Category: Nursing Types & Specialties

Kesha Walton, DNP, RN, FNP-C is a practicing family nurse practitioner who also serves as an officer in an NP professional organization. During a recent meeting, the members discussed the noticeable decline in membership. This conversation alerted Dr. Walton to a professional concern and sparked an idea for her DNP evidence-based capstone project. Research for the capstone project revealed the following reasons for low participation in NP professional organizations:

• Personal and professional time constraints 
• Cost of membership
• Working too much
• Lack of understanding around the nature of the organization

Are any of these reasons keeping you from joining an NP professional organization?

What Is a Nurse Practitioner Organization?

While many organizations exist, the national group that represents all NPs is the American Association of Nurse Practitioners (AANP). The AANP charges one affordable annual membership fee that connects the NP to one of eleven regions. Each AANP region has their own regional director and state representatives. Many other specialty NP organizations exist in conjunction with the AANP. All professional organizations share similar benefits:

• The ability to enjoy discounts on education and board certifications 
• Access to practice and career support services
• The opportunity to engage in political advocacy
• The chance to collaborate through networking events

Acknowledging the professional expectation of membership, many NPs will pay the membership fee and take advantage of a few discounts and services. Identifying the unique value that you offer the organization is critical to accessing additional perks that are only known by those who participate in the group. NPs who are willing to actively engage in the organization are able to experience these unforeseen benefits.

Top Perks of Joining a Nurse Practitioner Organization

1. Discover a New Arena to Demonstrate Skills and Expertise

Finding like-minded professionals to support NP efforts and exchange ideas about current and future healthcare challenges is the key to staying engaged in your patient care practice. Taking an active role in subgroups of a professional organization showcases your value and unique perspective.

2. Increase Your Social Acumen

Social acumen refers to making the most of every moment you have with others. This means becoming comfortable with the "meet and greet" moments and other social rituals we use to connect with each other. You will develop a sense of confidence in making your first impression, which is critical to establishing memorable relationships and serving as a notable presence in the organization.

3. Find New Resources and Best Practices

Expanding your network of NPs and healthcare leaders will expose you to creative changes in your own environment. NPs who are excited to share novel projects, initiatives, and successes with their networks are a great source of support for making positive adjustments in your own practice.

4. Discover New Career Directions or Make a Job Change

A shared environment is a great place to hear what other NPs are doing, learn about jobs, and let others know that you are interested in new opportunities. Policy is a critical element of nursing. As the highest employment group in healthcare, it's important that nursing has representation in the government to guide lawmakers in patient protection and healthcare law. Ask to represent NPs on national committees or take part in research and data gathering to help legislators advance the NP role. You can also consider taking part in the Multi-state Reimbursement Alliance, an organization that tackles NP insurance reimbursement and credentialing. Additionally, the field of healthcare informatics requires educated professional users to participate in discussions about future needs and patient protection in the current internet age.

RELATED: Tips and Tricks for Nurse Practitioner Networking

5. Gain Recognition for Your Accomplishments

Many professional organizations offer fellowships and mentorship connections, which showcase accomplishments and guide industry contributions. Review award nominations and set professional goals for future consideration. Inform other NPs that you're interested in the awards and adding to NP professional contributions. Speak up and never apologize for it – NPs are educated, communicative leaders who deserve recognition for their accomplishments. Your success will inspire others, leading to future mentorship and a respected position in healthcare.

The Bottom Line: Become an Active Member of Your NP Organization

Joining a professional group offers an opportunity to develop relationships, share ideas, and expand your network. Being an active member provides you with a venue to maximize your strengths and improve on weaknesses. Active membership is about more than paying an annual fee and taking advantage of a few discounts. Consider investigating current policy initiatives and notifying members through emails or phone calls. You can also write articles for the organization's blog, suggest ways to increase membership, or participate in different committees. When people see your work, they will have a better idea about your competence and reliability—two aspects of NP life that are highly trusted and valued. Active membership allows you to gain recognition for your contributions, which ultimately leads to personal and professional growth.

