Five Things Advanced Practice Providers Struggle With

Five Things Working Practice Providers Struggle With
(Or, things I wish I’d really been prepared for in NP school)
By: Terri Schmitt PhD, APRN, FNP-BC, FAANP
Executive Director, NPACE

Below, In no particular order, are five things I’ve noted both myself and fellow colleagues struggle with plus some suggestions for overcoming them. As social media acquaintance Phil Baumann wisely noted, nurses are the last Jedi Knights of the republic in healthcare. Like Jedi Knights, we struggle and are challenged with tests of ability and skill. Knowing what we will struggle with, being prepared, and working to overcome shows emotional and professional maturity.

1) Imposter Syndrome: As an NP 23+ years and a nurse nearly 30 years I still fight this. There is not a shift worked where I don’t find new patient challenges or practice areas I feel inadequate to address. Many days my mind shouts, “I cannot believe they let me do this work! They have no idea that I am not the best person for this job.” Many of us continue to battle similar self-talk. However, don’t mistake the universe continuing to show you areas you can grow with imposter syndrome. Educate yourself on new areas constantly and hone your craft, but leave the negative self-talk at the entrance door to your work. 

Remedy: Find a strong organized group of APPs to belong to and get involved. Local APP groups are excellent for this. Then, find a smaller circle where you can share, be genuine, and be built up.  This smaller circle of 2 to 4 people should be an honest sounding board in building your professional strength and brand. Finally, take responsibility and build your own knowledge and dive deep, really deep. Become an expert in this area. Education does not end at the completion of school. 

2) Time: There is never enough. Finding enough time in the workday to get everything done is difficult. The tasks keep coming, they don’t stop. They never will. Hard lesson to learn, but there is no moving everything off your list, not in healthcare. There is no point wishing for more hours in the day, as you would just fill it with things to do and we are not time benders. 

Remedy: Make a morning list and keep it short. Only 3 things you must get done that day. In a patient room use short cuts and prioritize patient care with them. Be gentle with yourself. You are always going to forget something – I still do, but just know work will always be there tomorrow. Come back to it later. Limit taking work home and working on your own time. Your employer needs to know the genuine amount of time it takes to do tasks. If you don’t bill them for hours charting or stop at 40 hours a week if you are salaried, then they will never be able to figure out the true cost of operations. If you are feeling employer pressure about time, know nearly every provider gets this, but also evaluate if that environment is right for you. It’s ok to take time for you! 

3) Charting: Writing a good soap note, giving report to the ER or a specialist, and reporting off to other clinicians are all forms of charting. Charting is a legal responsibility. Charting is an art form, a succinct and organized storytelling about a patient. Good charting affects every single clinician you send a patient too and the patient themselves. Charting affects patient outcomes. You must master it. Channel your inner jedi knight in training and hone your charting skills. 

Remedy: Memorize the order of a health history – the most vital information in a chart in my opinion. Memorize gathering chief complaint data every time, succinctly. Do not roll your eyes at your student who still cannot discern what should go in a review of systems and why or what is subjective vs. objective data – instead quiz them daily and give them activities on writing. Learn to keep it succinct and develop your own templates and tools. Set aside dedicated and uninterrupted time to build your own templates and charting. In the end, this will pay off for giving you more time and improving your patient diagnosis, communication, and outcomes. 

4) Patient Health Insurance & Finance Challenges: I feel like this one doesn’t need much expanding on except that we are all tired of the struggle and it seems to continue to worsen. Inhalers and insulin are now not covered due to price caps. Every procedure and medication requiring a prior authorization. Things that used to be covered now not like preventive health screenings, basic physical therapy, etc. Navigating pricing, deductibles, co-insurance, tiers of insurance, certifying with insurance and state Medicaid and on and on and on… When I think about walking away from healthcare- and I have thought about it numerous times over the last 3 decades – this is the primary reason why. 
I top this with the ever-growing cost of healthcare in general. I read an article this past week that said healthcare costs will raise about 8% for next year due to so many new costs being passed to patients. I watch patients forgo healthcare like yearly fasting lab or biopsies of suspicious lesions because they have a high deductible. Every single shift I leave feeling sad and defeated as a healer. 

Remedy: We are all in the same boat. We are, except maybe our friends who have great jobs in covered entities like the VA or military, but I would hazard a guess that sometimes even they struggle with the above. To battle this, 1) Speak up and out – write your congress people continuously about this issue. Get them involved. 2) write the insurance companies you work with. Tell them about patient issues and difficulties. Do it frequently. Have some form letters you keep sending off via snail and email when this happens. If we don’t speak up for our patients no one will. 3) Keep your PA forms mostly filled out and know guidelines. Ever changing recommendations and research are your friend to support why your patients need things. 4) Talk to your patients. Be transparent. Validate their struggles and yours with health insurance and get them to speak up and be active as well. 

5) Taking Time Off:  This section is all Remedy. Let me be clear. Take your time off! Particularly if you do not get to roll it over. It is a benefit figured into your salary and benefit package. Your time off is about your own physical and mental health. For too many years I felt like I need to just keep working and that there was not a good time to take off. The truth is healthcare keeps coming. It never stops. There is never a good time, but you need rest and peace. Take your time off and don’t check email, go to meetings, or take calls. If your employer is restricting your use of your own benefit, reconsider if they are worth the balance and peace in your life.

6) BONUS Struggle: Giving bad news and having difficult conversations. Healthcare providers have difficult conversations. We give bad news, and we do it in a challenging environment. Healthcare is hard and it concerns people’s lives. Patients and families arrive often already battered by a brutal healthcare system and hoops of payers and billers. 

Don’t depend on a specialist to do the work. Recently I had a colleague in oncology share that they saw a patient for a very obvious breast lesion and yet the patient had no idea why they were being seen by oncology or that the suspect was cancer. The referring provider simply made a referral after mammogram results and did not explain why to the patient. Such actions erode trust. 

Remedy: Take a course in having difficult conversations and in motivational interviewing and practice the skills daily. Just like you cannot be good at music, art, exercise, cooking, etc. without practicing, so can you not be good at having difficult conversations unless you practice. Find a mentor or friend to practice with. Finally, don’t avoid having the conversations. Putting it off or avoiding only makes it worse.