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.

I am also anticipating an interview with a hospitalist. A close friend informed me of this position, and I feel it is important to let your close friends and former preceptors keep an ear out for any potential opportunities, and this was one of them. I previously taught at this community hospital, and I would love the opportunity to return. I anticipate in the next couple of weeks I will have to make the difficult decision to choose the career I wish to pursue, but I look forward to the challenge.

It's not easy being green. I'm not talking about the color, either. I'm talking about being the rookie, the novice, the newbie, the beginner. You see, I can be an impatient person. And all this low rung on the ladder stuff -- well, it doesn't always sit well with my innate perfectionist. I want to know EVERTHING. And I want to know it NOW.

That's my id. My superego is laughing at this. There is no way that I am going to learn everything there is to know about primary care in one day. Clinical hours and school get you started -- but they can only cover so much. Ironically, I find that I practice very similarly now as two months ago when I was still in school, whipping out my Derm text for a skin rash I don't quite understand, or scouring respected medical websites for information about an obscure disease that my patient happens to have that we never covered in class. It is at these times when somewhere inside I think, "Wow, I have a really long way to go."

I do hear while the learning curve is steep -- it is going to flatten out. And I am hoping that even three months from now, I will be able to look back on these first three weeks of my new NP career and be amazed by how much I have learned. I realize, too, that the learning will never end. But I am hoping that I don't always have to pore over every clinical decision I make -- I am yearning for the ease of a seasoned professional. Not cocky, yet confident and assured.

Well, it requires work to get to that place right? And on that note, I am finishing this blog to go do some remedial reading on titrating insulin for hard to control diabetics. I'm seeing that person tomorrow -- and need to be ready.

I am being pulled in a hundred different directions, only taking time for the bare necessities.  Something has got to give. There is no way I can keep up this pace for much longer. I am exhausted. 

Every time I check off one thing on my to-do list, it seems as if two more things mysteriously appear on the list. Baseball season is finally over. My oldest son's team won their league's championship. With three kids playing baseball at different times on three different teams, I sure don't miss spending my Saturdays at the baseball field. I even got to sleep late this past Saturday.  I can now check baseball off the list, but I am going to keep that little secret to myself.

My duties as family social worker have a "hold" status. Thank heavens for caller ID. I am screening all calls. The children have been warned not to answer the phone, unless it is one of their friends. Only mommy and daddy answer (or not) all other calls.   

There are some things I can't put on hold. Therefore, I will travel to Texas in about a week and half to visit with my friend and his family. I don't want to think of it as a good-bye trip, but I know it very well could be the last time I see him alive. Just the thought brings me to tears. So, that's all I am going to say about that. 

Next on my list is my job. Just as I predicted, none of my patients have been "simple" annuals or problem visits. The first problem visit ended up being a direct admit to the hospital for surgery. The second problem visit was complicated enough to leave the veteran office NP scratching her head. I eventually ended up consulting with the patient's physician who was on call at the hospital. The third problem visit was supposed to be just a follow-up. Well, she was scheduled for next day surgery. 

I am a fairly private person and need some sort of relationship with someone before I can share deep, personal thoughts and feelings. In this week alone, I have had 7 patients weeping, telling me about problems with finances, husbands, wives, work, and so forth. And it is only Thursday!

All of these folks were new patients for me, and none of these confessions were prompted by me other than to ask something to the effect of "is anything new going on since we last saw you" -- meaning new medical diagnoses, surgeries, etc. One patient cried so much that she had to sit in the exam room for awhile after the visit to rein in her emotions before she could leave.

I feel ill prepared for these cathartic events and feel that I am doing little for the patient other than listening, offering tissues and resources for counseling. I didn't really have this type of interaction with patients as an RN or while in my NP program, so I feel like I am struggling with learning a new skill.

When I first began practicing, I felt uncomfortable and tended to try to console the patient, just to bring an end to the visit and get me out of the room. Now that I am getting more used to these emotional torrents, I am no longer uncomfortable but feel that I have nothing helpful to offer. I like being able to recommend solutions to problems, but for patients with anxiety, depression, overwhelming social situations and lack of coping mechanisms - that is easier said than done.

So, to those of you that work in behavioral health - a big round of applause for what you do! I want to be like you when I grow up!

This past month has certainly been jammed packed with changes. With change, comes excitement, but stress as well.

First and foremost, I was offered and accepted a position in the Denver metro area (I currently live in Montana). It is a small family practice with a physician, a part-time PA, a part-time NP, and then me, who will be full-time. I put a considerable amount of time and effort into finding a job, and was extremely gratified to get this position.

Then there was graduation. I really wanted to bawl when we were processing into the gym to "Pomp and Circumstance," just because it felt so incredible to see the investment of time and energy, by me and my family, come to fruition. I was so proud to walk across the stage and to see my classmates do the same. I went to school with some amazing nurses.

