- Do you feel prepared to practice as a Family Nurse Practitioner? Why or why not?
- What skills and common diagnoses do you feel you need to research further for independent practice?
- Reflect on the goals you set during Week 1 of the course. What goals have you met? What do you need to do to take what you have learned with you into practice?
- What new goals do you have to prepare yourself as you transition into practice?
My time as a nurse practitioner student in Samuel Merritt University’s accelerated NP program did go as expected. I feel prepared to practice as a Family Nurse Practitioner who can work in the primary care setting with some guidance in the initial period. I’m not ready to work in urgent care setting as I have very less exposure to all the procedures that a provider in urgent care should know how to do it in the case of triage such as suturing. The medical field is a journey of lifetime learning in which you never stop learning different treatment approaches, diagnostics, prevention plans based on evidence- based guidelines and recommendations. I learned a lot during my clinical hours.
New learning goals for N680L during Week 1
My learning goals for next semester includes working in the specialist clinic as Coumadin clinic, express care, ortho specialty, I want to be more confident in making treatment plans, be excellent in SOAP notes and seeing a different variety of patients.
I met my Coumadin clinic goal as well as express care but unfortunately, I’m not able to find preceptor who only deals with Ortho problems. I have seen patients in family practice with back pain, sports injuries, and muscle spasms. I’m confident with them but never get exposure to do knee injections. It took time, hard work, dedication, always eager to learn something new, the sacrifice of family and personal life to achieve these goals. Now I’m confident to make treatment plans for diseases I encounter. I’m able to see 15-18 patients in 10 hours of clinical practice.
New goals for transition into nurse practitioner
Transition phase of RN to NP is quite bit challenging, as a scope of practice of an RN is totally different to the NP. The organizational expectations to be clinically competent and able to meet the demands of a complex healthcare system can be overwhelming.
My new goals are to get my certification, finding a job in primary care where I can work for the underserved population. I want a mentor who helps to pass this phase smoothly. I will always follow the evidence-based practice, keep myself updated with new guidelines to work in primary care practice. I will join NP organizations to attend meetings and conferences to gain more confidence in practice.
Delivery difficult news to patients is sometimes very challenging to the providers as it involves emotions, stress, anxiety and fear. I’m going to the transition from RN to the provider so I have to face this type of situations very often. Empathy approach, a good listener, staying calm in stress situations as well as maintaining professional attitude are some of the qualities needed in provider during this task. All concerns of patient need to be cleared, the treatment plan should be discussed as well as follow up. SPIKES protocol is helpful for the provider to stay focused in this situation.
In this case, I will get her previous pregnancy history if she has any. I will start with some general discussion as a friendly approach in beginning will help patient to discuss all of her concerns. Based on the 2 consecutive HCG drops, I will initiate a difficult discussion with the patient that progressive decline in HCG as representing, a nonviable pregnancy. I will address the issues of guilt, blame, and grief associated with miscarriage. I will discuss with her need of further transvaginal ultrasound. I will discuss management options, including chemical induction, dilation and curettage, and watchful waiting. I will reassure her by letting her know that spontaneous abortions happen to many women, it will not affect her future fertility.
I will start the conversation with a patient based on her knowledge and by making her comfortable in the room, I will start the conversation by saying I get her biopsy results and then will interpret the results in a language she understands and based on how much she knows about breast cancer. I will reassure the patient that breast cancer is very common in the United States and the prognosis in stage 2 is very good. I will further discuss treatment options that include surgery, chemo, and radiation therapy. I will provide information about resources and support group. Emotional support with time spending with the patient is needed in this case to answer all the questions and concerns of the patient.
In this case, I’m dealing with a teenager, so I need a patience because it may involve lots of anxiety, lack of knowledge and concern about confidentiality. I will reassure her it is a Herpes and it is one of most common STD’s but it is curable. I will explain to her causes of Herpes such as multiple sex partners, previous histories of STD’s, then I will explain her treatment plan which involves Acyclovir 400mg Po 3 times a day for 7-10 days. This will clear up the outbreak she is currently having. I will let her know she can have outbreaks again or may not have but if she again develops outbreak then suppressive therapy can be useful. I will give her instructions to not having sex until her symptoms clear, avoid unprotected sexual intercourse and her partner needs to be evaluated so that he can start treatment.