RELATED: A 7 Step Health Policy Toolkit to Flex Your Political Muscle as a Nurse Practitioner

"If you want one year of prosperity, grow grain. If you want ten years of prosperity, grow trees. If you want one hundred years of prosperity, grow people."

This Chinese Proverb is a testament to the magic of networking with other professionals in a similar field. In fact, a survey conducted in 2016 revealed that 85% of jobs were fulfilled through networking. So why are nurse practitioners not actively practicing this method? It is not stressed in school, since our profession is not a sales-driven community. However, networking may land you in a top working environment, or provide you with connections that can continue to benefit you as you transform your professional identity.

Networking Tip #1: Offer Incentive

I am not suggesting you pay for your network, but sometimes it can help if you offer to treat your prospective referral with a coffee or lunch date. The life of a nurse practitioner is busy; work-life balance is an entire topic in itself. It’s courteous to offer to pay for a meal or coffee in exchange for picking their brain a little on their current career position. Suggest that they pick the best time and date for their schedule, so they are more willing to proceed with the meeting. During these unprecedented pandemic times, it may be harder to meet in person due to social distancing. This may work out in your favor for those who are busy! Familiarize yourself with Zoom, and suggest a quick Zoom call to check in and catch up. If you can't offer coffee or dinner, offer your help in some other way, such as promoting their practice or suggesting a referral program.

Networking Tip #2: Rehearse Your Questions and Conversation Starters

Consider your networking event like a very casual interview. Although you will most likely be conversing in a friendlier atmosphere, it is always a possibility a job may come from your networking experience. Write out a few points to make sure you cover during your meeting, and highlight any questions you have for your resource. It is also a good idea to have a quick, thirty second "elevator pitch" about yourself and your current job situation.

RELATED: New Graduate Nurse Practitioners: Keep Learning to Build Confidence

Networking Tip #3: Scroll Through Your Rolodex

Not many people actually have a Rolodex anymore, but you understand the concept! The good news about obtaining a nurse practitioner degree is that you are required to have clinical time with other nurses, and this gives you an automatic contact list. These former classmates of yours may be working for employers who are looking for new providers, and they will be able to vouch for you first-hand and speak to your work and school ethic. Don't forget about the friends you made in nursing school, too! Many of them may have become NPs or advanced practice providers as well, and you can pick their brains about where they stand now. Sometimes it can feel awkward to message someone out of the blue, but more often than not your former schoolmate will be excited to reminisce and catch up. If you don't have their number, try messaging them on a social media platform.

RELATED: Conquer Uniqueness: 5 Novel Ways to Educate Yourself and Expand Your Advanced Practice Nursing Career

Networking Tip #4: Join a Facebook Group and Tidy Up Your LinkedIn Account

Facebook is a great tool to use for networking; the entire premise of the application is to mingle with other like-minded individuals. There are many local and statewide Facebook groups that pertain particularly to nurse practitioners and advanced practice providers, and they can be a great networking tool! The groups highlight many job postings, volunteer opportunities, and educational resources. This may also be an easy way to initiate a prospective in-person meeting, where you can have face-to-face contact with other NPs in your area. LinkedIn is a prime tool for networking – it is literally a network of millions. Update your profile picture, provide some links to your page, and ask some of your connections to endorse you and your skills.

“Networking is a lot like nutrition and fitness: we know what to do, the hard part is making it a top priority.”

– Herminia Ibarra

There is an art to networking, and these tips only brush the surface. It can sometimes feel uncomfortable approaching someone that you do not know very well, but most professions run entirely off of networking. Although the healthcare field does not rely solely on mingling to make business run, if you break your comfort zone a little and make the right connection, you may find yourself in your dream job that would not have been possible previously by a sea of online applications.

Nurse practitioners (NPs) are typically hyper-focused on the health and well-being of their patients, constantly encouraging them to eat nutritiously, exercise regularly, stick to a regular sleep schedule, and participate in stress relief activities. However, when was the last time you practiced what you preached as an NP? With healthcare professionals pulled back and forth between balancing patients and administration at work and family and daily responsibilities at home, it is no wonder that so many providers suffer from burnout without even knowing it. From family care to acute care, burnout does not discriminate in the healthcare field.

