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Tess:Welcome back. This is another episode of Friends of Flo, Friends of Florence Nightingale. My name is Tess Judge Ellis.
Andy:Hi Tess, this is Andy Whitters here
Rebecca:Hi Andy and Tessie. This is Rebecca. Nice to see you guys.
Andy:Good to see you guys.
Tess:We're back.
Rebecca:I know. It's good to see you. So Tessie you have a paper that was published called"Time and NP practice: Naming, Claiming, and Explaining a Role of Nurse Practitioners". Where did the idea come from.
Tess:Thanks. First it was published in The Journal of Nursing, Journal for Nurse P ractitioners last October and it was I'll tell you this is a thing is a lot of people have a lot of think about it piece. It's a thought piece a scholarly written thought piece. And it came from that idea about time like what is it that you do in there. So we open the paper with three quotes which is"you take too much time" and that is from maybe a practice administrator or a colleague standpoint and then the patient saying"I'm so glad to see you take so much time with me" and then the last statement is"I wish I had more time with people" and so I started to look at, well, what does time mean with nurse practitioners. And so that's kind of where we got moving with the paper. I think my goal is to bring people back to what really is nursing and moving into being an advanced practice nursing and in this era where we're still trying to figure out what it means to care for patients. But yet in frankly a business that's fee for service or as I like to say widgets on a you know assembly line. And so that's where this paper was born from. So...
Rebecca:Yeah, I think you and I have talked a lot about nurse practitioners. What happens to the nurse part of practitioner when you're working alongside a host of physicians. And I watched in my hospital where I work and the nurse practitioners are right in there with the medical model and I'm always wondering how do they present themselves and to the patients as something different. You know?
Tess:Well that's part of the article was how do you name how do you claim...how do you name what you do as nursing and how especially in today's society and how do you claim the resources you need in order to practice. And how do you explain it to people why it is that what you're doing. And it is you know Rebecca and I you and I share this crazy love for nursing theory. And you know the nursing scholars of the day and so you know one of the things that we did with the paper then that I took was going to I came across the American Association of Nurse Practitioners actually has a definition on their website or an explanation on what makes nurse practitioners unique. And so part of what we did in the paper was to unpack that. And so I'm going to quote right from the Web site"what sets NP's apart from other health care providers is their unique emphasis on the health and well-being of the whole person, with a focus on health promotion disease prevention and health education and counseling. NP's guide patients in making smarter health and lifestyle choices which in turn can lower patients out-of-pocket costs." And that's our professional organization that says that.
Rebecca:So how does that translate into nurse practitioners in a wide variety of settings? So I get that in primary care I used to do primary care when I was an NP and that fit really well. But when I was an MP in acute care that was more challenging. And you know where you are on this?
Andy:So first of all I think that's holistic care right? I mean this is a definition of holistic care. This is our professional identity that we don't look at someone just as a disease diagnosis but we look at them as a person with nearly endless variables that make up their entire person including their problems. And for me coming from a specialty world I was in vascular and thoracic surgery for the better part of 10 years, if I saw someone with heart disease, chances are they they probably had hypertension, they probably had hypercholesterolemia even though they might not be in their record coming to me. You can ask those questions, you can do a record search understanding like what those variables are all about. And then see of course if they're well controlled; asking the patient about their primary care concerns and how innervates into their specialty form of care wherever they're seeing you for.
Tess:I like that. I think that's...well I do. I think that the nurses or nurse practitioners and nursing in general's interested in the lived experience of what goes on with people and helping them move towards a better way of living with health and illness related issues right?
Andy:Absolutely
Tess:So in order to do that you have to understand the whole person, right? And what makes them who they are. I think it's really hard in an acute setting. You know how you do that, but I think that extends maybe then to how you interact with the entire team. You know the relationships with the team is probably different for a nurse practitioner than not. But I guess just drawing back to what you were talking about when I talked about, like, what's the difference between a NP and a PA or MP and physician education models. And all of us were registered nurses or currently are registered.
Rebecca:You are a registered nurse. You have to be an RN to become an NP.
Andy:Right, and you have to maintain that as you practice
Tess:Whatever age you were when you started you did care plans that said my person as a bio psycho social spiritual cultural person. We had to assess the person...
Rebecca:In context of how they're living their lives
Tess:And what are their roles, what's their educational level it's their socio economic status, how did they go through and live their lives. And then we said oh now the disease happens to that person versus medicine whose specialty is the disease at the cellular level. And you know even molecular level and they specialize in that and then they dissect it from the pathology and that's where they spend their undergrad years and whatever. And then their medical school years and then they say OK a person happened to this.
Rebecca:A person happened to the diabetes. That's how you get the 80 old diabetic who happens to be a person somewhere in there, instead a person who's 81 years old who happens to have diabetes.
