The Entry into Practice for the Family Nurse Practitioner - Essay Example

The Entry into Practice for the Family Nurse Practitioner Introduction The family nursing practitioner field is one of the fields of advanced practice nursing. As implied by its words, it mostly focuses on the family and on the role of the nurse practitioner within the family set-up. This paper shall serve as a discussion of the entry into practice for the family nurse practitioner. Discussion Description of place First and foremost, I chose the rural clinic setting which has multiple physicians. This facility is in a rural medically-underserved area where the clinic is part of the hospital system – but is not a hospital in the strictest sense. The clinic however shares the tax ID number with the hospital. It is also a provider-based health clinic (more on family practice and services). It is well-funded and is qualified under health provider shortage and medically-underserved categorization. In this sense, it is qualified to use either category, depending on need and on advantages. It is a small community of less than 20,000 inhabitants but it would likely serve more than one county or community. This type of town is one where everyone would most likely know each other. All the providers would have an LVN and the clinic has a clinic manager who would be acting as a liaison between the clinic and the hospital CEO; this manager would also be an intake coordinator; he would also coordinate staff for rescheduling, for billing, and for referrals. Pros and cons of working in identified arrangement One of the advantages of working in the identified arrangement is that the provider would be able to get to know his patients and the circumstances surrounding his patients’ lives. Such arrangement helps the provider administer the best type of care for his patients. Assessing the patient within his home environment is one of the ways for a provider to reach maximum efficacy (Hunt, 2008). The provider would not have much difficulty in evaluating his patients in their home setting because the community is small. Moreover, the provider would already know where the available resources are and know who would likely have access to such resources (Buppert, 2007). For the more specialized needs of the community, the clinic schedules specialists to visit at different times each month in order to reduce the need for patients having to travel to distant places to seek medical care. In the end this practice helps ensure continuity of care for the patients. Continuity of care is an important aspect of health care because it helps ensure that the patient would be fully monitored throughout his illness and would be able to eventually gain full recovery (Haggerty, et.al., 2008). Disadvantages are however also apparent in this set-up. For one, not many people would prefer living in medically-underserved areas because of the difficulty in accessing adequate and quality medical care (Shi and Singh, 2008). The more technical and higher level of services would be limited in this area. I noted however that the clinic where I precept conducts many high level services because the health professionals in the clinic are very skilled. Throughout their years of practice in the rural setting, they have picked up and mastered various skills. They have encountered various patients and have come up with different ways to treat them or to stabilize them long enough to reach the next referral hospital. Even with the disadvantages which practitioners have encountered in the rural practice, the clinic has managed to work around its challenges and provide the best quality of services it can provide. It is important to note also that there are not as many positions for practitioners in the rural setting; the pay scale is lower than the average pay. The cost of services is however also lower than the cost of services apparent in the urban setting. Essential elements of employment contract My employment contract is not that of a solo practitioner. My work includes a specific physician I frequently collaborate with. This physician signs off on 10% of my patient charts every month. The clinic pays the supervising physician a separate salary for such services. My expected starting salary is atleast $90,000. This is divided by 2080 equivalent to the number of hours the yearly wage is based on. There is also an incentive bonus plan or a threshold set with the practitioner receiving a specified dollar amount for every patient seen above the threshold. I have noted however that some practitioners have higher bonuses than other practitioners based on the amount of time needed to perform a procedure. The practitioner can consult with 3-4 patients in the time needed to carry out the procedure. This seems to be an unfair arrangement as I can be thorough with my provision of care for my patients and still receive less compensation for my effort in the patient’s care. There seems to be an implied need for the administrators to resolve this issue. Financial basis of the practice As mentioned earlier, as compensation for my services, I expect to be paid $90,000 annually. The clinic is government-funded with a significant number of Medicaid and Medicare covered patients. Some are private-paying and self-paying patients, but without capitated payments or sliding scale. Sources of expenses include salaries of employees, medical supplies, medicines on stock for patients (especially those without insurance), equipment purchases, maintenance and repair of equipment and clinic facilities, and utility bills (electricity, water, gas, phone, etc). Develop and financial plan to identify a “break-even point” There are about 40 individuals entering the clinic on a daily basis with most of them covered by Medicare and Medicaid. Reimbursement for