However, the relief was short-lived as the reality of an upcoming move and taking the certification exam set in. I got my approval letter from the AANP and the testing people on the same day. I scheduled my exam leaving only two weeks to study. During this time, I also went to Denver for five days to shadow the PA whose position I am taking. I had a horrible cold the whole week (a little run down from the stress, ya think?), was trying to find a place for us to live, had a car break down on me, and missed my family immensely. It was tough.

But, it was just like the sun coming out after the rain once I took the exam. I just took the certification exam three days ago -- I passed! And all that stress just melted away. I am so honored to join the ranks of my fellow NPs. It is the best profession in the world, I think.

A couple of thoughts - most people don't have to move as quickly as I did from school to certification to work. If you can take time off, that's great -- savor it! But if you can't, know that you will make it through all the changes just fine. Additionally, studying for the certification exam as I am about to embark on my first job was a helpful refresher. I will be seeing fairly complex patients, and reviewing everything I learned in school gives me confidence that I have what it takes to be a good NP.

There have been ups and downs - working through the certification process was frustrating, but seeing the message on the computer screen that I had passed the certification exam was exhilarating! I will never forget checking out of the testing center choking back tears of joy - the proctor was looking at me like I had lost my mind.

I will also never forget seeing my first patient. Even though I had worked really hard to get to this place in my career, seeing my name as "provider" on the encounter sheet gave me butterflies in my stomach for a few minutes.

Now, a year later, my desk is covered with stacks of patient charts with lab and radiology results to review and go almost in a blur all day - seeing patients, doing dictations, calling reports to patients, answering questions, mentoring staff, and overseeing the day to day running of the clinic activities.

I'll admit, I still get nervous from time to time when I am faced with a patient that is much more complicated than expected and have moments of self doubt (for example, "am I missing anything?" "maybe I should recheck her eyes", "are those liver enzymes really that high?"), but I have never regretted my decision to become an NP. I learn new things every day and feel eager to approach each day. Of course, a day off to celebrate my one year anniversary would be nice too......

Almost two months to the day I passed the ANCC certification exam, I finally received my temporary license to practice as a nurse practitioner. The official words used by the Alabama Board of Nursing were "TEMPORARY APPROVAL FOR COLLABORATIVE PRACTICE." How fine is that?

Finally, I can start providing care to my own patients, which I believe will go a long way in boosting my confidence level. I can't quite cut the apron strings yet, nor do I want to, but this is a major step in that direction.

My journey to NP has been a rollercoaster ride, to say the least. Most of the bumps, I will freely admit, were due to my own lack of understanding the process. If I had seen this article before graduation, I would have been better prepared to navigate through the sometimes rough seas. Leave it to me to complicate things. I am at my best under pressure.

Speaking of being under pressure, I am feeling more and more comfortable with my choice of employment. I love the patients. They seem to like me, too. Go figure!! My collaborating physician, who by the way recruited me, is the BEST. The other nine physicians in the group are great. The two NPs are mother hens. I am so very grateful to have their wisdom, knowledge and expertise at my disposal.

I could not ask for a better working environment. There is a lot of flexibility, which is what drew me to the practice in the first place. With three school-aged children and blessed enough to not have to be the breadwinner of the family, convenience and flexibility are most important to me at this time. As the children get older, the future will hold a different possibility. But for right now, this is the best fit for me and my family.

The next few weeks will be interesting. I noticed on my letter from the Alabama Board of Nursing that a copy was sent to my collaborating physician. I am sure my own schedule of patients will be forthcoming, soon.

I went into nursing knowing that I eventually wanted to be an advanced practice nurse. I had a wonderful nurse practitioner provider in my teenage years, and she was the model of the ideal healthcare provider that I wanted to emulate. 

I completed Creighton University's accelerated BSN program in 2002. After graduation, I took a job as a staff RN on an intermediate care unit that specialized in cardiology. It was very fast-paced and a tremendous learning experience. However, this unit struggled with many issues familiar to nurses such as short staffing, high nurse and management turnover, and subsequent nurse dissatisfaction.

I then took a job in geropsychiatry at a state mental institution. We cared for the severely demented, especially those whose loss of mental capacity caused aggression. I was commonly the only RN on the unit, in charge of eight to ten staff members. This job was challenging, but the growth there was exponential in terms of leadership. I loved the patient population, but common forced overtime and working most holidays inspired me to look elsewhere.

For the next three and a half years I was an RN in family practice. I was the primary nurse for a busy MD. I think the perception is that ambulatory nursing isn't quite as demanding or enriching as floor nursing. It's true that the hours are regular, and there are not many true "emergencies." However, I learned by observation what I consider now my foundation of primary care. In addition, the doctor with whom I worked had a large and busy practice; he always had patients in the hospital. Even though I wasn't caring for these patients while they were acutely ill, I coordinated everything for them outside the realm of the hospital. I was constantly on the phone with the floor nurses with patient status updates and orders.

