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BostonFNP Guide 41,346 Views

Joined Apr 4, '11 - from 'Northshore, MA'. BostonFNP is a Primary Care NP. Posts: 4,653 (61% Liked) Likes: 11,256

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  • Mar 25

    I am a Direct Entry grad who has been practicing as a FNP since 2009. I had a lengthy career in another health profession, but really wanted to be involved in direct patient care. I have no regrets about obtaining my NP through a direct entry program. I worked harder in this program than I ever had in my life. I was only able to work a limited number of hours per week, as school took precedence and the volume of work was high. My program's standards were high, as they should be. It was stressful, but I never felt that I couldn't handle it or that I had made a mistake. Maybe that's a benefit of going back to school as an older adult. I worked in a community health center for a few years, which was very stressful due to lack of support and resources. I'm now in a private specialty practice, and I don't find it to be very stressful. I'm paid well, I'm good at what I do, I have a great work-life balance. Oh yeah...I also really help my patients.

    If you choose to go the DE route, make sure you choose a reputable program with stringent admission standards. Do not settle for a for-profit school that will admit anyone willing to pay. I personally chose a 100% brick and mortar, no online component school. I felt that being in a classroom and working with other students was a better way for me to learn. I also liked meeting with faculty face to face and being able to ask questions in real time. I think it's also important to find a program that will help you find preceptors for your clinicals.

    Best of luck to you.

  • Mar 24

    I think a doctorate can come in handy for a future role in teaching so I'm considering it but I'm in a state that doesn't offer a great selection of DNP programs that I can attend in person. I'm also considering the cost factor and don't want to spend a lot of money on a degree. I never had loans for my Master's and want to be able to do the same for DNP.

  • Mar 24

    I think you should consider a few things while making your decision: where do you want to be in 5 or 10 years? What are your other goals- professional @ personal? Also, for me, at least, age is a factor.
    I am 53 years old & have been a nurse for 32 years; nurse practitioner for 16. I really like what I do & hope to remain in my current position for at least 5 more years, but I'm tired! If the opportunity arose, I would probably go part time. Obtaining a DNP at this point is just not something I want to put time, effort & money into. It would not help me in my current position & I would not make any more money.
    You, however, may be much younger & plan to work a lot longer than I will. You may just want to bite the bullet & get it over with. Just another hoop through which you will have to jump...good luck!

  • Mar 23

    Quote from SobreRN
    Actually that is what I said. I do not care if they want to get high. Was not my drug of choice but could've been I suppose...I feel a bit sorry for anyone who is strung out on Rx meds given the hoops they jump through. Really I do not see what the big fuss is over anyone altering their mood, that is the whole idea behind alcohol...
    If I interpret your post correctly, I think that you are grossly downplaying/understating the effects/consequences of alcohol and narcotics addiction. Addiction is often a tragedy for the individual afflicted and has negative effects and huge cost on society as a whole. If it was isolated to people simply "altering their moods" and had no other detrimental effects I'd agree with you, but that's far from reality.

    Alcohol and narcotic addictions often lead to a number of crimes, both violent crimes like assaults, spousal abuse, child abuse (and neglect), robberies and murder, property crimes/thefts and prostitution. Addiction often has very negative effects for the addicts themselves. Loss of job, loss of home, loss of custody of children, loss of health, loss of freedom etc.

    My opinion is that as a healthcare professional it's not my job to "police" my patients. My focus as a nurse is to provide appropriate treatment for whatever the patient is hospitalized for, and not moralize about someone's personal choices or withhold medication based on my own personal opinions and biases. My decisions should be based on medical considerations and since I'm cognizant of the fact that I can't objectively measure what my patient is experiencing, in an acute care setting I will err on the side of "overtreating" rather than "undertreating", as long as it's safe (for the patient) to do so.

  • Mar 21

    Quote from madglee
    I make about $300 per hour or $200k+ working 4 days, 8 hours per week, just billing insurance. If some physician is paying you less, you're getting ripped off. I'm a PMHNP.
    Uhhhh did anyone get that these numbers aren't even close to adding up based on a 32h week?

  • Mar 20

    A lot of time, thought and teaching went into this article, and it shows. Yes, we've all met Jake I would guess.

    I wonder how many of us have met Harry too?

    The year was 2002, and I worked in a VA facility at the time. Harry was 71 years old, and among other things he was Dx'd with chronic pain. Harry had only recently started on MS Contin 30 mg PO BID in the past 6 months, and it worked fairly well for pain he had suffered for a long, long time. Harry had also been on coumadin for many years.