these patients is $300 per Medicaid and $180 per Medicare service or patient. There is a need to consider the procedures and services rendered and their cost. In instances when these cost more than the reimbursement for the clinic, these patients would be referred to the outpatient centers. Collaborative arrangements The collaborative arrangements which are necessary in order to implement the practice include the arrangement between the nurse practitioner and the physician, between the nurse practitioner and the pharmacist, between the nurse practitioner and the midwives, between the physicians and the midwives, and between the clinic administrator and the main hospital. There is a need for the nurse practitioner and the physician to collaborate with each other because these individuals need to relay vital information about the patient to each other (Clarin, 2007). The nurse practitioner for example needs to regularly update the physician about the following: the patient’s assessed symptoms and condition; significant changes in vital signs; adverse reactions to medications; improvements or deterioration in condition; medications and possible changes in the type, dose, and administration of medications; and other pertinent changes and information essential to the patient’s care (Clarin, 2007). The physician also needs to coordinate with the nurse for patient orders which may include monitoring on: vital signs, adverse reactions to medications, orders for laboratory tests, changes in diet, NPO orders, and similar orders (Clarin, 2007). These orders are details which the physician would need to control and note in order to ensure adequate patient care. There is also a need for the nurse practitioner to coordinate with the pharmacist in order to evaluate drug interactions and effects on patients, especially those on multi-drug therapy (Reeves, et.al., 2010). This interaction would also include the proper preparation and dosage for drugs administered to the patients. It would also include health education considerations which the nurse needs to explain to the patient on particular drugs being taken – when the drug should be taken (before or after meals), what not to take with the medications, what to expect from the medications, how the medications would work, what not to do to counter the effects of the medication, and the drugs which must not be taken alongside these medications (Reeves, et.al., 2010). Since the clinic is in the rural setting serving a community, infant deliveries are often expected as additional functions for the clinics. This is no exception for this clinic which delivers about 1-3 babies on a weekly basis. The midwives are therefore important members of the staff as they are highly skilled in making these deliveries (Bowden and Greenburg, 2009). Based on normal maternal and fetal conditions, these deliveries are carried out in the clinic. There is a strong coordination between the nurse practitioners and the midwives in this case as the nurses assist the midwives in these deliveries. In some instances, the nurse practitioners are also qualified to deliver the babies. These practitioners also help coordinate post-partum care for the mother and child (Littleton and Engebretson, 2005). The plan of care is coordinated with the midwife who also teaches the mother how to breast feed. Nursing education in terms of expected discharges and possible signs of bleeding and infection are taught to the patient by both the midwife and the nurse (Littleton and Engebretson, 2005). The nurse shall also coordinate with the midwives on schedules of home visits for the mothers and their infants. Home visits are one of the essential aspects of rural health. Midwives are often the ones fielded to carry out such home visits because they are much more familiar with the community set-up (Littleton and Engebretson, 2005). The residents are also often more comfortable with their care. The nurses would have to coordinate a schedule with the midwives on whom and on what time the mothers are due for their follow-up check. These midwives also have to coordinate with physicians when they would examine pregnant mothers who manifest some possible complications of pregnancy and delivery (Littleton and Engebretson, 2005). These cases have to be referred to the physicians for possible actions on referrals to hospitals. In this case, the pregnant mother would be able to receive adequate care which matches her needs. All in all, maternal and fetal mortality or morbidity would be prevented the soonest time possible. Finally, there is a need for the clinic administrator to be in full coordination with the administrator of the main hospital. This coordination involves the referral process of patients from the clinic to the main hospital. This would help ensure that clinic patients would immediately be cared for upon reaching the main hospital. This would also ensure that when the patients from the main hospital are sent home, their care would still be coordinated with the clinics for monitoring and follow-ups (Coward, 2006). This is especially important for mothers and their babies in the post-partum period. The follow-up and monitoring for these patients need to be coordinated with the clinics in order to prevent maternal and fetal mortality or morbidity. The coordination process between the clinic and the hospital also involves the referrals for laboratory examinations, especially those not available in the clinic. The clinic provides X-Ray tests, as well as CT scans and MRIs, however it does not have an in-house radiologist. The tests have to be coordinated with the main hospitals for interpretation and readings. The clinic also cannot carry out complicated laboratory work. The more complicated lab work is referred to a laboratory testing center with whom the clinic