Nothing frustrates me more as an NP than the variability of nurse practitioner rules and legislation from state-to-state.

Every state should be the same.

In headline news this week, nurse practitioners in Missouri are pushing for more autonomy, arguing that the existing law, requiring physician collaboration, are “preventing them from providing the best possible care to their patients.” Read the full story here.

Case in point. Sixteen states and the District of Columbia do not require advanced-practice nurses to have a supervisory relationship with another health care provider.

Why does Missouri?

This is a critical matter in Missouri, where 109 of the state’s 114 counties are designated as health care provider shortage areas by the U.S. Department of Health and Human Services.

Barriers to NP practice autonomy in states like Missouri perpetuate some of the nation’s worst healthcare problems: access, quality of care, and affordability.

Missouri lawmakers agree.

Two bills brought before the Missouri State Legislature, House Bill 1371 and Senate Bill 679, would remove limits on nurses’ ability to practice, allowing nurse practitioners, certified nurse midwives and clinical nurse specialists to prescribe controlled substances, give orders to respiratory therapists and allow them to be reimbursed for care by Missouri’s Medicaid program.

Those who oppose such legislation argue for the safety of consumers.

There is no basis for this argument.

In reality, it is unsafe is not being able to provide the best possible care to patients.

The fact is, in those states in which NPs are practicing autonomously, their safety ratios are 23 times better than those for physicians in the same states.¹

“NPs must use malpractice and malfeasance ratios and figures to show legislators that the rationale for physician supervision over NPs is unfounded.”¹

NPs  have earned patient’s trust and are the key to solving our nation’s healthcare crisis.

We must continue to fight to remove barriers to fully autonomous NP practice.

Lawmakers, let nurses practice!

Help support Missouri’s bill to remove barriers to full autonomy for advanced practice nurses. Send a message directly to your legislator through the AANP Advocacy Center.

1. The Pearson Report. 2012. A National Overview of Nurse Practitioner Legislation and Healthcare Issues. www.webNPonline.com.

Patients who are difficult, demanding, easily angered, impatient, manipulative, noncompliant, unreasonable ____ (fill in the blank).

As an NP, I’ve had my fair share of unruly patients lash out at me in moments of frustration and disappointment.

This can be tough when you feel criticized when all you’re trying to do is help your patient.

I know how this feels firsthand.

Once, I had a such a negative encounter with a patient that I told the scheduler not to book them with me again. EVER.

Maybe this wasn’t the best way to respond and usually, I’m able to turn the most unruly patients around.

But not this time.

I felt disrespected….and hurt.

I’m human, after all.

But, I broke a cardinal rule in the patient-nurse relationship.

I took it personally.

So, what do you do in these situations, instead?

Our formal training hardly prepares us to deal with unruly patients.

After my “nightmare” patient encounter, I started searching for advice/tools that would help me deal more effectively with unruly patients. While there are many approaches and each situation is different, perhaps what I learned will help you the next time you have a difficult patient encounter.

First & foremost, try not to take it personally when patients criticize or lash out in anger.

Usually, it’s not about you.

Often, there is more going on beneath the surface; a long wait to see you, stress at home, frustration, fear, & sadness about their diagnosis, not feeling heard by health care providers in the past, etc.

Instead, incorporate empathy by imagining how the patient might be feeling, suggests Edward Leigh, Founder & Director at Center for Healthcare Communication.

Next, state your perception of the patient’s feeling, Leigh suggests. “Reflect back with a feeling word or phrase. Once you have found the word you think fits best, incorporate it to a sentence. Here are some sentence beginnings to get you thinking:”

“Sounds like you are…”
“I imagine that must be…”
“I can understand that must make you feel…”

Finally, take time and listen. Effective communication is the key to dealing with unruly patients. Maybe you’re the first person who’s taken the time to listen. It is not uncommon for me to hear this from patients who’ve seen other providers.

Do this and you’ll lower your risk of malpractice.

Patients don’t like feeling rushed or ignored by physicians and nurses who are “too busy” to sit down, listen attentively, and respond to their questions and may set themselves up for problems, such as a lawsuit, down the road, says Leigh. Breakdown in communication between NPs, nurses and patients “fuel distrust and pent-up anger” and patients who are unhappy with their health care provider are more likely to sue.

