly so) but I had gained enough self-confidence to know that I could learn and practice and become a proficient, caring provider. And while it’s the least romantic of my motivations, a better salary was definitely on the list. Getting paid more money for less physical labor is always a good thing.

But the question of why I chose FNP over ACNP (acute care nurse practitioner) also puts me in a honest place because I’ll have to give you an honest answer. The most compelling reason, the one that comes from a deep place in my heart, is that I was tired of seeing the worse case scenario day after day. I was heartbroken from seeing family members weep and watching people kiss their loved ones goodbye. As much as I loved the intensity of the ICU setting- the adrenaline of codes and the significance of standing in the gap during those crucial moments- I wanted something different. I wanted to work normal hours and to treat happy kids sometimes and to forget that those terrible, horrible things happen everyday. To those of you who are in that setting as ACNP, I respect you more than you can know. You’re dealing with vast responsibilities and dying patients and desperate families. You’re in a different spot than me and it’s a good thing we’ve both found our individual callings.

The HOW: So I applied for a FNP program at a local university, got accepted, and signed up for my first class. However, it didn’t quite work out like I had planned and I will tell you a slightly embarrassing secret about my journey through NP school. I took one class and quit in 2013. I had thrown myself into my nursing graduate research class for that entire semester only to discover upon completion of the class that I did not have the stamina for the program. There were many reasons behind my decision to not resume school, mostly to do with my tenuous health at the time, but I felt embarrassed. I had touted this new career ambition to almost everyone and then found myself backtracking, having to admit that it was too much for me right now.

When I think about that decision now, I see clearly that it was the right call. I wasn’t ready to take on life as a FNP. Two years later in 2015 I started school again and now here I am only two classes away from graduation. During that interim time period I took a new position in the ICU and gained valuable experience that I wouldn’t have had otherwise. So for those of you who find yourself in the same boat, don’t give in to the voices of guilt or shame or insufficiency. Maybe it’s just not the right time for you and there’s nothing wrong with that. Maybe it’s not the right career move for you at all and that’s ok too.

I’m not going to discuss choosing the right NP program because that is a whole other blog post in and of itself. There are a plethora of programs and they each have varied requirements, advantages, and disadvantages. Since I have a daughter, I chose a program that had all the didactic course work online followed by three intense semesters of clinical. I will say that online school is not for the faint of heart- you have to be disciplined and self-motivating. You have to make time when you don’t want to study. You have to stay up late and get up early and make your school work a priority in the midst of everything else you do in life. It’s grueling but in my case, it was worth it to not have to travel to school and find someone to watch my daughter. Choosing a program is a unique decision and you should be prepared to do some investigation.

Finding clinical preceptors is also an arduous part of this journey. Wait, let me rephrase that, an exhausting part of this journey. For my school, I was left on my own to find preceptors, which meant pleading for friends and family to help me. I emailed NPs and never got a response back. I cold called offices and never heard a thing. I did end up finding three fantastic preceptors in my area but that was only because of nice friends who put me in contact with their provider friends. This is where the word networking comes into play. You can never underestimate the value of establishing good relationships with other people in the medical world. If you’re trustworthy, kind and smart, they’re likely to endorse you to other provider friends but if you bad-mouth other people, seem uncompassionate towards your patients, or don’t care about your job, you may have a harder time finding someone who will spend a chunk of time investing in you. In short, make friends and don’t burn bridges.

Remember, preceptors for a NP program (MDs, NPs, PAs) aren’t getting paid to teach you (unless you’re involved in a paid preceptor program). They are giving of their time and energy willingly with no guarantee of a return. Ideally, I would like to get a job at one of the sites that I worked at during clinical because I already have an understanding of how the clinics work, the types of patients they see, and the responsibilities that I would be asked to take on. In this instance, it pays off for everyone because the clinic doesn’t have to spend as much time training you, but this isn’t the norm.

Making the jump into graduate school isn’t for the faint of heart. You have to have a clear vision for your future and be motivated enough to stick with it. You need the support of your family and friends and your job. You will have to give up some things now for a better return later. And if you stumble along the way? Forgive yourself. Nothing in life ever goes the way that we think it will.

I hope this gives you a glimpse of what it takes to go from a RN to a FNP. I hope you can understand my reasoning and my desires. And I hope, if you’re sitting at home contemplating these same things, that this helps you along your journey.

Go get that MSN.

 

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A Clinical Conundrum

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Have you ever found yourself in a sticky situation with a patient? Of course you have; we all have. I recently found myself locked into an awkward moment with a patient during my FNP clinical rotation, unsure of how to proceed. I had to navigate around the issue of divulging personal information and I was unprepared. Do I share my own story with her? Do I hold back and hope that she can find commiseration someplace else? What do you do when you get shoved into these tenuous situations with patients? I don’t think there’s one right answer. It’s not black or white; it’s not a clear divide drawn in Sharpie, although we all wish it would be that easy. No, it’s simply a blurry, gray pencil line that leaves smudges all over you no matter which direction you go with it.

When I was young, unmarried, and working in the ICU I had my fair share of sticky situations, most of them surrounding requests for my phone number. A grandfather patient asking on behalf of his couch-potato grandson (yeah, that sounds promising) or creepy older guys who think it’s funny to make jokes about nurses giving bed baths (let me go find our two hundred pound male nurse and he’ll help you). People get delirious sometimes; they make statements or assumptions that are inappropriate because they’re on narcotics or recovering from head injuries. So, to some extent, you can easily forgive them their verbal fumbles.