and the main hospital are affiliated with. With close linkages with each other, the clinic is able to carry out its functions in appropriate and efficient means. Impact of barriers and facilitators on the development of the practice There are different barriers to the development of the practice. One barrier is that it is difficult to recruit staff for the clinic. The clinic is hardly an ideal facility to work in because it is medically underserved and the limited staff would be asked to care for more patients than they can handle. At times, the numbers would not seem overwhelming for staff, however, most times, there may be more patients for the staff to care for. The limited staff available would reflect a nursing shortage, with the available nurses in the clinic being overworked and underpaid. Nursing burnout can result from this situation (Andrews, et.al., 2005). Nursing burnout, in turn, can lead to more medical mistakes and decreased efficacy of services in the clinical practice (Andrews, et.al., 2005). This barrier can interfere with the development of the practice in the sense that it would reduce the quality and efficacy of care in the clinic. This is dangerous to the clinical practice because the people in the rural setting do not have any other immediate means of gaining medical services aside from the clinic (Crooks and Andrews, 2008). It is important for the community to have access to quality medical services in their rural setting because their lives depend on it. If they would have to seek medical services from the hospital which is some distance away from the community, their conditions may get worse or they may not seek medical services at all. As a result, higher mortality and morbidity rates may set in in the community (Crooks and Andrews, 2008). Staff shortage can also prevent the development of the practice in the sense that less staff can reduce the coverage of the services, preventing such services from covering more areas and limiting services offered by the health practitioners. Another thing which makes the above issue more complicated is the fact that the bulk of the community being served is Hispanic; therefore, the need for bilingual staff is dictating the hiring process for health care staff. It is a legal requirement for the clinic to have bilingual staff or translators available in order to ensure efficient and accurate patient care. As a result, in order to meet this demand for bilingual staff, the clinic has been prompted to send their staff to language courses in order to be certified translators and bilingual personnel. Communication is an important aspect of the clinical practice. Learning to communicate with non-English speaking patients is essential to accurate health care delivery (Meyer, 2005). It is important to gain accurate interpretation of the patient’s symptoms and anything else he wishes to communicate. Accurate data gathered from client is the basis for accurate diagnosis and subsequently, accurate treatment (Meyer, 2005). The process works both ways with the transmission of information to the patients – on medication intake, on seeking patient consent for procedures, and on other aspects of patient education (Meyer, 2005). Learning to communicate with the Hispanic patients also helps establish better rapport with patients. It is part of the process of proving oneself to the client, to learn his language and to speak with him in his native tongue. It would make the patient more cooperative with the health care givers and it would make him more comfortable communicating with his health care givers (Meyer, 2005). Moreover, learning to communicate with the Hispanic patients would make the health care giving process faster. The delivery of services would be timely, based on patient needs as they arise. The nature of the clinic which is on family care practice is an important service in health care delivery. It is a practice highly beneficial to the community and rural health setting because these communities are founded on primary health care which mostly includes services to the family, including maternal and child care, pediatric services, promotive, and preventive health services (Buppert, 2007). The services offered in this clinic assist in the development of the practice in the sense that it makes services available in the grassroots level of care – primary care. These services would decongest the burden of care away from the hospitals and into the more manageable community settings. Specific actions to address barriers Barriers involving difficulty in staff recruiting can be resolved by the nurse practitioner by hiring staff which are highly specialized in family nursing practice. They must have sufficient experience in family nursing practice in order to eliminate the possibility of hiring staff which cannot pull her weight in the clinic. Their experience would ensure that the staff are efficient and can carry out the tasks in the most efficient way without having to need additional support staff (Buppert, 2007). Nursing shortage is a major problem in the nursing practice, including advanced nursing practice. In order to help resolve this issue, nurse practitioners can be the voice in the press. As articles are published in the media discussing the shortage of nurses, the nurse practitioners can write letters to the editors acknowledging the difficulties which nurses face in the practice and yet also expressing the rewards of the practice (Andrist, et.al., 2006). In this case, the image of nursing being a difficult can be less focused on; instead, its rewards can be highlighted as a means of enticing interested career seekers. Family nurse practitioners can also help in the recruitment process in high schools – participating in career seminars in these schools and discussing with students the