While preventing burnout is important in any role, it's especially pertinent when working in healthcare during a pandemic. It has become increasingly crucial for providers like NPs to recognize what burnout looks like, the different causes, and how it can be prevented and treated. This is not only valuable for providers, but for the safety and well-being of patients as well.

Causes of Nurse Practitioner Burnout

Hours

Depending on the employer, providers may or may not have a set schedule for work. However, the scheduled hours are not the extent of the hours worked. NPs could come in early, leave late, or work through lunch, which ultimately cuts into their availability to care for themselves.

Low Control of Daily Pace

In both hospitals and outpatient environments, NPs have little to no control of their patient load and acuity. Providers who work in hospitals or urgent care facilities have no say over who walks in and is admitted to their service. Outpatient providers may have a daily schedule of the patients who they expect to see that day, but it often changes throughout the day.

Time Pressures

Regardless of the employer, there is always an expected number of patients that an NP will care for during a shift. Oftentimes, the allotted time for patient care is not enough to thoroughly examine and address all of the patient's concerns. This can ultimately increase the amount of follow-up appointments, further filling up an already tightly-packed schedule. Alternatively, an NP may try to address all of the patient’s concerns in one visit. However, this approach typically causes delays in other patients' care or scheduled appointments.

RELATED: 5 Must-Have Apps and Tools for Nurse Practitioners

Electronic Health Records (EHR) and Documentation

EHRs are a vital asset for billing, legal liability, and continuity of care. Outside of caring for patients, documentation is the next most important job for providers. This means that everything must be completed accurately and succinctly in a timely manner. However, the real challenge for NPs is finding time to complete this work with no breaks between patients.

Symptoms of Nurse Practitioner Burnout

1. Mental exhaustion
2. Emotional exhaustion
3. Physical exhaustion
4. Depersonalization
5. Insomnia
6. Sadness or irritability
7. Increased vulnerability to illness
8. Decreased sense of personal accomplishment

It is important to understand that the responsibility of preventing and treating burnout does not fall solely on the employer.This process requires some level of effort from the provider as well. Here are some ways to prevent burnout from occurring, or treat it if symptoms have already begun.

Nurse Practitioner Burnout Prevention/Treatment

Schedule 10-30 Minutes of Exercise Daily

Physical activity strengthens the cardiopulmonary and musculoskeletal system and releases endorphins. This boosts both physical and emotional health. With time constraints, squeezing in small exercise breaks may be more feasible than developing one longer exercise routine.

Seek Support

Healthcare burnout is very common, and finding a colleague who may be going through a similar experience can offer a great source of support. Discussing your frustrations and feelings with a counselor or psychologist can also help relieve burnout. These conversations can be conducted in an office or virtually.

Evaluate Work Options

If there are no promising changes after sharing your thoughts on imbalances in expectations, it may be time to start looking for a new job or employer.

RELATED: How to Negotiate Your NP Contract

Staff Meetings to Evaluate Office Flow

Engage in open discussions with support staff to determine what type of patient flow works best in your office or unit, ensuring that it is as optimized as possible. Also, aim to schedule small breaks throughout the day to complete documentation and other administrative tasks.

Streamline EHR Flow

Create smart sets and favorites of orders, diagnosis codes, and patient instructions to streamline the documentation process. Consider the possibility of hiring a scribe to help reduce the strain of documentation.

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Nurses and nurse practitioners are the most trusted professionals in America, but this high honor can lead to a significant amount of pressure. While we should continue to provide the best care possible to our patients, it's important to take notice when it's negatively affecting our physical, mental, and emotional health.

Being a nurse practitioner is so much more than just assessing, diagnosing, and treating patients. Providers are also regularly responsible for breaking bad news, calming frustrated patients, and explaining the complicated world of treatment plans based on accessibility and insurance requirements. This is a daunting task to add to the already demanding world of medicine. So, what are some approaches that can help lighten this burden? Understanding the source of the problem and creating a game plan to ease the situation is key.

