I am also really uncomfortable about renegotiating the employment contract - I think it is because I am 1) from the South, 2) female and 3) vintage (that's a nice way of saying "old").

I was raised to please other people, taught to never talk about money and to choose a career path to help people. So sitting down at a table to ask for things I want and deserve feels wrong. I don't even want that much - mostly a salary increase and more support for fulfilling NP continuing education requirements - but I get palpitations just thinking about saying those things out loud to my employer.  

When dealing with patient situations that involve negotiations, such as patients that are habitually noncompliant with treatment, I have no problems being both kind to them and yet firm with the issue at hand. I know that it will become easier over time to do contract negotiations as I get used to this aspect of being an NP, but for now, it's quite stressful.

So many new things to learn and do in the course of my first year as a new NP!

At last report I was believing that I would be making a decision between the MICU position over the nephrology position. Well, that has not come to fruition. I did, however, make a follow-up call to all whom I have interviewed, only to be told that "we are still in the interviewing process." I guess that is where the no news is good news comes in.

I should not be sour because I truly believe things happen for a reason, and the career for me has to be a lasting one, and when this is all worked out I will definitely reveal it to all of you! But I cannot complain, I am currently teaching for the university, and I find that very rewarding, and nothing strengthens your knowledge base more than junior nursing students challenging you at every turn. This opportunity has encouraged me to return to my textbooks, journals and research articles, allowing me to take my time and actually learn, which is something I was not able to do while in school.

I hope I am not putting out negative vibes, because I am encouraged that within two weeks I will have a job offer (I have found if you put out to the universe specifically what you want, it will happen for you).

I am happy to report next week I have an interview for an Emergency Room NP, and I did have a follow-up interview to an Internal Medicine Physician who is looking to grow his business by using an NP to perform rounds in the hospital setting and seeing patients in the office. The only down side is that he does not offer health insurance as of yet, but he did inform me that he is looking to get a health savings account for the staff.

1) Ask, ask, ask. When job hunting, ask as many questions as possible about a potential offer. For example, in my contract it said "health benefits after 3 months." I did not ask exactly what those benefits were, how much I would be responsible for paying each month, or how much my employer would pay. I was functioning under the assumption that every healthcare job has good healthcare benefits. WRONG! If I had explored this further with the right questions, I might have made a different job choice.

2) Practice your professional communication skills. Remember the call schedule fiasco? Not all conflicts will be that dramatic, but they will pop up in the workplace as much as they do anywhere else in your life. The difference is that you can't scream and yell (or you can, and get fired). You must prepare yourself to practice assertive, professional communication with staff and colleagues. Don't become one of those people that say nothing and inwardly stew, or someone that is always verbally abrasive and draws everyone's ire. It's not good for you personally or professionally.

3) There is still so much to learn. I am longing to go to a lecture on renal failure, or seizure disorders, or orthopedics, or chronic pain. These are problems I see all the time and feel like I know a thumbnail's worth of knowledge. My next goal this year is to get myself into some CE classes stat. You can't afford to not update your skill set constantly. In primary care, the breadth of what you need to know is vast.

I was a nurse that really enjoyed working, loved challenges, and was proud of what I did. Suddenly, though, it was 25 years later, and I still hadn't fulfilled my goal of getting a master's degree. So, I thought about it, and thought about it, and thought about it some more, until I finally decide to take that plunge and see if I could still learn at my age. You know, that "old dog, new tricks" thing.

When I finally enrolled, I made a decision to embrace every opportunity, try things that I wouldn't have when I was younger and just see what happened. As it turned out, I loved being back in school and had an absolutely great time getting involved in activities and projects.  

So, as a new NP, I decided to keep up that policy to try new things and have found it to be extremely rewarding. It is work, of course, to be a committee member of a professional organization, or to run for office (and lose ... but it was an amazing experience!).

I am now working on trying my hand at writing professionally (who knew there were so many nuances to submitting a manuscript for publication?) and am thinking about submitting an abstract for a conference next year.

With all these experiences, I have made new friends, met very interesting people, and am constantly learning -- and that's not even counting my day-to-day life of seeing patients.