Tess:Right. And I think so and we need both right we need we need all hands on deck, but as the system defines us by our ability to diagnose and treat which is a fee for service model and moves us in a really you know right along the way. You know arguing for time is is hard because how does that make a difference, right?
Rebecca:So are the outcomes, you know everybody reimbursement is always focused on patient outcomes patient satisfaction and patient outcomes.
Tess:Right, value based care is different than fee for service. Value based care is wrapping around, and that's the contention and the argument, is that especially when you look at the definition of nurse practitioners guide people you can't guide someone without a relationship. And people just don't make changes. A lot of them do, just because a doctor says,"do this", but mostly it's a guiding relationship and I think you know what really hit home to me a couple of things. When I was a baby nurse practitioner I was at the free medical clinic and I apologized to the receptionist and I said,"oh" you know"the medical students the doctors are going so much faster than I am" and she said"Tess, I don't know why you worry about that. You do more than they do in the visit" and I thought whoa whoa wait a minute. Someone valued something more than just the diagnosis that I was making and it was the receptionist who said you do more in the time that you're with them. Isn't that interesting.
Rebecca:That is really interesting and I think it goes back to what we're talking about on our previous podcast about trust. Nurses are the most trusted profession repeatedly in a Gallup poll every year. And we talked about this another time and I think that's one of the reasons people value NP's is because you see that nurse part. They're not so hooked on the practitioner part, but they're hooked on the nurse part.
Tess:You hope so. I think some people more and more are seeking out the nurse practitioner. So you know a lot of it though you're swimming upstream in a system that's calling you either a mid level or a physician extender.
Andy:Those are fighting words there Tess.
Tess:It's what they use. And you're swimming upstream when you say, actually I do a little different practice and I need more time to do that.
Rebecca:You have to be so clear today. I didn't get a job one time, this is a long time ago I have a little story. A physician phoned, I had applied for a job and this physician phoned me for a phone interview. He said"Well, I'm looking for a physician extender. And I said"Well I think you'll find that person in the hamburger aisle, Hamburger Helper aisle in your local grocery store. If you want an expert nurse with many years of expertise in nursing and now graduate level education in nursing who can collaborate with you and work alongside you in a collaborative way, I'm your woman, but until then I think you better go to the hamburger helper aisle. I didn't get the job.
Tess:I wouldn't imagine.
Andy:When I hear that vernacular in the professional setting, I immediately think of it as an opportunity to educate whoever it is I'm talking to, typically it's an administrator.
Tess:That is a very much an administrator term for sure and same as mid level.
Andy:So when I hear a physician extender or mid level which is that, that just drives me crazy because what is a mid level I mean like I don't get it.
Rebecca:I always would tell them there's nothing mid level about me I'm an expert nurse. By the time I got to be a nurse practitioner with a few years under my belt, I was an expert at what I was doing and so there's nothing mid about me.
Andy:But those are great ways to explain like hey I'm a nurse practitioner is what I do. This is what I'm all about. This is my general theory and approach to care.
Tess:Right. And this as we say, I take time. You know I'm more than that my practice is different right. I take time because my assessments focused on the whole person and that whole person is complex and at times the assessment does take more time. The care I provide goes beyond a prescription or ordering a test and includes the development of a relationship with the patient so we can work together on health goals.
Rebecca:So one of the things I really liked about paper was the elevator talk.
Tess:Yeah the elevator, putting something together
Rebecca:You have to have something together. People have asked me about what I do cause I'm not a nurse practitioner anymore and I have to have that down in five seconds. This is what I do. And I think you know when you've got that administrator and you've got them for 30 seconds deciding whether to hire you or not or whatever it is that you're going to do you've got to have that elevator talk down and it has to reflect your own theory of nursing and your philosophy of practice. Andrew is laughing over there.
Andy:No, I totally agree.
Tess:It looks like we're time for a break.
Andy:Time for break.
Narrator:Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.
Tess:We're back with Friends of Flo, this is Tess Judge-Ellis
Andy:This is Andy Whitters
Rebecca:and Rebecca Porter
Tess:OK Andrew you had a question.
Andy:Tess, yeah I wanted to go back to what you said about the process of education. The differences between the classic MD, DO, PA and then the NP. NP's are rooted in a nursing experience. All right. Starts even at the two year college level were exposed to patients.
Tess:Even as a nursing assistant. Every which way down there you are, yeah.
Andy:So we are exposed at arguably a young time throughout the course of the profession. Even at a young age. And we understand what it means to communicate with a person, see a person, and see them as such not just as a disease process.