The Root of the Problem

Difficult patient and family interactions come in a variety of shapes and sizes, and they go beyond bearing bad news or discussing potentially ominous test results. Challenging interactions most frequently stem from discrepancies in expectations, perceptions, and communication. Common real-life challenging interactions include:

• Patients feeling left out of treatment decisions 
• Patients not feeling heard or listened to
• No concrete answers or diagnosis after a workup
• Treatment non-compliance 
• Expensive treatment options
• Delivering bad news

Challenging patient interactions are a multifaceted experience, and these situations aren't only about the provider and patient. In reality, they include a variety of internal and external considerations. Factors that can affect the difficult interactions include:

1. Environment: The office, clinic, or hospital may not always be able to accomodate the ideal privacy and comfort setting for these discussions.
2. Audience: The environment where the interaction occurs may have a larger or smaller audience than the patient would like. Patients may or may not want family present, and additional staff members can occasionally be present as part of their daily role. 
3. Empathy: Long working hours, an increased workload, and the frequency of certain interactions may invoke an unintentional lack of empathy from the healthcare provider. 
4. Resources: A lack of staffing, specialists, and diagnostic testing can lead to long wait times, drawn-out workups, and delays of treatment. 
5. Nonverbal communication: Nonverbal communication is equally as important as verbal communication. However, this form of communication is open for interpretation and can lead to incorrect perceptions.
6. Ambiguous/complicated plans: Treatment plans are not a one-size-fits-all strategy. Sometimes, a full treatment plan cannot be created as it depends on diagnostic results or responses to first-line treatment. These incomplete plans can cause anxiety in patients and families as they do not know what to expect. Overly complex treatment plans can also be overwhelming and confusing to patients and families, potentially encouraging noncompliance. 

While the primary goal of a difficult interaction is to create a positive outcome for the provider and patient, that's not always the case. Potential worst-case scenarios include:

• Consulting "Dr. Google"
• Frustrations that lead to threats of legal action
• Failure to accept the diagnosis
• Lack of trust related to no diagnosis, despite having signs and symptoms
• Noncompliance
• Negative focus on continuing symptoms, as opposed to recognizing progress

RELATED: Nurse Practitioner Practice Authority

Managing Difficult Patient Interactions

Nurse practitioners experience difficult interactions on a regular basis. Unlike the doctors and nurses on television, healthcare providers cannot rely on a writing team to deliver an eloquent, jaw-dropping speech to patients and families. So, what's the best way to manage these situations? Should we just accept that they are bound to occur and we have no control over them? Absolutely not. Managing these situations might take a lot of work on our part, but it will ultimately make our daily practice less stressful. Here are some ways to prevent and control a potentially difficult interaction:

1. Plan your interaction with the patient or family.
2. Consult a colleague or seek additional training before the interaction.
3. Create a comfortable environment by introducing all present parties, sitting with the patient, and maintaining eye contact.
4. Pay attention to your nonverbal communication, as well as the patient and their family. 
5. Ensure everyone's safety and maintain situational control.
6. Use empathy and active listening to encourage a patient's emotional control.
7. Provide multiple options to focus on solutions and resolve areas of disagreement.
8. Avoid using language such as:
   1. "I'm afraid I have bad news."
   2. "This is a terminal disease."
   3. "You are lucky it is only _________."
   4. "There is nothing left for us to do."

After a difficult interaction, it is important to reflect upon the situation – whether it went well or not. If it was a positive discussion, it's helpful to take note of the particular approach and utilize it for future interactions. If the encounter with the patient and family did not go as planned, it's critical to note what didn't go well and develop new approaches for future patient conversations.

Difficult patient interactions will inevitably occur in a nurse practitioner's career. However, it is the NP's responsibility to serve as a trusted resource in their patient's care. Understanding which factors create difficult interactions and customizing the appropriate approach to the patient's needs can help develop a dynamic that fosters the best possible health outcomes.

Gail Adcock, MSN, FNP, FAANP, FAAN, and North Carolina state representative, describes herself as "a nurse by grace, a North Carolinian by choice, and a politician by necessity.” Representative Adcock is a nurse practitioner and the Chief Health Officer for a global data analytics company. Despite her busy professional and personal life, Representative Adcock made time to respond to an important call to action.