For more information on effective patient communication, read Great Communication Skills = Lower Risk of Malpractice and Get the Message! 8 Ways to Dramatically Enhance Your Listening Skills

If you’re a nurse practitioner student, you’re probably overwhelmed with the amount of information you’re learning in class, in clinical, and from all those books!

It can be a love-hate relationship when you’re short on time but need those books to teach and help you succeed.

If you’re a nurse practitioner in practice, especially a new one, you too need quick access to quality, concise, information to make the best clinical decisions every day.

Your education never ends.

Everyday, as an FNP, I look to my books to teach and sharpen me.

Although, more and more textbooks are going digital, I have my favorites I affectionately pull from my shelf.

Whatever format you prefer, it is important to have a core list of reference books you can rely on as a student and nurse practitioner.

Here are 10 books I believe every nurse practitioner should have.

1. Nurse Practitioner’s Business Practice And Legal Guide A must-have resource for every new or current Nurse Practitioner (NP). It defines what an NP is and does, while explaining their legal scope of practice within specific state and federal regulations.

2. Zitelli, Atlas of Pediatric Physical Diagnosis The go-to reference for pediatric diagnoses. More than 3,400 hundred illustrations-3,000 in full color-capture the full range of gross anatomic signs as well as laboratory and radiologic findings for hundreds of pediatric disorders. Plus, the 5th edition includes online access with downloadable pictures for electronic presentations. The 6th edition will be released in April 2012.

3. Guyton and Hall Textbook of Medical Physiology: With Online Access No library should be without this classic. Guyton had a gift for explaining complex ideas so they made sense to students. I refer to it almost daily in practice.

4. Family Practice Guidelines, Second Edition A comprehensive resource for NPs, presents current national standard of care guidelines for practice and select 2011 guidelines.

5. Tarascon Pocket Pharmacopoeia 2012 Classic Shirt-Pocket Edition The quickest, most concise drug reference book you’ll find. Quicker to use than a mobile app!

6. Ferri’s Clinical Advisor 2012: 5 Books in 1, Expert Consult – Online and Print An invaluable resource for nurse practitioners & students. Combines state-of-the-art information on over 700 medical disorders in a user-friendly format. Evaluates all evidence-based treatment on rating system.

7. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology: Sixth Edition With 1500 high-quality full-color images covering skin lesions and disorders of the hair, nail, and mucosa, Fitzpatrick’s is the clinical reference for skin diseases.

8. The Harriet Lane Handbook: Mobile Medicine Series, Expert Consult Fast, accurate information on pediatric diagnosis and treatment written by experts at Johns Hopkins University. This pocket handbook is the first go-to for all nurse practitioners who treat children.

9. Clinician’s Guide to Laboratory Medicine: Pocket The only book that walks you from abnormal lab test to diagnosis through a series of steps.

10. The Sanford Guide to Antimicrobial Therapy 2011 The gold standard for all antimicrobial treatment.

These books can be purchased at http://www.amazon.com and in online digital formats through http://expertconsult.com and http://www.mdconsult.com.

Chances are it was another nurse or NP who modeled exemplary care, compassion, leadership and passion in their roles advocating and caring for patients.

For me, it was my aunt, who worked over 25 years as an OR nurse. Later, in the early 90’s, I was inspired to pursue higher education in nursing by my mentors at the City of Hope National Medical Center, Dr. Betty Ferrell and Dr. Marcia Grant, who dedicated their lives to studying and improving patient quality of life

Today, I still look to my colleagues, who inspire me to pursue education and excellence in nursing and patient care.

There’s no need to look further than the internet or newspaper to find many inspirational nurses in the news.

Here are just 5 of the most influential nurses making headlines today.

If you know an inspirational nurse, I would love to hear about them.

1. Dr. Loretta Ford, PNP, FAANP, co-founder of the nurse practitioner education program in 1965, Ford was recently inducted into the National Women’s Hall of Fame for her work, which has led to more than 140,000 nurse practitioners in the U.S. who have the ability to assess, diagnose, treat and evaluate. Read more about Ford’s life and career.