features of nursing practice which can entice them to consider it as a career (Andrist, et.al., 2006). Family nursing practitioners can also participate and support political actions which seek to support higher salaries for nurses and better funding for rural health services (Andrist, et.al., 2006). Supporting these advocacies in nursing can help provide a stronger voice for the nursing practice in general – with more nurses interested in the cause, more political notice can be gained and possibly favorable outcomes for improved funding in the health and nursing practice. By implementing these solutions, the family nurse practitioner would be able to set forth solutions in improving the recruitment process for nurses. In relation to the language barrier, as was mentioned, family nurse practitioners can participate in language courses which can teach Spanish and other pertinent languages to the nurses. These practitioners must be active in these language courses, to apply it with their patients, and to be willing to learn and improve their knowledge of other languages. In order to facilitate acceptance of the nurse practitioner in the work setting, there is a need to improve the coordination and the collaboration of the nurse and the physician. There is a learning curve which needs to be understood and appreciated by both the nurse practitioner and the physician. The nurse and the physician will have to be very specific on when the nurse can go to the physician. This is related to autonomy in practice (Bailey, et.al., 2006). The nurse practitioner is a highly skilled and trained practitioner in the family practice. This grants her autonomy in nursing care decisions – autonomy which must be respected by the physician (Bailey, et.al., 2006). Some physicians may not be comfortable with the nurse practitioner’s autonomy. In this case, the nurse and the physician must agree beforehand about the boundaries of such autonomy and the extent to which it must be respected and honored by the physician. The law sets forth particular roles and responsibilities for the family nurse practitioner, and the physician needs to acknowledge the existence of such rules (Bailey, et.al., 2006). This would make the practice easier and smoother for both the nurses and the physicians. The physicians would know when to let the nurse practitioner have free rein over the patient, and they would know when the nurse is overstepping her bounds (Bailey, et.al., 2006). Some physicians are very comfortable in letting the nurse practitioner have the autonomy in her practice. It is important however for me as a practitioner to have the assurance that I will have a supervising physician accessible and willing to consult or assist when needed in the actual clinical practice, especially in my first year of practice. This would help me transition as an NP with the clinic. In order to support and inform the public of the services of the clinic, print-outs can be distributed to the community rural setting. Advertisements can also be taken out in newspapers within the rural community and nearby counties to let the public know about the availability of the practice. My credentials and background can also be included in such print-outs. I can also capitalize on the fact that I was born and raised in West Texas and is very much one of them. The fact that I chose the rural health setting over other opportunities can also be a plus factor in my family nursing practice. Describe outcomes to be assessed to evaluate effectiveness of the nurse practitioner’s practice There are different ways by which the nurse practitioner’s practice can be evaluated. One way is on the number of return visits for different illnesses. Patients returning to the nurse practitioner indicate an acceptance of the nurse’s practice. When patients return to the nurse practitioner for other ailments, and bringing different patients, it means that they are trusting the nurse to adequately care for them and for their loved ones (Molter, 2007). A measure of effectiveness of the nurse’s practitioners practice is the patient outcome itself – whether or not the patients admitted and treated in the clinic are getting well (Molter, 2007). If the recovery rate for patients seeking treatment from the clinic is high, then the effectiveness of the family nursing practice is also high. If the patients are not getting well after seeing the nurse practitioner and following her advice, then the practice is not effective in administering proper care for the patients. There may be a need to refer the patient to the hospitals or to other private practitioners. Frequent referrals to the hospitals for patients in the rural setting being served by the nurse practitioner also indicate a lack of effectiveness of nurse practitioner services (Molter, 2007). Mortality and morbidity rates for patients in areas covered by the clinic are also indicators of efficacy in the practice. When these rates are high, it means that the available health services, one of them being the clinic, are not effectively addressing the health issues in the community setting (Sidani, et.al., 2006). These outcome measures can be carried out on a quarterly basis. Quarterly basis can accurately provide clear efficacy measures for the services and care rendered by the nurse practitioner. It can indicate differences in trends within the year, showing in which months and quarter the services are going well and when they are not doing well. In this case, it would be better to identify the areas and the services which need improvement; and it is easier to identify the barrier or the issues encountered within a particular time period – issues which reduce the efficacy of family nurse practitioner services. Quality improvement/quality management plan for selected practice issues in