Per the 2011 Institute of Medicine report "The Future of Nursing: Leading Change, Advancing Health," the call to action is: "Nurses must see policy as something they can shape rather than something that happens to them." This report outlines the vital role, power, and influence of NPs and nurses in the healthcare system.

Why Aren't There More Nurse Practitioners in Political Positions?

The answer is that politics is definitely out of their comfort zone. Busy NPs are often unfamiliar with and intimidated by the political process. However, as patient care champions, NPs also offer a unique view of community and health care needs. Nurse practitioner qualities that translate to health policy include the following:

• Nurse practitioners advocate. Nurse practitioners advocate for patients on a daily basis and advocating health policy and legislation is equally important. An upstream approach to advanced practice, nursing, and health care issues impact communities and patients on a broader scale. 

• Nurse practitioners vote. 89% of NPs vote in national elections, compared to just 69% of the US population (O'Rourke, et al., 2017). Therefore, it's important to encourage both your NP and nurse colleagues to vote.

• Nurse practitioners and nurses are the most trusted profession. For nearly 20 years, Americans have rated nurses as the most trusted professionals. And why wouldn't you want somebody you can trust in office? Honesty and integrity are important assets for holding leadership positions in both community organizations and public office.

• Nurse practitioners are part of the largest sector of the U.S. healthcare workforce. Over 3 million NPs and nurses provide direct care to patients and communities. Nurse practitioners administer care in patient homes, neighborhoods, and health networks, and identify social and healthcare needs in a unique way that is unlike any other health profession.

How Can Nurse Practitioners Respond to This Call to Action?

NPs need to expand outside of their comfort zone, discover their collective voice, spark others, take interest in the legislative process, and translate the patient care experience into action. Remember that it's okay to start small! This seven-step health policy toolkit serves as an NP blueprint for health policy involvement.

1. Learn About the Political Process of Local and State Governments

Investigate local governments and governing bodies in your town and community. Next, learn how laws are introduced and passed in your state. You can find this information through state legislation websites. These websites also allow for bill searches using specific keywords. Search for "nursing" or "health care" to stay up-to-date!

2. Vote

There is strength in numbers for NPs and nurses, and this political strength begins with voting! Aim to include health care policies in your legislative decisions, and discuss these policies with your NP and nurse colleagues.

3. Join Nursing Organizations and Find a Mentor in the Advocacy Group

Professional nursing organizations have expanded from education and certification resource centers to include political advocacy groups. The American Nurses Association (ANA), National Council of State Boards of Nursing (NCSBN), and Campaign for Action are some state and national nursing organizations that offer health policy guidance. Additionally, NP organizations such as the Gerontological Advanced Practice Nurses Association (GNPA) offer health policy resources that are applicable to the specialty NP group.

4. Seek Nursing Leadership Positions

Advancing nurse practitioner responsibilities beyond patient care into policy builds increased public confidence in the NP role and demonstrates that nurse practitioners are educated, trusted, and reliable leaders.

5. Participate in Community Groups

As health professionals, gaining NP input on Parent Teacher Associations, support groups, and fitness and nutrition groups is beneficial. Nurse practitioners can contribute health and safety strategies, assess community needs, and offer valuable health and illness-related guidance.

6. Identify a Bill That You Are Passionate About and Write to Your Legislator for Support

Nurse practitioners are valuable constituents due to their close proximity to stakeholders and community needs. Search your state government website for health care bills, and then research local politicians to ask for support. In your letter, mention your community and how the bill impacts your patients. 

7. Apply for a Health Policy Fellowship

Distinguished programs developed through organizations like the American Association of Colleges of Nursing, National Academy of Medicine, and Robert Wood Johnson Foundation seek nurse practitioner leaders to participate in national policy development. As NPs evolve into policy leaders, these fellowships provide a stepping stone into health policy development positions.

READ MORE: Nurse Practitioner Practice Authority

Nurse practitioners can answer this call to action in various ways, and every little bit helps! By following the simple actions included in the toolkit, even the busiest NPs can begin the path to understanding and participating in health policy.

