As I walk through the side entrance of the hospital, my white coat flapping in the Texas breeze, I am quiet and introspective. What will the day hold for me? Do I have the knowledge and skills necessary for assessing and diagnosing my patients? Will I know the current evidence based guidelines? Am I good enough to do this job?
When my patients enter the hospital, they have a problem which is causing them physical or psychological distress. They did not come into my professional realm for a social call, they need me to intervene and fix the problem. Usually, by the time they are admitted to the floor, they have already been examined and assessed by a physician in the emergency room, and it was deemed necessary to admit them to the hospital for further evaluation and care.
I look over the information obtained in the ER and try to come up with a list of questions I need to have the answer to. I have to evaluate past medical history, family history, personal habits, current medication, and finally complete an interview which is followed by a physical examination. Sometimes, if I am lucky, there are symptoms and risk factors that are glaringly obvious and I know an effective treatment for the malady. Other times, most of the time it seems, I am handed a vague list of complaints which fail to give me a concrete diagnosis. Now, I have to evaluate the things I cannot see with the naked eye or hear through my stethoscope. Subjective complaints are the most difficult to assess. Is the patient telling me the entire story? Are they being truthful? What am I missing? How do I get more information? How can I get this quantified? Is this part of the story pertinent? What else do I need to know? How do I avoid offending or embarrassing this person that came to me for help? How do I bring up sensitive topics? How do I reassure this person that I care? How do I facilitate communication, while using time wisely?
Now, I am not usually seeing only one patient at a time, and all the information I need is not handed to me in a nice little package. I am waiting for diagnostic results and other professional opinions. I am also juggling the needs of the hospital, insurance regulations, personalities of the patients, their loved ones, other hospital staff, and a ticking clock. I make a decision based on the information at hand, and I have to trust my skills to obtain all the information.
I have taken my time to listen to the patient, asked invasive questions meant to probe and uncover the secrets their body keeps hidden in a shroud of mystery. I explain my plan of care and explain the results I am seeking from my interventions. I walk out of the room and sit down to record in the official medical record my findings. I have to maneuver my way through an electronic medical record that seems to have been designed to make finding the details of care difficult to find. I am granted peace and quiet, and no one ever interrupts me and breaks my train of thought. Oh, wait that is not true. I am constantly bombarded with questions and requests for my time, attention, and energy.
Constant terror that I missed some potentially fatal condition, or that I will not order the proper intervention or screening lies just under the surface. I find myself double checking and reviewing medications and test results. I discuss the case with my supervising physician. I waiver at times in my resolve. Then, I have to make a decision. I find myself reviewing the case with other members of the health care team and asking for their insight on the patient’s condition. I attempt to make sure the nurses concerns are addressed. I seek to educate and give them insight to the rationale for proposed treatment. I have to give them options and hope they are agreeable to the plan. I have no power to force compliance. So, my argument had better be convincing. I have to be able to communicate with people regardless of the language they speak, their cultural biases, and their education and intelligence level. I have to provide care that is accessible to everyone regardless of the barriers to knowledge. I have to find a solution for any roadblock. This requires extensive knowledge and comprehension of an unending list of resources and rules for utilization. It also requires the ability to overcome whatever social issues arise. I am tasked with having difficult conversations, while maintaining a professional manner.
One of the biggest issues I face is discharge planning, which actually begins the moment a patient enters the hospital. What has to happen in order for the patient to be deemed stable for discharge? What kind of follow-up care will they need? How am I going to plot a course of improved health for this individual? What are the financial implications? What resources are available? What are the rules for the care I seek? How do I properly justify medical necessity?
Oh! Don’t forget patient satisfaction scores affect every thing I do. If the patient is not happy with the proposed treatment, or if they feel something else would be more enjoyable, they can affect the amount of reimbursement the hospital receives in the future. How do I satisfy someone when they are sick? How do I explain the difficulties with pain control? Is it my job to somehow make you pain-free, when there is some part of your body malfunctioning? How do I make the patient understand they have to get out of bed when all they want to do is sleep through this process? How do I make them happy about the dietary restrictions for their particular condition?
Sometimes, I go and speak to a patient and spend a considerable amount of time with them, I explain my role and that I am going to be providing their medical care. Yes, I am operating under the supervision of a physician, and I would not have it any other way. After I have gone over every thing and I have documented the encounter adequately, and met with all the members of the healthcare team, I hear this statement, “The patient and their family are upset because no one has talked to them today.” I am sorry, but WHAT? I just spent an hour with this patient and their family IN THE ROOM. This is not including all the time spent with care coordination and other necessary actions. OH…. you want a DOCTOR. Okay. No problem. Now, I have to approach the physician who I have reviewed the case with, assured them I have it under control, and review and recap the entire case, explain exactly what I have done, and reiterate the entire conversation I had with the patient and the family. The doctor walks in the room and spends a couple of minutes, and magically every thing is right with the world.