2. Lt. Col. Sandra McNaughton, FNP, an Army family nurse practitioner, helped care for Afghan women and children at more than 30 locations in their country. “They never had care in their lives,” she said in a recent interview for The Courier-Journal.com. “Many patients had to travel long distances and brave threats from the Taliban.” Read the full story in The Courier-Journal.

3. Robert D. Donaldson, NP-C, clinical director of emergency medicine and president of the hospital’s medical staff at Ellenville Regional Hospital in upstate New York was selected as one of the top 20 Health Leaders of 2011 by Health Leaders Media. If that isn’t enough, Donaldson is a “volunteer pilot for an organization that helps transport patients to hospitals, using his own six-seater Cessna 210.” Read Donaldson’s full interview with HealthLeaders Media.

4. Allison Batson, RN, transplant nurse at Emory University Hospital in Atlanta, went above and beyond the call of duty by donating one of her kidneys to a patient earlier this month. When asked why she would risk her life for a stranger she said she “hopes her story will make others aware of living donations.” Read the full story in the Los Angeles Times.

5. Lillie Shockney, RN, 2011 recipient of the Johnson & Johnson Amazing Nurse Award, her 40th award, Shockney is a two-time breast cancer survivor and administrative director of the Johns Hopkins Avon Foundation Breast Center who has has worked tirelessly to improve the care of breast cancer patients around the world. In addition, she is a published author and nationally recognized public speaker on the subject of breast cancer. She has written 13 books and more than 200 articles. Read more about Shockney’s life and career.

Recently, I was talking to an NP and friend whom I admire for being the best at what she does.

“How do you do it?” I asked.

“How do you stay on top of your game after 10 years in practice?”

“There’s no secret. I’m always learning and looking for ways to improve,” she replied. “My patients want and deserve
the best from me and I don’t want to disappoint them.”

That got me thinking.

Whether you’re a new nurse practitioner or a veteran, becoming better at what you do every day is essential to providing excellent patient care.

So, if you’d like to up your game, here are 10 tips that will help get you there.

1. Join a local and/or national NP group or association such as the American Academy of Nurse Practitioners (AANP). It is their mission to promote excellence in NP practice, education and research.

2. Become board-certified through the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP). This will not only increase your earning potential but ensures that you continually meet the standards of practice.

3. Attend a national conference. Not only with this provide opportunities for networking, it provides current, practical, and clinically oriented practice information for NPs in every specialty. Check out annual conferences held by American Academy of Nurse Practitioners (AANP),  The National Nurse Practitioner Symposium, and Nurse Practitioners in Women’s HealthCare Conference.

4. Invest in an ipad or smart phone. Not only are they great teaching tools for patients, apps such as AHRQ ePSS, designed by the US Department of Health and Human Services to assist primary care clinicians in identifying what screening, counseling, and preventive services are appropriate for their patients, and MedPage Today, which brings “breaking medical news into practice,” can really expand your knowledge base and save you time .

5. Use 3-D video animation to educate and motivate patients. Patient compliance is key to your success as an NP. You know the saying; we only remember 20% of what we hear. Empower patients to better understand and manage their health with help of interactive video animation. My favorite is TheVisualMD.com, which uses breathtaking video animation of the human body to help patients “understand, prevent and live.”

6. Keep up to date on new developments in drug therapy. I highly recommend monthly updates from The Prescriber’s Letter. The Prescriber’s Letter is totally independent, and has no connection with any pharmaceutical firm so it is completely objective.

7. Follow evidence-based guidelines. Are you sure that z-pack is the best choice for your patient with strep pharyngitis or are you just following the crowd? Providing the best care requires providing treatment recommendations based on the best medical evidence. Find evidence-based guidelines through UpToDate and the National Guideline Clearinghouse.

8. Find a mentor who can provide wisdom, guidance and advice. Search for a good mentor in your current practice, your local NP group/association, school of nursing, or the FAANP Mentorship Program.

I remember the day I decided leave primary care to specialize in holistic health & wellness.

I was writing a prescription for a 45 year old obese patient with uncontrolled diabetes, high blood pressure and kidney disease, when he asked, “What’s wrong with me? How come I’m not getting better?”