Ethics provides a set of standards for behavior that helps us decide how we ought to act in a range of situations. Ethics is sometimes conflated or confused with other ways of making choices, including religion, law or mortality. Ethical dilemma that I have seen couple times during clinical practice is when family advocates for their elders who don’t speak English. Mrs. M.G. is an 83-year-old Hispanic female who is diabetic, CHF patient s/p CABG done 5 years ago. Currently taking 2 oral pills for diabetes and long acting insulin but the way she cooks food her blood sugar tends to be high. The family wants to add another Insulin to control sugar whereas a patient herself doesn’t want to add more medicines. Clinically provider has to manage the prescribed meds to control high sugar whereas patient is alert/ oriented and refused to add another treatment which puts the provider in dilemma. Mrs. M.G. has a right to make her own decisions. Patients the right of self-determination, independence and the ability to be active participants in their care but when they don’t want to make correct decisions it is a hard situation for providers to deal with. in this case provider will refer this patient to the endocrinologist to manage her diabetes.
- Evaluate the language needs of the population you are serving at your clinical facility.
I serve in a low-income clinic where most of the patients belong to the Hispanic and Punjabi (East Indian) culture. They have very limited understanding of English and barely able to communicate in this language. We use Spanish speaking interpreter throughout the appointment. I speak three languages English, Punjabi and Hindi so I don’t have a problem in communication with Indian patients.
- Determine if resources available for translation allow patients with language barriers to experiencing the same level of care as English-speaking patients.
We have a Spanish-speaking interpreter in the clinic but I realized sometimes it is hard to communicate properly to address all the needs os patient’s visit as it involves lots of distractions. We recently start using a video call in each patient room for interpretation but to me, it is worse than using the in- clinic interpreter, the voice quality is not clear when the whole family is sitting in the room.
- Identify the benefits and the shortfalls of the systems in place.
Benefits of having in clinic interpreter are: you can interact with your patients more actively then video call for a translator. The staff is medically trained so they can do the translation of medical terminology effectively.
- Recommend ways the system could better serve the patient base in the community your clinical site serves.
Having well-trained medical staff that is available all the time for translation is the solution of communication problem for people who are not able to speak English. Providers who speak dual languages are more able to gain the trust of their non- English speaking patients.
Practice inquiry is an opportunity for providers to look for help from evidence-based resources when they are in doubt to learn new outcomes. Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. In some cases, however, a sufficient research base may not be available, and health care decision making is derived principally from nonresearch evidence sources such as expert opinion and scientific principles. My preceptor uses Up ToDate and Medscape to check evidence-based practices to be followed during patient care. She also uses CDC guidelines that are available online for recent guideline changes when she treats patients with STIs, travel-related vaccinations, immunizations, opioids prescription in chronic pain management. The electronic charting collaborate the progress notes of a patient from all providers, which helps them to review the past medical history.
Titler, M. G. (n.d.). The Evidence for Evidence-Based Practice Implementation. Retrieved February 06, 2017, from https://www.ncbi.nlm.nih.gov/books/NBK2659/
The technological tool that I have seen in my clinical site is Medscape. It provides information about chronic diseases with their clinical presentation and treatment approaches. It provides students and new graduates an idea of what to look for with differential diagnosis tool. Medscape is based on the evidence-based practice which provides up to date information about diseases and drugs. It is very accurate and adequate to get information by medical professionals.The deficiency in Medscape is involvement of some unnecessary information for patients when we tried to print education for them as that information can be over warming for them.
The EMR systems in which I came to contact with are Nextgen and Centricity during my clinical rotation. Nextgen program is very basic, less complex and easy to understand for new users as well as older age users who are not very familiar with technology. It is very easy to do charting, ordering medicine, refill the prescription and submitting the chart for billing, whereas Centricity is more professional. Visit summaries are very easily assessable for previous visits. Bright future is an excellent tool during pediatric physical examinations and immunizations/vaccinations are easy to find. This program is more fitted to do customized charting shortcuts. I like both EMR systems as they both have their own good and bad features.
Reflect on your first semester and identify new skills emerging or developed from the Skills Checklist
On my first day in the clinical rotation, I did shadow whole day and when next day my preceptor asked me to assess I was not confident enough with my assessment. As gradually I moved in the semester I developed confidence in my skills and during the second semester I start thinking critically and my preceptor allowed me to see patients independently before she sees patient herself so that I can make a treatment plan to promote my problem-solving skills.
New learning goals for N680L
My learning goals for next semester includes working in the specialist clinic as coumadin clinic, express care, ortho specialty, I want to be more confident in making treatment plans, be excellent in SOAP notes and seeing a different variety of patients.