the practice site One practice issue in the family nursing practice is on missed appointments. Missed appointments can indicate many different things. Especially in instances when no notice is given to the clinic explaining the reason for the missed appointment and requesting for a rescheduling of the appointment, there is a valid cause of concern for the patient. In order to prevent missed appointments and to improve the handling of these incidents, it is important for the nurse practitioner to implement a confirmation system with the patients. A staff in the clinic can be assigned the task of writing down the dates of appointments and the purpose of such appointments. This same staff would then be tasked with calling the patient the day before the appointment for confirmation and for reminding the patients about the appointment and the time they should be in the clinic. If the clinic would call for laboratory tests which require fasting or any other preparation, reminders can also be given to the patient on what they should do, should not do, and should prepare. This staff shall also be tasked with calling the patients during missed appointments, to check in with them, to inquire why they have missed their appointment, and to remind them of the consequences of their missed appointment (Chiari and Vanelli, 2005). In case they are not answering, this staff shall inform the nurse practitioner and this practitioner shall check who can be contacted in the nearest vicinity to check on the patient. This needs to be done in order to safeguard the safety of the patient in case the patient is injured or is too ill to make his appointment (Chiari and Vanelli, 2005). In these instances, medical services have to be deployed to the patient’s house in order to transport him to the nearest care facility for proper medical care. Among patients who reschedule appointments without valid reasons or explanations, it is the responsibility of the nurse practitioner to remind the patient of the dangers of postponing the appointment. The study by Neal, et.al., (2005) sets forth that the most common reasons for patients missing appointments are mistakes, misunderstandings, and forgetfulness. Some patients may have put in a wrong date for their appointments in their calendars, some may have misunderstood the time set with the health practitioner, and some may just have forgotten about their appointment. The confirmation of the appointment by clinic staff is therefore important and can work to clarify and resolve these common reasons for missed appointments (Neal, et.al., 2005). Giving the patient a day’s notice or reminder about his appointment would give the patient enough time to correct any mistakes or misunderstandings and to remind him about his appointment. For patients wanting to reschedule or cancel their appointment, it is important for the nurse to try to convince the patient to keep his appointment. The nurse practitioner must be highly knowledgeable about the patient’s case and the importance of the appointment. The consequences of missed appointments for patients who may be diabetic, who have CVD, who are pregnant, or who may be seriously ill must be expressed to the patient. Some patients may miss their appointments because they fear the process (Chiari and Vanelli, 2005). It is therefore important for the nurse practitioner to explain to the patient the importance of keeping his appointment. It is also the role of the practitioner to reassure the patient and to calm his fears (Chiari and Vanelli, 2005). These actions would help encourage the patient to continue with the appointment and to be reassured of the emotional support he will be receiving during the appointment and its consequent procedures. Some patients may also not feel that it is important for them to keep their appointment – that their medical issue is something they can just ignore and not seek medical help for. In these instances, it is once again the role of the nurse practitioner to accurately inform the patient of the importance of keeping the appointment and the possible implications of missing the appointment, and of not being medically treated for his illness (Chiari and Vanelli, 2005). The tone of the nurse practitioner must not be on striking fear into the patient so that the patient. His role would be to paint an accurate picture of the patient’s possible medical scenario and to use such scenario to convince the patient to keep the appointment. The nurse can also act casual about it, to tell the patient that it may not amount to anything, and that there would be no harm in checking and verifying his illness. And that it would not take up much of his time. It is the nurse’s duty to emphasize to the patient the importance of early detection and early treatment of any disease. It is also important for the nurse to emphasize to the patient the importance of prevention, and how keeping his appointment can prevent worse medical issues from cropping up (Chiari and Vanelli, 2005). With the assistance of the staff member keeping record of the appointments, the clinic appointments can be smoothly carried out without much issue for the nurse practitioner and the patients. Conclusion The above discussion successfully explains my entry into the family nurse practitioner practice. With the above details, I was able to establish my role and the clinic’s role in the rural health setting. These details also discuss issues and barriers to care and the different solutions to such barriers. Through these solutions an improved practice can hopefully be implemented in the rural health clinic where I am setting up my practice. Works Cited Andrews, D. & Dziegielewski, S. (2005). The nurse manager: job satisfaction, the nursing shortage and retention. 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