Now that I’m a bit older and in the outpatient environment I don’t encounter those invitations as much anymore (probably thanks to that ring on my finger) but I still have awkward moments with patients, mostly around revealing information about my personal life. It’s a fine line that creeps up from time to time and I found I wasn’t trained for it.  Nobody tells you in school how you should act or react to personal questions, probably because it varies with each patient and situation. Sometimes you develop a relationship with a patient and voluntarily want to share more intimate aspects of your life. Stories about your kids, details of your recent vacation with your husband. In these cases, those topics come up naturally and since you both recognize the inherent formality to the relationship, you feel free to share personal tidbits and look forward to seeing that patient again in three months.

Other times patients press, wanting to feel like they know you, searching to get some need met from your relationship that falls outside the boundaries of professionalism. These needs can be obvious or complex. They want to be best friends or they want to manipulate or they’re desperate for attention. They have good intentions but it comes out wrong. They feel like they can’t talk to anyone else in their life so they completely unload on you. These conversations sometimes leave you feeling unnerved and you know that this patient isn’t capable of putting in appropriate stops in your relationship right now. But not every case is clear cut. It gets sticky. And if you actually talk to your patients when they’re on the exam table, you’ll surely encounter this problem at some point. You have to learn to straddle the amorphous line between being a healthcare provider and a friend, a listening ear and a professional.

To be fair, the inverse can be true. Sometimes healthcare providers are searching to get a need met from a patient- approval, attention, friendship- and it can make the patient uncomfortable. In short, the door can swing both ways.

I’ll share my recent example. One day we had a middle-aged woman with autoimmune complaints come into our clinic, so exhausted she could barely sit up in the chair. I had never met her before so I went into the room prior to my physician and talked with her about her chief complaint, did a focused history and performed a physical assessment. From the instant I saw her, my heart hurt for her. Between bouts of crying, with mascara staining her cheeks, she related the events of the past few months- how she had gotten sick out of nowhere, how she couldn’t get out of bed to go to work, how she felt useless to her family. She described a whole host of physical symptoms- fatigue, joint pain, and an inability to eat- and I knew how she felt. It was all too familiar. It was like listening to myself talk years ago when I went to the doctor’s office, desperate for help.

What this patient didn’t know is that I had been diagnosed with an autoimmune disease eight years prior and had struggled along the roller coaster of a relapsing-remitting condition ever since then. I knew what it felt like to be so tired that you can’t even get up and take a shower. I knew the physical symptoms that come from having an autoimmune disease. I knew how depressing it is to feel worthless, useless, permanently glued to your couch and addicted to prednisone.

She was understandably angry. Life had dealt her a harsh hand and she wasn’t coping with it well. She was bitter and hurt and experiencing all the emotions you would expect to feel if you were confronted with a life-long disease that you didn’t ask for and didn’t expect. As I gently asked more questions, she grew more and more hostile. She was taking out months of frustration on me and I couldn’t blame her for it. The conversation culminated when I said, “I know how you feel,” and she shot back sarcastically, “really? Do you know what it’s like to have an autoimmune disease?”

Ha, if she only knew. And I immediately started to feel conflicted. Do I share with her that I have a similar condition? Is it appropriate to commiserate that way? Would it make her feel better or make her feel like I was invalidating her feelings? I had no idea what to say and all the words stuck in my throat as I sat paralyzed in indecision.

Without knowing the right answer I blurted out, “actually I do. I have a similar autoimmune disease and I know how you feel. I’m so sorry you’re going through this.”

And the woman broke. Before I knew what was happening, she was bawling, telling me how hard things have been and expressing relief at being able to talk to someone who understood. I held her hand; she cried some more. We finished talking through the necessary components of the visit and then she actually smiled. I hadn’t done anything profound besides write a prescription for some prednisone (the best and worst drug in the world). Mostly I had helped her feel like she wasn’t completely alone. Someone else knows how you feel. Someone else can relate. It won’t always be this hard.

Was that the right thing to say? Should I have kept my big mouth shut? I don’t know. In this case, she responded well to my confession. I saw her several more times during my clinical semester and she remembered my name, asked if I was going to be there during her appointment. I gained her trust and while I still tried to keep the focus off of me and not reveal many specific details of my condition, we developed an appropriate, professional, beneficial relationship.

Afterwards, my preceptor and I discussed the situation. He laid out the pros and cons for me like I’m trying to explain it to you. Both extremes of the spectrum- sharing too much or not relating to your patients at all- can be detrimental. You’re a human being too and your patients should know that. You have a life, a family, your own issues. But you need to be self-aware enough to know when you’re searching to get a need met from a patient relationship. You need to be able to stay professional. In the end, he thought I had made the right call and I let out a huge sigh of relief.

There were other times during the semester when I had patients with similar complaints and I didn’t share my personal experience. Why not? I have no idea. I guess I just listened to that voice in my gut that whispered yes or no, and I went with it. Call it clinical intuition. Call it timidity. Call it whatever you want- you know what I’m talking about.

This topic of divulging personal information with patients is complicated and I make no claims to have it down. I’m not even suggesting approaching the issue from one side of the spectrum or the other- simply relating my own experience. I know I will have to continue to navigate these blurry lines for the rest of my career because I want my patients to know that I care. But I also want them to know that I’m competent and professional, someone they can trust with their life and sensitive information.

We all find ourselves in sticky situations every now and then because medicine is tricky business. Dealing with people is tricky business. We’ve all regretted saying or not saying something to a patient. And we all will have to find our own way of managing the tightrope of professionalism and friendship. It’s blurry; it’s difficult. We all walk around with smudges on our cheeks. But for the sake of our patients and ourselves, I believe it is a line worth walking.