I’d been studying integrative medicine and reading the research on using lifestyle medicine for reversing chronic disease and was very impressed. I knew I could make a bigger impact.

Today, I get to live and work with my passion. I am a holistic health & wellness family nurse practitioner within a busy family practice. When physicians need help turning patients’ health around, they turn to me. Part detective, educator and counselor, I have more time to listen to patients and help them reach their goals through lifestyle medicine.

What about you?

Have you thought about expanding your clinical skills and expertise to enhance the quality of life of your patients?

Are you interested in increasing your revenue in a niche practice?

According to Barbara Phillips, FNP, founder of Nurse Practitioner Business Owners, “Specialists often charge more for their clinical services (cash and insurance other than Medicare). If you are also providing services such as teaching and speaking, you can also charge for those services.”

With a growing population of aging Americans and increasing obesity & diabetes rates, there are many opportunities for nurse practitioners to specialize.

Here are top 4 nurse practitioner specialties for 2012:

1) Health & Wellness NP
With two-third of adults and nearly one-third of children being overweight or obese and rising health care costs, there is an urgent need for health & wellness NPs in disease prevention as part of health care reform.

2) Survivorship NP
An emerging specialty, survivorship NPs are usually found in cancer centers with survivorship clinics. With the shortage of primary care doctors and oncologists who are short on time & training in this area, more survivorship NPs are needed to educate and develop follow-up care plans for cancer survivors.

3) Brain Health & Fitness NP
According to the U.S. Census Bureau, in 2020 almost 20% of the U.S. population will be older than 65. After cancer, what baby boomers fear most is losing their mind to Alzheimer’s and dementia. Through exercise, nutrition, mental stimulation, stress reduction, and socialization, Nurse practitioners in this specialty can help improve brain health and prevent mental decline.

4) Urinary Incontinence NP
According to Barbara Phillips, FNP, “A continence practice is a fantastic opportunity “ for Nurse practitioners, stating, “This is an area that clinicians can make a huge difference in the lives of their patients. The need is great, the need is now.” For more information, contact, Helen Carcio, NP founder and director of the Health & Continence Institute @ The Health & Continence Institute (HCI). She offers intensive courses a few times per year.

For more information on specialty care practices, I recommend reading, Why Niching your Practice Might be Better than Primary Care.

There is no better time than now to become a family nurse practitioner. 

With an increasing demand for quality, affordable, accessible health care, a new national health care system in 2014, aging baby-boomers, and an increasing shortage of primary care physicians, the need for FNPs has never been greater.

Every road paved before us. Every barrier removed, has provided today’s family nurse practitioner more opportunities, autonomy, and public acceptance than ever before. 

Still not convinced that now is the time to become an FNP?  

Here are  5 compelling reasons FNPs are in big demand.

1. Nurse Practitioner  is one of  today’s hottest jobs

Nurse practitioner ranked #1  on the top ten list of Today’s Hottest Jobs by Kiplinger’s in 2011, citing increased hiring demand, annual salary range: $83,273-$96,650 and 10-year growth projection of 22%.

2. FNPs are needed for a new health care system

The nation’s top health advisors recognize the need for more NPs in the new government health care system beginning in 2014.

In October, 2010 the Institute of Medicine (IOM) stated, “Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients.”

3. FNPs improve access to health care

There will be an estimated shortage of 40,000 primary care physicians by 2020.

In states like Florida, where aging baby boomers and a shortage of primary care physicians have created a higher demand for primary care services, FNPs can fill in these gaps, dramatically improving access to healthcare services.

4. FNPs reduce health care costs while maintaining quality

Research in Massachusetts has shown that using NPs to their full capacity could save the state up to $8.4 billion over the next 10 years.

Citing a potential cost-savings of $339 million annually across Florida’s health care system, last month, Florida TaxWatch Briefing formally endorsed NPs, recommending, “The Florida Legislature remove the barriers of practice for Advanced Registered Nurse Practitioners…granting authority for the prescription of controlled substances and direct billing to insurance companies and managed care facilities.”

What about the quality of care?