This was my pivotal nursing job, when I realized for sure I wanted to be a family NP.

After leaving this job for graduate school, I haven't worked too much. I did some casual call at a local internal medicine practice, but being a full-time student and then having my first child (she's 16 months and WONDERFUL) put the brakes temporarily on work. I will be leaving stay-at-home mommyhood shortly, however, and all the challenges coming down the pike are both exciting and scary. I look forward to sharing them with you.

It's interesting, being in a different role. Some providers totally ignored me as the caregiver and only spoke with her, even when she was in pain and distressed. Some spoke only to me as if she wasn't present. I have found some providers that are fairly dismissive, and others that had a completely unrealistic view of what an elderly woman with only one functional arm could do.

One example is of a young man that handed her a clipboard with a pain rating scale on it and told her to complete it while he was working on putting his assessment into EMR. She couldn't grasp the clipboard with her hand and arm in the restrictive brace used for fractured shoulders and she certainly couldn't with the polio affected extremity. She was annoyed at that point and just let the clipboard slide onto the exam table without allowing me to help her. When the resident looked up and asked if she was finished with the form, she smiled sweetly at him and said "yes". When he picked up the clipboard and asked why she hadn't completed it, she told him that she was unsure which hand she was supposed to use.  It was only then that he noticed her incapacity.

Since her fall, I have entered into a new realm of our relationship - giving baths, applying the brace, giving pain medication, talking about constipation far more than anyone should have to do, going back and forth to doctor's appointments, and working on my improving my patience.

Now that we have settled into somewhat of a routine, I have had a chance to reflect on this experience and realize that not only has it brought me and my mother-in-law closer together, it has also given me more insight on being a caregiver. I think that I always tried to be sensitive to the caregiver, but now I am not sure that I really have been. Lessons learned, both for me as a caregiver and for me as a provider.

At the risk of sounding like a whining brat, this is not what I had imagined. I don't know where to begin. Looking both ways, I am just going to jump right in. My first mistake was to accept a job without having my license to practice and provider number in hand. I was expected to complete my orientation, provide healthcare and generate income after 3 weeks of employment.

My second mistake was to assume (I know) just because there were nurse practitioners working in the clinic, the administrative staff were experienced with the process of hiring a new NP. In addition to the above paragraph, the board of nursing has its own time table and licensure takes time. And just as importantly, I don't have malpractice insurance.

My third mistake was not having a clear and detailed understanding of what was expected of me and when. Hindsight is 20/20 and looking back on it now, I should have negotiated a formal orientation with a defined time period. I am the type of person who enjoys structure. It is stressful for me not knowing who I should be orientating with from day to day. It is stressful for me when I have not been given a computer (to practice on) or password when patients' medical records are electronic. It is stressful for me not having my own space. And the list goes on and on.

My fourth mistake was contracting the "haste makes waste" syndrome. In other words, after 4 years of not earning a paycheck, I was so focused on finding a job that I broke one of my own cardinal rules by accepting the first job that was offered to me. Not only did I accept the first job I was offered, I also accepted the first salary offered. Much to my chagrin, I did not counter. For the ultimate slap in the face, I have recently discovered that new NP grads in the area, working in comparable clinic settings, starting salaries are $10,000 to $15,000 more than mine.

Several of my friends have suggested that maybe this job is not the right fit for me. After hearing their voices over and over in my head and seeing it here in black and white, I am beginning to rethink my decision to accept this job.

This has been a difficult month to say the least.  Many changes are taking place, both in my personal and professional lives.  Change is never easy for any of us, and usually seems to happen all at the same time! 

For several reasons, I have decided to look for another job and consequently, will be leaving my NP program.  It was a very difficult decision, and I have agonized over it for awhile, but in the end, I feel it is the best choice for me at this time in my life.

I think the most frustrating thing is being so close to finishing the program, but even if I would stay to finish, my life and career are going in a totally new direction.  What's that old saying about the winds of change?  I guess Spring really is a time for ‘housecleaning'!

In any event, my program has certainly given me additional knowledge and experience that will only serve to increase my skills in mental health, where ever I land in the future.

I have met wonderful people, both patients and colleagues, and can only hope that I have given them as much as they have given me.

For all of you still in school and graduating this year;  Good luck and best wishes!

On the other hand, I find myself doing tasks or taking care of situations because I have done it for years in the past. I know it is easy to fall back on what is comfortable, both for me and for my employer, but sometimes I feel that I am pulled in so many directions that I am going to be pulled into a thousand little pieces.

Although I am doing better at saying "No", a hard word for me to learn as a good Southern girl, I often wonder if the transition to NP would have been more smooth if I had gone to a new practice and been only recognized as a provider.