Tess:It's not even just how we see. It's our clinical experiences but also our educational model is a holistic care plan right? You have to have a plan that addresses the biological, psychological, social, cultural, spiritual, all of those modalities of a person. And you have to understand that and then you weave in the disease process and your care plan is then holistic and that is embedded in nursing. Education: that's the philosophy underpinnings and all of that tied to the patient relationship. So that's the nurse patient relationship. So all of that that is just steeped into our professional under-pinnings and we bring that to our advanced practice role.
Andy:Absolutely
Tess:Medicine is well well educated and cellular, you know all of that they look at a disease. They pick it apart from a science standpoint to the disease to understand the path of phys the modalities of treatment and all about that. And then it happens to a person totally different. There's tons of overlap.
Rebecca:But were educated at the bedside and in the community which is a very different mode. But it's still a very different paradigmatic shift to be educated as a nurse practitioner.
Andy:Well I think it's interesting to ask given the M.D. model of education is largely unchanged. In the course of, since its inception, you know 100 plus years ago.
Tess:Well one thing they've done is reduce the hours...
Rebecca:But it's evolving
Andy:And I'm not here to bash on any of the M.D. the M.D. way of life or...
Tess:But I'll tell you what it does though is it provides a place for argument against the nurse practitioner. And this is where they get into a little trouble and where nurses cannot hang their hat on how many years I was a nurse or anything like that because physicians will always have more credit hours, right? They'll always have more time in residency programs, so they have lots more time in school. All these different hours. So compared to nurse practitioners. But you'll never as a nurse practitioner win that argument. But what you will win on is outcomes. And for 35 40 years study after study after study there's no evidence that in fact everything shows that nurse practitioner physician outcomes is comparable at times better and patient satisfaction is very high if not better with nurse practitioners so you can only know a lot. I mean you have to have your knowledge base as power and then know the outcomes. Don't engage in the argument on educational models necessarily.
Rebecca:And I think you have to be very well versed and as Tess said not to hang your hat on anything here, but to be really well versed and ready about the outcomes of your patient group and how you get value based care of your patient satisfaction. The American Medical Association put out Resolution 214 you might want to Google that. They're trying to limit nurse practitioners.
Tess:Continuing to try. I mean they make an overt statement...
Rebecca:To limit the scope of practice of APRN's and have a look at their American Nurse Association response to that resolution because it's a very forthright statement in which the President of the ANA talks about we have to be very careful about addressing how the AMA is perpetuating the dangerous and erroneous narrative that APRN's are trying to act as physicians and I'm quoting here"are unqualified to provide timely effective and efficient care." And I think it's really important based on your paper Tess that we are saying that we are not practicing medicine. We're practicing nursing. And that's really important to say. And we regularly consulting collaborating and referring to physicians as we see fit and as necessary. So I think it's really important to be able to say and in response to challenges that we respond that we are not practicing medicine. We do not have a medical license. We have a nursing license.
Tess:Well then you point people back to the ANP statement. We're unique providers for a certain reason
Rebecca:And we consult and we collaborate and it's a team based model and I think one of the really important thing is when you're talking to your physician colleagues is to when they say we're a team is to ask them who is on their team. Is it a group of physicians or does it include you physical therapy and dietary and everybody else.
Andy:And take that a step further, I like to say our team leader is our patient. You know.
Tess:Wouldn't that be lovely? Well I mean I think the system doesn't always...I think people try to do patient centered care and nurses have to be at the heart of that.
Andy:Well nurses have to be the I think the biggest advocates on that team. I mean it's like we're like the reminders in my experience. And that's an important aspect to a team based model of care.
Tess:The other thing that I found in this and doing the research for this paper was of course Rebecca we go back to nursing theory, so linking together all the other meta concepts in nurse practitioner in nursing theory although they're meta concepts in nursing theory and they say that it's almost like it's that nurse patient relationship unites the practice of nursing. And because nursing actions occur within the context of a unified relationship, I'm quoting from Margaret Newman...
Rebecca:One of my favorites
Tess:That commitment is to caring relationship focused on understanding the meaning of the current situation for the people involved. The meaning for the situation of them involved in appreciating the pattern of evolving forces shaping help so that appropriate actions can be realized.
Rebecca:So it goes right to my favorite book of health of"Health As Evolving Consciousness"
Tess:You know I want to make sure I have that citation for anybody who's interested in that Neuman article. It's Newman It's in ANS, Advanced Nursing Science 2008,"the focus of the discipline revisited". Anyway it's a good if you're a bit of a theory nerd and really want us to be able to explain what we do that's different. Related to the big thinkers in nursing which are our high level nurse scientists and nurse thinkers then we have to go there every once in a while and pull out their concepts. And when you think about it and we were doing some work and looking at surgical nurses, what does the thing that unites the surgical nurse and the geriatric nurse practitioner and the psychiatric nurse and the neonatal nurse that we all have in common is the care for the patient that nurse patient relationship is the uniting force.