I think that as a new NP, it would have been easy for me to be totally stressed out with changing my role after so many years in my comfort zone. Getting involved has helped me to continue to grow clinically as well as professionally, and I think the time spent has been well worth it.

I can remember a year ago while still in school all the job opportunities my professor would share with us for illustration, and I can remember thinking how needed and sought after NPs were.

Now I know that to be true, but due to the economy, employers are slower to hire. I know there are job opportunities out there, I see them in my professional journals and search engines. Currently, I have returned to teaching as an adjunct faculty member for the college of nursing teaching junior nursing students about the fundamentals of nursing in a clinical setting. This has allowed me to use my skills and knowledge to help mold future nurses, a responsibility I take very seriously.

Recently, I attended my local organization for nurse practitioners, and I had opportunity to network and connect with many nurse practitioners who shared a lot of great information and encouragement for me. I can honestly say the most helpful has been my former professors with whom I have stayed in constant contact. They have been sending me e-mail on all types of job opportunities.

One professor put me in contact with her manager in the perioperative department, where I could potentially be performing H&Ps for patients going to surgery. Currently they are not hiring, but I was told that a position will be coming available. My professor told me to try for prn, at least that way I will be in the system and working as an NP (that's a thought) so I will definitely stay in touch.

My second opportunity came from another professor who e-mailed me several job opportunities, and thanks to her, I have 3 interviews! The first one was with a nephrology group managing dialysis patients. I am really very interested in this position although I have never managed a dialysis patient, but I do understand all the challenges that are prevalent in this population of people.

Secondly, I have an interview with an internal medicine physician. The office manager and I have had several conversations with her last saying that she would send me confirmation and directions. She has not so I decided to Google the physician looking for the address, only to find that he was arrested on a domestic assault against his wife...Hmmm. Well, we will see how that one goes.

Thirdly, and interestingly, I have an interview with the medical director of the pulmonary and MICU division at the university, which is largely research based and teaching, and it is where I am adjunct faculty. Anyway, this group offered me a position 2 months ago, and I turned them down because I was positive that I had a job at a former hospital where I was the CNS. This was a big mistake (note to self: never turn down anything if you have not signed the papers!). I will not make that mistake again.

As NPs we need to keep this in mind not only to keep healthcare costs down overall, but also because many a self-pay patient forces us to use our budgeting skills like never before. For example, the patient only has x amount of dollars to spend. What is the highest priority problem to address? The hypertension or diabetes? As most of us would say BOTH, you see the conundrum we are placed in. Our current health system needs to change. Personally, I am not concerned so much how it changes (government or private run healthcare) only that it does change, soon.

Interestingly, I am sorting out my own little insurance problem. My clinic has about 10 employees. Health insurance is offered as a benefit, but my employer cannot contribute enough to the cost to make it affordable for me and my family. So I presently am shopping around. I am constantly struck by the irony: a healthcare provider without insurance. I often think: I have these skills to provide others with care, but right now who can I go to take care of me if I needed care without paying an arm or a leg?

Fortunately, we can afford some of the private plans out there. We just have to make it through the "pre-existing condition" minefield. In the meantime, I will continue to see people every day making difficult decisions about what they afford regarding their health. And I will try to help them make these decisions as best I can.

In my practice, I see kids with ADHD, migraines, seizures, motor tic disorders and developmental or learning differences.  These kids typically do not have happy school experiences because of the medical conditions with which they struggle.  I write letters to teachers describing the conditions, write detailed instructions for medical problems that may occur in the classroom, and talk with the kids and their parents to form action plans. 

Despite all this, I still deal with these children being treated in a negative manner by their school or their peers. One child that I saw recently has a motor tic disorder, and he was disciplined by his teacher for the jerking movements of his head. 

Despite my letter of explanation about the tics and that stressful situations and fatigue could increase the frequency and severity of the tics, she remained unconvinced.  She felt that he was deliberately making the movements and that if he was separated from his peers and denied access to activities that he enjoyed, that he would stop the behavior. As expected, her attempt at correction only resulted in increased stress for the child and therefore increased motor tics. After talking with his parents, I resubmitted the letter but with a physician's signature. The teacher then made changes in her approach to the child, simply because the letter was from an MD. 

