In some ways, I feel prepared to work as a Family Nurse Practitioner, but I know that there is still a lot to learn. I know that working as an FNP will be much different than being a student at clinical with a preceptor. I still remember that difficult first few years as a new grad RN. As difficult as it is to be in school, being on my own as a provider seems even more daunting. I am nervous to be stepping into a new role with more responsibility but I am also excited for the chance to learn more. There are so many opportunities for NPs and I am excited to grow in my career and be able to help people. Throughout the year, I have seen several different areas for NPs including urgent care, pain management, primary care, spine and rehab, and a vein clinic. I am glad that I could complete some hours in specialty clinics. It gave me an idea of what working in a specialty could be like. However, I feel that I have learned the most at primary care. I have been able to see many different patients with different diagnoses. Overall, my experiences completing clinical hours have helped me feel more comfortable and enthusiastic for this new role. I have had great preceptors that are willing to teach and their passion for providing great health care is inspiring. I think that my goals to gain better assessment skills and general knowledge are still applicable. I will need to research common diagnoses, such as diabetes and thyroid disorders to feel more comfortable in independent practice. I would like to feel more confident in determining a treatment plan and prescribing medications. Some new goals I have are to attend a national conference and join NP organizations.
Delivering Difficult News
When giving bad news to a patient, the SPIKES protocol gives steps to make the process straightforward, comfortable, and educational for the patient. The provider should choose a setting that is private and includes loves ones if desired. The patient’s perspective should be asked before delivering unfavorable news to determine their expectations. After telling the news, the provider can invite the patient to ask for more information. This discussion should be at the level of the patient’s understanding. The provider should acknowledge and explore the patient’s emotions about the news they received. Lastly, the provider should have the patient summarize what they know to ensure the information is understood.
Case 3
A 69-year-old male patient is in for follow up on his labs. He had a CPE last week, including DRE. He complained about some urinary hesitancy, increased frequency, and dribbling at times. On exam, his prostate was soft, left side firmer with noted two lumps, total size approximately 6cm. You completed routine labs including a PSA. His last PSA was 4 years ago and was 3.7. All labs look normal, however, his most recent PSA is 29.1. What do you tell him? What are the next steps in his treatment?
I would tell this patient that his PSA is high and indicative of prostate cancer that is potentially metastatic. The next steps in his treatment will be a prostate biopsy and referral to a urologist. I would make sure to let this patient know the importance of getting the biopsy and making sure to see the urologist.
Case 4
A 27-year-old male patient is visiting you complaining of burning during urination and a thick penial discharge for the past 6 days. He reports being monogamous with his wife of 3 years. He reports no history of STDs. What do you tell him? What are the next steps in his treatment?
For this case, I would tell this patient that he will need to be tested for STDs based on his symptoms. If his results are positive, he will need to be treated along with his wife. She will also have to tell any other partners she has to be treated. I would also make sure to discuss safe sex practices with this patient.
Case 6
A 17-year-old female was seen today for painful vaginal sores. She just had her sexual debut 11 days ago with her boyfriend of 3 months. She is diagnosed with genital herpes. What do you tell her? What are the next steps in her treatment?
I would tell this patient that she is diagnosed with genital herpes and will need to tell her boyfriend as well. She can manage her outbreaks with antivirals, but there is no cure. I would make sure to emphasize the importance of safe sex practices and that genital herpes is easily transmitted especially during outbreaks.