I am left feeling moderately unimportant. I have spent time to pull up a chair, listened compassionately, and truly worked so hard to take good care of you. I feel like all of my hard work was for nothing. The patient and their family were not pleased with my efforts. They wanted a doctor. I get it. I really do. The problem is… if I am being honest, at times it hurts my feelings. I know it shouldn’t. I am able to think through it and brush it off, but I am left with a little bruise on my ego.
You see, I am only a nurse practitioner. I am not a physician. I am competent to provide medical care, and I know my limits. I have no qualms with admitting when I do not know the correct answer, and I am not afraid to ask for help. I crave and value the education my supervising physicians provide for me on a continual basis, and I am never offended when they provide alternative treatment plans or point me in a different direction. I am a physician extender. They are ultimately responsible for the care I provide. I respect that role. I respect my role.
I work hard to gain new information and to learn more about caring for patients. I like to gain new understanding from other specialities perspective. I look up the things I have never heard of or don’t particularly understand. I am exquisitely curious, and I am driven to constantly be better. My professional goals center on providing the best care possible for the patient. I am here to provide safe, competent medical care.
Due to my professional path, I am still a nurse. I have a complete grasp of the realities and responsibility of this role. I was also a unit secretary. I understand the complexities of the relationships between all the people on the team. Sometimes this is a hindrance. I held myself to high standards, and sometimes I find myself judging other people as harshly as I judge myself. I have to work continuously to encourage and promote open lines of communication. I want the other people involved in providing care to feel they can come to me with any issue or question that arises. This is difficult at times because I am entrenched in my own inner battle with my own insecurities.
I am not certain if the fear of making mistakes is normal for all healthcare providers, but I believe this fear keeps me on my toes. The balance between humility and confidence is sometimes difficult to achieve, and I fear I may fail to provide the necessary reassurance that I will do every thing in my power to meet your needs. It is difficult to be confident when every thing is so gray. I think this may be one of the most difficult parts of my job.
I have learned healthcare providers are just human. We are attempting to unlock the mysteries of your body, and there are infinite factors that must be considered. We are bound by limitations of medical knowledge, as well as the logistical nightmare of resource utilization. We can offer suggestions and proposed treatments, and we can attempt to forecast the results of those treatments. However, we are left powerless as to the actual outcomes. We do our best. We do what has worked the best in the most number of people possible.
Nothing is guaranteed, yet we are held responsible for the end result. If you live, God saved you. If you die, we killed you. This is a huge burden. The emotional toll it takes on me when there are bad outcomes has to be faced head-on. I have to process the feelings, evaluate the situation, and hopefully learn a lesson. Sometimes the lesson is simply a reminder of human limitations and the fact we are all mortal.
So, I live in constant fear and feel an enormous amount of obligation to provide the best care for my patients. I have to push my ego aside and bury my pride. I have to portray myself as competent to facilitate confidence in my abilities. I have to remember my limitations, while simultaneously trusting my skills and intuition. I will chase every resource available to improve your health or quality of life. Sometimes, the patient or their family’s wishes are in direct opposition to the best treatment. We are tasked to keep someone alive on life support when their quality of life is dismal. Or, we keep providing measures that simply prolong suffering when there is no chance of survival. These cases are distressing. Running a code on someone when in reality further care is futile seems like torture. However, we are not in charge of what care the patient receives. We offer advice and suggestions, everyone is allowed to make their own decisions. It is difficult to keep every thing in perspective when we are held responsible for the outcomes when the proposed plan of care is not carried out or the patient refuses to comply with instructions and advice.
Please do not forget the required tasks involved in maintaining licensure, hospital privileges, and employment. I have continuing education, certifications, privileges, and meetings I am required to attend. I have to juggle the business of being employed with providing patient care. I have to put my personal life on hold, and out of mind while I focus on life and death issues. I also have to make time for the people in my life who need me to be there. I cannot be preoccupied with work stuff. The amount of compartmentalization required to be a healthcare provider is enormous. I have to remind myself to put work on a shelf sometimes. It is difficult to not be consumed by it all.
Please, just remember: The physicians and other members of your healthcare team are only human and we cannot perform magic. We do the best we can. I have to be remain constantly vigilant. After all, I am only a nurse practitioner.