Consider diagnoses, procedures, and medications you have become familiar with
I have become women’s health diagnosis and procedures such as bacterial vaginosis, STD’s, vaginal bleeding, contraception, pap smear, IUD insertion. I did some hours in the pediatric rotation and get familiar with URI, croup, strep throat, asthma, ear infections, pharyngitis, eczema, bronchitis.
What thoughts do you want to share about your first week back into clinical practice?
I’m currently in family practice rotation wants to gain as much hands-on and independent experience as possible to prepare for the upcoming real world of being FNP who works under the guidelines approved by evidence-based practice.
“Practice Inquiry” is proposed as a set of small-group, practice-based learning and improvement (PBLI) methods designed to help clinicians better manage case-based clinical uncertainty. Clinicians meet regularly at their offices/clinics to present dilemma cases, share clinical experience, review evidence for blending with experience, and draw implications for practice improvement.
Health promotion is one of the practice inquiry that I have seen in my clinical site. Every woman who comes to the clinic for their GYN problems my preceptor asks them about their well women exam which includes pap smear and mammogram. Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. My clinic also has a reminder of well women appointments and medical assistants often call patients to schedule their appointments. PI’s usefulness for practice improvement will require more focused modeling and assessment. Timeliness: reduce waits and sometimes harmful delays for both those who receive care and those who give care. It is a practice inquiry that I have not observed in my clinical setting and needs to be implemented.
Sommers, L. S., Morgan, L., Johnson, L., & Yatabe, K. (2007). Practice Inquiry: Clinical Uncertainty as a Focus for Small-Group Learning and Practice Improvement. Journal of General Internal Medicine, 22(2), 246–252. http://doi.org/10.1007/s11606-006-0059-2
Mayberry, R. M., Nicewander, D. A., Qin, H., & Ballard, D. J. (2006). Improving quality and reducing inequities: a challenge in achieving best care. Proceedings (Baylor University. Medical Center), 19(2), 103–118.
Continued education is a vital part of professional development and it helps in maintaining a higher level of services provided by professionals. In the healthcare field, evidence-based practice brings a new era of development. As a provider, it is essential for a nurse practitioner to keep up to date with current research so that evidence-based practice can be used in achieving a high quality of care. Continue education can be obtained by numerous resources such as classes are available online as well as through in site classes. There is evidence-based databases are available which provide information on whole healthcare topics, such as CINAHL, PubMed, Lexicomp, Up-to-date, and Medscape. Classes are offered by American nurse practitioner Associates approved institution which provides CEU’s to NPs.
My process in discovering modalities and developing resources includes continuing education classes, renewing my ACLS, BLS licenses, my preceptors, clinical site providers, academic resources provided by Samuel Merritt University and online research. I’m also planning to participate in nurse practitioner association so that I can be up to date on current health care issues and research. I use Medscape during my clinical hours to look up information regarding medications.
Definition of patient-centered care: “It is well established now that one can, in fact, improve the quality of health care and reduce the costs at the same time”. Physicians practicing patient-centered care improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals. Patient-centered practitioners focus on improving different aspects of the patient-physician interaction by employing measurable skills and behaviors. (healthaffairs.org).
Collaboration on the plan of care: Providing evidence of what works and what does not work regarding the implementation of collaborative, interprofessional primary health care. Creating resources and tools to assist various health care professionals to work in a more collaborative environment; and obtaining support and agreement among various professionals about their roles and responsibilities in collaborative settings. Create a culture of interprofessional collaboration. patient/client engagement; population health approach; best possible care and services; Access; trust and respect; and effective communication (www.fhs.mcmaster.ca).
Patient and provider compromise on the plan of care: Lack of proper communication between provider and patient. Physician-centered care which ignores patients beliefs regarding health. lack of time for proper implementation; accountability for patient care is ambiguous.
Benefits of patient-centered care: Improves patient satisfaction. Help to establish a trustworthy relationship between patient and provider. Better communication and better outcomes. Better management of chronic conditions. Increasing the focus on prevention. Improving quality, safety, performance, and accountability.
Patient-Centered Care: What It Means And How To Get There. (n.d.). Retrieved October 23, 2016, from http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/
Putting Patients First: Patient-Centered Collaborative Care. (n.d.). Retrieved October 23, 2016, from http://www.fhs.mcmaster.ca/surgery/documents/CollaborativeCare