According to Dr. Jeffrey Bauer, medical economist and health futurist, “In more than 100 published reports on the quality of care provided by both Nurse Practitioners and physicians, not a single study found that nurse practitioners provide inferior services within overlapping scopes of licensed practice,”  

Finally, what may be most convincing,

5. More physicians want full partnerships with nurse practitioners

In his December, 2010 editorial, It’s time to collaborate—not compete—with NPs, Dr. Jeff Susman, Editor-In-Chief The Journal of Family Practice, wrote, “I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes”  Dr. Susman goes further to say, “I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs (advanced practice nurses).”

A family practice physician openly calling on physicians to embrace NPs as full partners?

I rest my case.

Why do you want to be an FNP? I always ask this question of nurse practitioner students and colleagues who tell me they want to become a family nurse practitioner.

Their reasons aren’t always compelling. “I think it will be less demanding,” “I’d really like to work with pregnant teens,” or “I think it will give me more opportunities.”

“No, why do you really want to become an FNP?” I am looking for passion, conviction and a vision.

For me, 8 years ago, working in outpatient oncology, I remember growing tired of calling the physician every time a patient needed Tylenol or a laxative. I wanted to use my brain and have more autonomy. I wanted to work 9-5 so I could spend more time with my children.

Looking back now, I realize that I really had no idea or vision for becoming an FNP.
When I graduated and passed my boards, I took my first job working in a clinic. I enjoyed helping patients in my new role but soon realized I wanted to be more than an extension of the physician. Patients wanted more too. For the first time, I looked deep within and found my “why.”

Because…
I want to help as many people as I can find affordable, quality healthcare.
I want to show patients how to reverse chronic illness and restore health.
I want to prevent cancer, not just treat it.
I want to empower patients with the latest research & information.
I want to learn and teach patients in new & exciting ways.
I want to inspire and teach FNP students to find and treat causes of illness not treat symptoms.
I want to be added to the list of visionaries who work hard every day to “improve the health of our population, our culture, our planet.”

So I ask you the same question. “Why, do you want to become an FNP?”
Why do you want to invest thousands of dollars and hundreds of hours learning to become a FNP? I must admit, there’s nothing worse than teaching unhappy FNP students. Unhappy because they don’t have a clear vision of why they are there.

If your answer is not clear or compelling, it’s time to do some soul-searching.

Find a quiet, relaxing place, free of distraction, and close your eyes.
Look within and listen to find…
Your passion.
Your vision.
Your mission.
Your WHY.

Write it down and read it every day; Staying focused will light the way.

Soon, you’ll be among the list of visionaries who work hard every day to “improve the health of our population, our culture, our planet.”

Brandi Funk is a board-certified family nurse practitioner and a healthcare industry expert with 20 years of experience working in hospital, private practice, retail clinic, and research settings. She is a faculty member at Azusa Pacific University, school of nursing and owner of BodyBalance Holistic Health Solutions. Her mission and passion is to help others achieve optimum health through lifestyle medicine and lower health care costs in America. She is the award winning author of “Cut Your Health Care Costs Now!” an American’s guide to finding affordable healthcare.

Once a week, Brandi will be writing about career and education tips for aspiring family nurse practitioners. This blog is intended for students and early-career FNP’s, although many topics will be of interest to all healthcare workers! You can find our latest blog posts on our Twitter page, http://twitter.com/#!/onlinefnp. Be sure to follow us to receive the latest posts and to ask questions about online FNP programs. As always, we aim to be the #1 resource on the web for aspiring family nurse practitioners.

Due to the dearth of doctors around the country, one of the careers that is gaining prominence right now is the family nurse practitioner job. Family nurse practitioners (FNPs) provide services that are similar to the services offered by certain medical doctors, although they don’t have the same level of training and expertise. Many family nurse practitioners operate under the direction of doctors, or at clinics where other doctors practice. In such cases, the doctor is expected to be the final word. FNPs, in some states, can also operate independently, due to their advanced nursing training. In these states, family nurse practitioners can open their own practices, without the need for doctors to look over their shoulders.

Many people may not realize that FNPs have a great deal of training. Most family nurse practitioners have an undergraduate degree in nursing before moving on to getting a master’s degree, although some are registered nurses without a bachelor’s degree before moving on to get the advanced certification. Regardless, you cannot become any type of nurse practitioner without a master’s degree in nursing. Some of these FNPs also go on to get doctorate degrees in nursing. Many family nurse practitioners also specialize in different areas of medicine including pediatrics, oncology, geriatrics, and more. A number of nurse-midwives are also NPs. Others are general FNPs, helping families improve their general health. FNPs are also educators, serving as health advocates who can encourage better outcomes.