Andy:Absolutely, I totally agree. Couldn't have said it better Tess.
Tess:There you go. So how do you get the resources you have to try to claim the resources for what you need is more time and then I think nurse practitioner. This is really where I need to give a shout out to Thad Wilson who is a co-author. When you go to write a paper and you get stuck in the weeds you have to know the right person to talk to. And Rebecca was really helpful with edits on the paper too.
Rebecca:Thank you Tess. I just remember you and I having those conversations at the gym together 20 years ago talking about what we're doing as NP's and nursing theory.
Tess:Did you guys have any more questions or I mean we could go on and on about this subject
Andy:What about billing for time? There are times I bill for time based on the counseling I'm providing to my patients.
Tess:I think so I think what we're really missing though right now is an opportunity to show the value of that over time.
Rebecca:You have to look at money saved.
Tess:Absolutely outcomes have to be high and the cost has to be important. And I think so then sometimes I really think that how we choose to use the nurse practitioner on a team is going to be looking at the patients who are very costly, you know, to this system because I think that if you are coming in with a sore throat or a cough or something like that of course you might not need to see the nurse practitioner expert. Right? You see a nurse practitioner, but I mean the ones where I really think in a team that's where nursing's going to be really essential advanced practice nursing in population health. is going to be in the really really vulnerable patients. You know the elderly with chronic diseases I think the advance practice nurse, but if we're going to bill on time and on those value based outcomes we have to keep really good data...
Andy:And one of those data variables might be decreasing hospital admissions.
Tess:There out there already some of those are out there.
Andy:Sure, but they're difficult to track.
Tess:And how do you link actions and this goes into documentation of time spent. So how do you link nursing actions? Like if you're spending Andrew two hours with one patient for an hour over the next and you're talking to staff and all of that. How do you get paid for that time when we're on a fee for service model. And so how do you in fact you know you're saving money otherwise they wouldn't be having you do these jobs you know you're saving money. How do we show that then to the payers and then get a cut of that to keep building on things because if medicine could have solved the high cost of medicine you know and interventions, by just medications and surgeries and you know we wouldn't have the health problems that we have now. So nursing can have a lot of opportunity to help out with the solutions there.
Andy:I do think that nurses tend to focus on primary care and preventive health.
Rebecca:That's a unique emphasis
:It's a really important getting vulnerable populations when you go back the economically challenged people, people who do not have health care insurance. There's so many opportunities to be there and to do good work.
Speaker 4:And you know and I also think in the I mean the primary care vulnerable and then the vulnerable populations in the inpatient settings too. I think that sometimes I bet you on some people that are on certain inpatient units that I work in and we can talk about to these people later, but I bet you there's some hospital systems that are saying these people are so complex socially they need the nurse practitioner there on that team most especially, right? I mean, anyway, so I think you know we've had these 50 years of Nurse Practitioner education and a model and they've proven that we're in fact you know...
Rebecca:Worthwhile
Tess:On par. I think the next 50 years is going to be demonstrating the value of the nurse component to nurse practitioners. And so the system is kind of starting, but it's really small. This is where I think nurse practitioners have a real great opportunity.
Rebecca:Tess when you're talking to your students and sending them out into the world to set up their own practice or to find a practice to join what's your best piece of advice to them about, A, presenting themselves as a nurse practitioner and, B, documenting what they do. So you could show the value of your work that they do.
Tess:I think the best thing...what I say is to first of all know what you're doing and why you're doing it as a nurse. So understand what are your core values in nursing. How are you going about documenting a holistic assessment. What's your philosophy of nursing. What is your philosophy. And then not being afraid to share that with anybody, with administration, and this is why I need 45 minutes for a well woman exam or whatever you need is because I'm developing relationships that over time I know are going to enhance this practice and save outcome, save money, and maybe win the next value based opportunity comes along. You'll keep me in mind because I'm really interested in value based care not just fee for service. I mean, I can diagnose your strep throat with the best of them and at the same time I think we can really build relationships along the long run.
Rebecca:And I think it's really important. My best advice would be to sit down and actually write down your philosophy of practice.
Tess:It's the next paper to write.
Rebecca:What is your philosophy of nursing. And just to be able to write that down and keep it in mind you don't have to share it with anybody, but it will inform how you relate to patients and how you relate to your people that you are working with.
Tess:It's a good time. Going into the business right now it's a good time. It's chaotic, but there's lots of opportunities.
Andy:Is there ever.
Tess:All right. Well that's Friends of Flo we're going to sign off I guess.
Rebecca:Take care everybody.
Tess:Keep your eye on the patient
Andy:Innovate, agitate, educate.
Narrator:Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.