I know this sort of thing happens frequently, because of the public's perception of NPs being "just a nurse."  The recent campaign to change language in the media to "healthcare provider" and not always "physician" has helped a little, but not enough.  I think we as a profession need to focus more attention on educating the public about the role of the advanced practice nurse. 

I was told this week that the position I believed to have landed in my lap was put on the back burner due to high turnover and financial difficulties. I wanted to tell the physician so badly, "Do you realize what I gave up waiting for you guys to make a decision!?" but I just thanked him for his time and chalked it up to "things happen for a reason" column.

My mentor informed me that since I did not have anything in writing, I should have at least accepted the interview, you do not know how much I am kicking myself right now that I was not more savvy.

 I did go back to the previous job offers, but of course they had already filled the position but they did say they would keep me in mind ... that's comforting.

Then, a curve ball. The practice manager handed out the new call schedule. Between me and my fellow colleagues, we each took a week of call on a rotating basis. Since there are four of us, this amounts to every 4^th week, or about one week a month. This was a term laid out in my contract, which I had signed not even two months prior. Lo and behold, the physician who owns the clinic took himself out of the call schedule, without a word of warning or explanation.

I was inwardly outraged and aghast. How could he do this, so quietly, so sneakily? I felt taken advantage of and betrayed. This may sound melodramatic to some, but taking call every 3^rd week as opposed to once a month is a serious change. Especially without any adjustment in salary.

And I was not the only one who was fuming. My physician assistant colleague, who had started working only a few weeks after me, had just been hired under the same call schedule terms. We felt as if he had gotten us in the door, and then as soon as we were up and running as providers, he made the old switcheroo. It was hard to believe that it was not premeditated.

We were upset, but did not want to be unprofessional. That night, I called my father. His first word of advice: calm down. He did not want me to do anything for about a day or so until I could have a rational and professional conversation without being angry. But I just was so annoyed and not ready for this kind of upheaval in my professional life. It was hard enough getting used to my new role, let alone having a less-than-forthright employer. It made me really sad.

HOWEVER, the lesson here is don't let your emotions get away from you, and don't think you can't express your needs to your employer and be heard.

The next day I had off, but my PA colleague sat down with the physician and expressed her concern about this change. And you know what? He listened to her. And he put himself back into the call schedule (at least for the next six months).

To back my colleague up, and to also express my own opinion, the day I returned to work I also sat down with my physician employer. I told him I was very thankful he had changed the call schedule back to its original format, and why. It made me realize that even if your employer does not take the initiative to communicate, you must. Or fester in angry silence.

So, if you ever find yourself in a similar position, take heed. Don't jump to conclusions! Assertive, professional communication does seem to work. We'll see what happens six months from now.

I don't know if it is the population of patients that I see, but I have a problem with patients that do not take responsibility for their own health or knowledge of their health insurance.

I couldn't begin the number of times that I am asked if their insurance would cover certain medications or tests. When I instruct the patient to contact their insurance with their questions, they are upset and do not understand why I do not have the information. My psychic abilities are just not what they used to be.

Similarly, when I ask them to list their medications, or tell me about their other health problems, they become annoyed when I explain that even though I see them for headache or neuropathy or whatever the case is, that I need that information to better plan their care. Or when they bring me a pill box with medications neatly divided into days and dosing regimens, but they cannot tell me what the pills treat.  

I saw a patient last week that had a weekly pillbox with dividers to take medications four times per day that was full to the brim with pills. She could only identify one pill out of the assortment. I spent time on the phone calling her pharmacy and her primary care provider to figure it out, which made me late with all patients for the remainder of the day.  

And yes, I could have asked her to reschedule when I had the information needed, but she was having an acute problem that needed to be handled.  

Now, where were we? Last month, I ended my post with the intention to discuss my time management concerns with practice shareholders. (Read Time Management for New NPs.) A meeting has been requested, but shareholders have not met since my last post. However, I have been able to voice my concerns to one of the group's physicians. The physician I spoke with agreed that these were legitimate concerns and encouraged me to pursue a placement on the agenda for the next shareholder's meeting.