Many people don’t realize that FNPs can, in many states, actually diagnosis disease, prescribe medications, and determine treatment. Here are 17 other facts about family nurse practitioners that you may not know:

1. 18% of nurse practitioners practicing in the United States work in rural areas. Indeed, many nurse practitioners, include FNPs practice in rural areas. With a lack of doctors in rural areas, it becomes important for these advanced nurses to help out in underserved areas.
2. 43% of NPs hold hospital privileges. This means that they can work in hospitals, and treat their patients there. For nurse midwives, hospital privileges are especially important, as well as for FNPs who have patients that need special attention and care.
3. Malpractice rates for family nurse practitioners are quite low. Indeed, only 2% of NPs are named as primary defendants in malpractice suits. Some believe that this is because FNPs spend more time with their patients — and that helps patients develop closer relationships with their care givers.
4. Only 7% of nurse practitioners see more than five patients per hour. Most FNPs only see three to four patients per hour. This can give patients more time to ask questions. It also allows them to build relationships that patients perceive as close and meaningful.
5. 97% of nurse practitioners, including family nurse practitioners, maintain their certification, according to the American Academy of Nurse Practitioners. This is important, because it means that FNPs are staying up to date.
6. On average, nurse practitioners, including family nurse practitioners prescribe 20 medications per day. Being able to prescribe medications allows FNPs some autonomy as they treat patients.
7. Indeed, FNPs can prescribe medication in all 50 states. This means that family nurse practitioners can write prescriptions anywhere in the U.S., even in states where NPs are required to work with medical doctors.
8. In 48 states, nurse practitioners actually have controlled substance privileges.
9. 96% of nurse practitioners are female. Perhaps this isn’t terribly surprising, since most nurses are also female; it makes sense that advanced nurse practitioners would also be female.
10. 88% of nurse practitioners are trained in primary care. This means that your family nurse practitioner can also be your primary care health professional. Because of this training, it is little surprise that FNPs are filling some of the void left by a lack of doctors — especially in rural areas.
11. Even with so many FNPs being trained in primary care, it is worth noting that 68% of work at primary care sites. Other FNPs work at health clinics, or in hospitals. Others work in specialty health care settings, such as cancer centers, or geriatric centers.
12. 49% of nurse practitioners have been in practice, on average, for 12.8 years as family nurse practitioners. This means that almost half of cases, a nurse practitioner is a family nurse practitioner, usually charged with being a primary care health provider.
13. Medicare reimburses nurse practitioners 85% of what is paid to doctors. Medicare is reimbursing these family nurse practitioners for the same services. As a result, FNPs are less expensive, and could play a role in helping to slow the rising cost of health care.
14. One of the main focuses of family nurse practitioners is prevention. In a health care system that is often about reacting to sickness, family nurse practitioners make an effort to help their patients prevent disease. FNPs focus a great deal on education, and on helping patients live healthier so that they don’t develop disease. Some believe that nurse practitioners focus more on prevention than medical doctors do.
15. Nurse practitioners are pushing for more responsibility. In some cases, family nurse practitioners feel as though they could shoulder more responsibility — that right now they aren’t being allowed to practice to their full capabilities. As a result, they want a wider scope for their duties.
16. Some medical doctors don’t want FNPs to take on greater responsibility. It might seem as though doctors would welcome nurse practitioners doing more, since it might take some of the pressure off. However, there are huge debates going on right now with regard to the role that NPs should play in health care. It’s an interesting debate, and one that is not likely to be resolved anytime soon.
17. Some family nurse practitioners make more than $105,000 a year in total pay. However, $58,000 – $75,000 a year is a more likely scenario. Some nurse practitioner specialties make more than others, though. Indeed, a certified registered nurse anesthetist can make as much as $135,000 a year. However, that isn’t exactly a family nurse practitioner job. But, in general FNPs can make a fairly good living while, at the same time, doing a fulfilling job that can help people improve their lives.