From insurance reimbursement and billing to coding and audits, these responsibilities can leave any healthcare provider with goosebumps – especially those who work in or own their own private practice. The most stressful part, in relation to insurance reimbursement, is that most healthcare providers like nurse practitioners are not formally trained in billing and coding and work in a clinical setting or facility with no certified billing and coding specialists. Luckily, there are a wide variety of resources available to help decode this unfamiliar territory.

Coding Basics

Accurate coding is critical for insurance reimbursement, succinct documentation, and identifying clinical care gaps. The Healthcare Common Procedure Coding System (HCPCS) codes and International Classification of Diseases, 10th Revision (ICD-10) codes serve as the building blocks of medical coding.

• HCPCS Level I codes: These codes are used to describe medical, surgical, diagnostic, and other types of medical services. In addition, there are modifiers that help identify alterations to HCPCS codes.
  • Category I: Common procedures
  • Category II: Performance measurements
  • Category III: Emerging technologies
• HCPCS Level II codes: These codes are used to describe products, supplies, and services provided during an encounter.
• ICD-10 codes: These codes are used to describe the reason for a patient encounter or outline a patient's characteristics, and are essential for identifying common diagnoses in a medical practice. They notify the insurance payer of the medical necessity of the visit.

Evaluation/Management Coding

Evaluation/Management (E/M) coding is the core of healthcare billing and insurance reimbursement. Understanding E/M coding can help maximize the insurance reimbursement of a practice and reduce stress levels during audits. These codes are based on several factors:

• The patient's history
• The patient's physical exam
• The provider's medical decision making
• The appointment time, specifically if the provider spent 50% of the visit coordinating care or counseling

There are different levels for the aforementioned factors, which decipher which E/M code to use.

1. History
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
2. Physical Exam
   1. Problem-focused
   2. Expanded problem-focused
   3. Detailed
   4. Comprehensive
3. Medical Decision Making
   1. Straightforward
   2. Low complexity
   3. Moderate complexity
   4. High complexity

The level of complexity related to medical decision making depends on the number of diagnoses and management options, the complexity of the patient data that was reviewed, and the risk of complications or morbidity/mortality.

Transition of Care Billing and Coding

Transition of care visits are an efficient way to support the continuity of care after a patient is discharged from a skilled nursing facility/nursing facility, long-term acute care hospital, rehabilitation hospital, acute care hospital, or observation stay in a hospital. A transition of care visit can only be billed one time per patient in a 30-day timeframe, and can be billed for both new and established patients at a particular clinic.

Transition of care visits can be billed using two different codes.

• 99495-This code can only be used if the patient has been contacted within two business days of their discharge, the medical decision making is of moderate complexity, and there is an in-person clinic visit within 14 days of the discharge.
• 99496- This code is used if the patient has been contacted within two business days of their discharge, the medical decision making is of high complexity, and there is an in-person clinic visit within seven days of the discharge.

Medicare Wellness Coding and Billing

Medicare wellness exams go beyond a typical annual adult wellness examination. In addition to focusing on a patient's wellness, these exams involve a thorough screening centered around disease prevention. The exam also takes a more comprehensive look at the patient's vital signs, medical/family history, and health risk assessments including their emotional and psychological well-being to develop a personalized prevention plan. Many types of healthcare providers can complete these wellness exams, including:

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Registered dietitians
• A team of medical professionals with an overseeing physician

RELATED: Complete Guide to the Adult-Gerontology Nurse Practitioner Specialty

Pediatric Coding and Billing

Accurate coding for the pediatric population is similar to the process for the adult population with several additional considerations including behavior screenings, developmental screenings, and vaccine administration. Another complication is that not all of these screenings and vaccines are completed at every age. Each well child examination typically has different screenings and different vaccine administrations or they may not have any vaccines at all. That's why it is important to follow the recommendations of Bright Futures, which establishes guidelines that insurances follow.

RELATED: Complete Guide to the Pediatric Nurse Practitioner Specialty

Initially, the billing and coding world can be daunting and confusing. Luckily, there are a variety of resources available to help providers make sense of this information. In addition to online resources, there are several textbooks and conferences that can strengthen a provider's knowledge of accurate billing and coding. Accessing the right resources can help providers boost their understanding, which leads to more efficient documentation, increased reimbursement, and decreased stress during chart audits.