In the meantime, I have voiced my concerns to the office manager. I went in with notes, specific dates and times. I explained which procedures I have not gained board approval to perform. I also offered suggestions as to a few simple patient screening questions for phone triage nurses, which hopefully will save the patients (and me) a little aggravation. Majority of my time is spent on public relations. If patient satisfaction is addressed at the first patient encounter, a lot of this could be avoided. Not only that, but one only has one chance to make a first impression. That first encounter sets the tone for the entire office visit.

After my discussion with the office manger, things did get much better. Maybe part of that was because three providers who were on vacation returned the week after my discussion or the office manager relayed my concerns to the phone triage nurses.

Here is an example of how much better things got. I had a patient come back in to hug my neck, thanked me for seeing her, and gave me a beautiful, spiritual card. In that instance, I forgot how slammed I was when three providers were on vacation. Suddenly, I remembered why I chose nursing in the first place.

Did anyone else feel this way? Over the last few weeks I have had interview after interview and was close to accepting my first position in the ED in a rural hospital setting. Even though I was not totally excited about the position, it would be a great opportunity and learning experience. Unfortunately, the drive was forty five minutes one way, and I was already contemplating what my next job would look like... that is not good.

Then it happened, my best friend called me telling me how she was having a conversation with the medical secretary making small talk when she casually brought up my name and was telling her about my recent graduation from the acute care NP program. She was excited when she learned that they were looking for an NP in a hospitalist role!

When my friend called me and informed me of this position I was soo excited, I had a new renewed energy. I contemplated what this would mean for me; 1. a hospital system where all I had to do was transfer, no starting over in a new system 2. I knew the staff because I was the clinical educator two years ago, and 3. the drive was absolutely beautiful and one I am very familiar with.

Since, I have been on three interviews meeting the physicians that I could potentially be working, learning and growing with, including the DNP of the group. For some reason I believed this to be a slam dunk position for me. In my opinion, it was a no brainer.

Then after the third and final interview, my potential employer stated, "We have another candidate." What!?!! I had  just turned down two offers for this one! But I remained calm on the outside while my potential employer stated, " I will call you next week, I just need to talk to the other physicians."

My heart sank,  well that ‘s fair... I guess. The disappointing part is, I am telling my friends and family that I have this great job. Oh well, in the meantime I remain positive, and in my heart I believe I have the position, but again PATIENCE! I must learn PATIENCE! Whatever happens this will make me stronger.

What is the antidote to this troubling affliction, you ask? Well, at this point I am not exactly sure. My hunch is that the more experience I get under my belt, the less mentally taxed I will feel as problems and patients will become familiar. Perhaps it is getting used to the pace and the workflow of the office. Perhaps it will be forming friendships and camaraderie with my fellow coworkers that will buoy my sagging spirit when the day gets long.

I recently attended the AANP annual meeting in Nashville, and other than the excellent speakers, one of the most beneficial things to me was networking with other NPs. I learned so much about how other NPs manage their caseload and their life. Everything from using the latest digital and electronic gizmos to how they arranged their life to get the laundry done, the kids to school and their elderly parents to appointments seemed to be a frequent topic in some of the breaks and social events.

For me as a new NP, even though I had years of experience as a nurse, my day-to-day life has changed in the past year. I hadn't realized how much I did on those weekdays off or mornings off when I worked second shift. Now as a Monday to Friday worker, whose days are usually about 10 to 11 hours each, I find that much more effort is involved in even simple things like going to the bank before it closes or shopping for a birthday gift for my father.

During the day, despite my best intentions, I always tend to have at least one patient per day that needs more than the 30 minutes allotted. So then the next patient is seen late and so on. If there isn't a place to catch up, I spend the remainder of the day late seeing everyone and getting more stressed out because I know that the clock is just flying while I feel like I am as slow as molasses.

In the big picture, though, I am incredibly happy with the decision I made to become an NP, but it has been interesting to me that it wasn't just a change in my work functions but in my personal life as well.