The journey to certification was a bumpy ride. After waiting for what seemed like an eternity (eight weeks) to receive the green light from ANCC, I began a long tedious studying regimen consisting of 12 hour days of studying and a Fitzgerald online review course.

By the way, the Fitzgerald online review course ROCKS!! After the review course, I was kicking myself for waiting so long to take the certification exam. The review course really pulled everything together and put me at ease.

I scheduled my exam for a Wednesday at 8:00AM. Wednesday is "hump" day, not the hectic Monday, or "TGIF". In my mind, Wednesday was a safe day. I chose 8:00AM because I am at my best in the early morning and most often need a nap after lunch. In addition, Mom's taxi had to be available by 2:45PM.

Speaking of Mom's taxi, the day before my exam, two of the three taxi riders had to be retrieved from school early (at different times) due to a stomach virus. I was worried about my riders but more worried that I would have to forfeit my certification fee, if the virus lasted the normal 24-48 hours. Fortunately, my prayers were answered. The youngest taxi rider was on the road to recovery by late evening. By bedtime, the oldest taxi rider had followed his sister's lead. This was the first sign the stars were aligned in heaven.

On the morning of the exam, I awoke at 4:30AM...couldn't sleep. I got out of bed, looked over my notes again, took a bath to relax, and donned some comfortable clothes. Make-up was not an option today because I have this bad habit of rubbing my face when I concentrate. I ate a piece of dry toast and drank a cup of cranberry juice. Stress goes straight to my stomach.

Around 6:30AM, the taxi riders were roused. The youngest complained of "stomach growling". "Stomach growling" is something I can handle...always a good sign when the appetite returns. The oldest complained of "feeling tired". After further questioning, tired feeling was a "sleepy tired" and not a "sick tired". Alrighty then, we are good to go.

Mom's taxi pulls in front of the elementary school around 7:00AM. School doors are locked until 7:15. I have to be at the testing center at 7:30AM. The testing center is about ten minutes away without traffic or accidents. School doors are unlocked early at 7:10AM. Taxi riders exit Mom's taxi. Next stop...well you already know the next stop.

I arrive at the testing center at 7:28AM. I am given rules to read regarding no tissue allowed in testing area, feeling cold, and several other rules I can't recall at the moment. After reading the do's and don'ts, I ask to use the restroom. While in the restroom, I take a few deep breaths and say another prayer. I return to the testing area and place my purse in a locker. I am given a key to the locker, two pencils, and scrap paper. I am taken into the computer testing room. My name is on the computer screen. On the scrap paper, I begin to write down mnemonics I have memorized from Margaret Fitzgerald. Did I tell you already how much I loved that review course? In addition, I write down some normal lab values I had memorized.

After taking the tutorial and prolonging the inevitable as long as I possibly could, I began the test. The first question threw me for a loop. It was a cardiology question. Cardiology is my Achilles heel. I answered it and marked it so I could go back to it later.

At this point, I am still very nervous, and my bowel sounds are hyperactive (without a stethoscope). I can only hope that others in the room either have on their earphones or too engrossed in their own test to hear my bowel sounds. I didn't look around to find out.

I move on to more questions and with each question, my anxiety decreases. After answering question #175, I glance at the time. I see that I have a little over an hour to go back to my marked questions. I revisit my marked questions until I am satisfied that I have done my best. I click on "end". A pop-up box appears to torture me just a little more by asking, "are you sure you want to end this test?" No, I am not sure but I have to end this sometime. It might as well be now. So, I click on "yes". My heart starts to pound through my chest, while I wait for the results. The results never came. Instead, I am taken to a survey. I complete the survey and wait again for results. Once again, there are no results.

I exit the testing room, give my scrap paper and pencils to the nice woman, and inquire as to why I did not receive my results. The nice woman checked the computer and printed my results. She gave me the results. I attempted to give the results back to her and asked her to read it for me. Reading the results to examinees is a "no-no."

As I was holding the paper, the weirdest thing happened. I began to read from bottom to top and missed the entire bottom line that read in part, "Your ANCC certificate will be mailed to you within 90 days of this report." Instead, my eyes went straight to my score, then to the minimum score to pass, and finally to the top of the page which read, "Congratulations! You have passed the Family Nurse Practitioner Examination." If only I had read from top to bottom, I would have saved myself a few seconds of anxiety.  

My body began to shake and I began to cry. The nice woman congratulated me and suggested I sit down in the waiting area to compose myself before driving. I took her advice and sat in the waiting room until I stopped shaking.

The first person I called from my cell phone was my mother. The second person I called when I arrived home was the administrator of the OB/GYN practice, who has been holding a job for me for about a month.

Check back here next month to see how I am doing in my new role and new job.