Ethical Decision Making Blog
I chose the viewpoint of Otto’s Family. The ethical principles and values I used to arrive at this viewpoint include beneficence, non-maleficence, and fairness and justice. Otto’s wife has made efforts in the past to discuss his diagnosis, which led to a confused and angry reaction. Keeping Otto’s diagnosis from his at this time embodies the qualities of beneficence and non-maleficence by preventing harm to the patient. He does not have the cognitive function necessary to comprehend and appreciate his diagnosis. Previous experiences have also shown that Otto becomes angry and cannot remember even discussing his medical problems. Using the ethical principle of fairness and justice also demonstrates the need for compromise between autonomy and the best interest of the family as a whole. The opposing view would likely choose the principle of autonomy to support disclosing the diagnosis to Otto. This principle emphasizes the patient’s need to make his own choices. However, Otto has shown that he is confused and unable to make clear decisions for himself. The best choice for Otto is to allow his family to be involved in his medical decisions, including telling him about his diagnosis. Additional resources that the provider may want to use are an in-person translator. Using a translator over the phone has limitations, such as not accounting for unspoken body language. A referral for a specialist to confirm if Otto is competent to make his own medical decisions would also be useful.
References
Bell, J. W., Dains, J. E., Flynn, B. S., and Stewart, R. W. (2015). Seidel’s guide to physical examination 8th edition. St. Louis, MO: Elsevier Mosby.
Cultural Differences
One of the clinical sites I have been going to has many patients who do not speak English. Many of the patients speak either Russian, Spanish, or Punjabi. Almost every staff member speaks multiple languages so it is always easy to find an appropriate translator if necessary. The nurses, ultrasound technicians, medical assistants, and clerks are all able to translate. I think the patients are able to get the same level of care as English-speaking patients. Everyone involved in translating is familiar with medical terminology. They are able to easily translate patient concerns as well as questions from the doctor. The patients are able to communicate their needs in person with a translator who works in the medical field and knows how to explain the procedures and medications. I think this is much better than phone translation services, which I have used in other settings. One shortfall of using translators could be any misunderstanding in translation, but I have not seen any evidence of this so far. Also, it does take more time to use an additional person when seeing patients. Overall, this clinic does great job of serving many different non-English speaking populations by utilizing staff as translators.
Practice Inquiry
Practice inquiry is a way for clinicians to better manage difficult or uncertain clinical cases. Clinicians can meet as small groups to discuss cases, share information, and review current evidence and literature in order to improve practice (Sommer, Morgan, Johnson, & Yatabe, 2007). The two clinical sites I am attending this semester have not had any meetings or opportunities for practice inquiry that I have seen. However, the pain management clinic has multiple providers and I have seen nurse practitioners consult with the physician regarding difficult cases or questions about medications. Also, the vein clinic utilizes a shared folder with videos and websites to educate other providers on current evidence. Using electronic resources and applications could definitely help improve practice inquiry at both sites. This could be a way for clinicians to discuss clinical cases and ideas if they are not able to meet in person. Increased access to other clinicians to ask questions and provide feedback can definitely improve patient care. Additionally, using electronic resources can be a good way to document practice inquiry for future reference.
References
Sommers, L. S., Morgan, L., Johnson, L., and Yatabe, K. (2007). Practice inquiry: Clinical uncertainty as a focus for small-group learning and practice improvement. Retrieved October 16, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1824750/
Tech Tool Blog
Both clinical sites I am going to this semester use EMR to chart patient progress and they are both fairly similar. Patients are organized by appointment time and their electronic chart contains all of their information on a shared drive. The vein clinic uses macros and the provider types or dictates a narrative HPI, physical exam, and plan. The MA’s are able to add information as well. This method seems to take a long time, but the files are easy to find and read. Files such as ultrasound information and lab results are also filed under the patient chart. The pain management clinic also has all information stored electronically. SOAP notes are organized by date seen and other documents such as lab results, MRI reports, and referrals are stored under another tab. This EMR system is a little easier for me to navigate because everything is accessible from one screen. Also, documenting uses templates and you can add your own phrases to type in the HPI and plan. Both EMR systems are much simpler and easier than the EMR we use at my current job. We use a system designed specifically for jail. It is relatively new, so there are often small changes and updates. It is tedious to chart and there is a lot of scrolling and clicking. For example, to chart an assessment on a new patient you have to click through several screens to document a few pieces of information and then leave that page to schedule any necessary appointments. I think an EMR should be simple with quick access to pertinent information, especially for patients with chronic conditions. The clinical sites I am going to this semester seem to have EMR systems that allow this. The providers are able to quickly review a chart and see their previous visits
Getting Started at New Clinic Sites
The first two semesters, I was at an urgent care. This semester I am at two clinical sites, a vein specialty clinic and a pain management clinic. After only the first week, I can tell that these clinical site will be much different from the urgent care. One difference is that the patients are usually planned and have appointments. Most of them have been receiving treatment at the clinic, so they have more of a relationship with the providers. Both clinics I went to were very busy. I had the opportunity to see procedures I had never even heard of at both clinic sites. At the vein clinic, I saw patients having their spider veins treated. I learned about noninvasive treatments for spider veins and varicose veins. On my first day at the pain clinic, a visiting doctor was demonstrating laser acupuncture. I had the chance to use this technology on several patients. Some of them felt some relief of their pain and almost everyone wanted to continue treatments. Laser acupuncture is fast and noninvasive as opposed to traditional acupuncture, which typically takes an hour and the patient cannot move. Although I am at clinics that are more of a specialty, I feel that I will be able to learn a lot. My preceptor at the vein clinic has already given me a few articles to read on vein disorders and treatment while my preceptor at the pain clinic was able to teach me more about musculoskeletal physical assessment. I am excited to be at new locations and I hope to learn a lot.
Practice Inquiry and Clinical Outcomes
According to Sommers, Morgan, Johnson, and Yatube (2007), practice inquiry includes a small group of clinicians that use “practice based learning and improvement” strategies to better manage clinical outcomes. These could be a valuable learning tool for primary care providers to learn useful information. The collaborative nature of these small groups can help individuals increase their knowledge and learn how to manage potential problems at work. Although the nature of my clinical site does not really allow for small group collaborations, I do see opportunities for practice inquiries. I have seen the clinical coordinator and medical director meet with providers to discuss charting or treatment options. It might be useful for the urgent care to have monthly staff meetings to discuss any relevant topics. This could be a way for providers to bring up any issues to discuss with each other. The providers may work individually on a day to day basis, but collaborating with a team could be helpful way to have some consistency and provide learning opportunities.
Reference
Sommers, L. S., Morgan, L., Johnson, L., & Yatabe, K. (2007). Practice Inquiry: Clinical Uncertainty as a Focus for Small-Group Learning and Practice Improvement. J GEN INTERN MED Journal of General Internal Medicine, 22(2), 246-252. doi:10.1007/s11606-006-0059-2
Continuing Education
As a nurse practitioner student, I am already looking forward to attending conferences as part of continuing education. The opportunity to travel in order to learn and grow in my profession is exciting. I have heard NPs at my clinical site talk about the fun and informative classes they have taken at national conferences. On the AANP calendar of upcoming events, there are conferences in Washington DC. Philadelphia, PA, and Reno, NV to name a few. I think that attending conferences offers a great chance to learn more and expand networking with other advanced practice nurses. There are also many places online to complete continuing education hours. Online continuing education along with in-service meetings at work have been how I’ve completed hours for renewing my RN license. Completing continuing education online is convenient and can be done at any time. There are many ways we can continue to learn more and fulfill the requirements of renewing our licenses.
Patient Centered Care
There are many ways providers can collaborate and compromise with patients in order to create a treatment plan that works for the best outcome possible. For example, I have seen many of the providers at my clinical site have discussions with patients about past medical treatments that have worked or their ability to pay for and pick up medications. They always make sure to go over the plan of care, answer any questions, and address any concerns. I think it is important for patients to give feedback about their understanding of their treatment plan. If they understand the purpose and benefits of a medication or treatment, they are more likely to be compliant. When providers can make compromises to make a plan more convenient or feasible for a patient, it also increases compliance. Showing deference to a patient’s preferences can build trust and strengthen the relationship between provider and patient.
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