    Harry was approximately 8 hours post-op. His post-op pain med orders were generic: percocet 1-2 PO Q 4-6 hours PRN, and demerol 50 mg IM Q 4-6 hrs PRN severe pain.

    Because Harry was Rx'd coumadin the night nurse opted to D/C the IM demerol for safety reasons to prevent hemotoma, but didn't think about calling to get IV pain med orders. Harry was NPO over night, so not only did he not get his evening dose of MS Contin, he never received any PRN percocet either after being transferred from PACU.

    I arrived at 0630 for report, and walked into Harry's room at 0700. Harry sat huddled in his bed sweating and shivering, gown and sheets soaked, goose flesh visible on exposed skin, miserable. Harry spent a sleepless night in pain, and unbeknownst to him, narcotic withdrawal too.

    Harry smiles wanely, "Well hello there young lady. I think I may have the flu! I'm not feeling so good …".

    "Hmmm, I'm not so sure", I say.

    The residents are making AM rounds as I check the med sheets. I find a tired looking pair at the unit clerk's desk sitting in front of computers, eye bags large enough to be hammocks for small rodents (an unwillng, irritable audience, but an audience nonetheless).

    I explain the situation unfolding in ICU room 12. The female of the pair turns to look at the male resident, "An addict" she says. He nods frowning, never taking his eyes off the computer monitor.

    Internally I'm steaming - Mt. Vesuvius - while externally my face is wiped clean of all emotion. My eyes are on the prize, which is relief for my elderly post-op patient who never should be experincing narcotic withdrawal in the first place.

    "I believe this would be symptoms from the abrupt discontinuation of a legitimate Rx medication doctor … physical dependence".

    Both residents stare blankly at me.

    I get a verbal one time IVP order to make my patient comfortable until rounds get to him, advance his dietary orders, and allow his PO meds to resume.

    Harry gets medicated, his symptoms subside and he feels much better. Later we have a talk about physical dependence and education ensues regarding his MS Contin for future need (Harry had another elective surgery pending in the near future).

    Harry was surprised to learn he should not abruptly stop his MS Contin, and was dismayed to discover the commitment he had made to be free from the worst of his chronic pain. He worried he was an addict - it took much convincing on my part to reassure him that he was not.

    Why was it I understood what was occurring when some of the staff interacting with Harry did not spot it for what it was?

    I myself am an addict, now 25 years clean and in remission. Even though Harry was not an addict per se, narcotic withdrawal looks the same regardless of the reason for it - and I know personally what it looks like like whilst others may not.

    When all was said and done, and Harry was transferred to the step-down unit later that morning I should have felt relief rather than uneasy. But sadly this was not the first or last time I encountered a scenario like this in my nursing career.

    I, as many of my colleagues understand that not all patients who take narcotics routinely are created equal, even if the residents that day did not.

  • Mar 20

    Quote from russianbear
    How many people do you know personally who have died because of an epidemic that we play a role in?
    Why did you ask this? Have you lost someone close to you to addiction? Is that what's affecting your response in this thread?


    Like I said before, I'd love to work in your hospital where "seekers" do not exist.
    I'm shocked one of you finally acknowledged the existence of drug seekers.
    Something seems to be affecting your interpretation of what posters have written. I've reread this thread and I can't find a single poster/post who has claimed that "drug seekers" don't exist.

    ...because they know eventually the docs will give in as opposed to telling them they will not prescribe them controlled substances th do not have a need for.
    (partial quote and my bold)

    Now, will you be courageous to say that physicians should not order them narcotics for the sole reason of feeding their addiction?
    (my bold)

    Again, I am trying to distinguish between people with medical issues versus those who do not.

    I'm former law enforcement and in that capacity I met thousands of addicts. My nursing career so far has looked like this: med-surg ---> ER ---> PACU --> anesthesia. Despite having met a large number of individuals battling drug addiction I have yet not figured out a method that is 100% foolproof in indentifying if someone wants opioids "for the sole reason of feeding their addiction" or if that someone actually also experiences pain or some other type of medical issue. I'm going to go out on a limb here and say that neither have you. Because there is no method to objectively measure what another person is experiencing painwise.

    To further complicate matters many nurses have a knowledge deficit as to how chronic pain presents. Most nurses have a good understanding of the presentation of acute pain but individuals who suffer from chronic pain will often show less of an effect on vital signs and behave in a way that you or I wouldn't intuitively expect someone in pain to behave. Whereas I definitely wouldn't be in the mood to fiddle with my iPad or be able to fall asleep with my freshly fractured femur a person with chronic pain can definitely sleep despite experiencing severe pain. Human beings simply can't stay awake for weeks or months on end. So they sleep, despite the pain.

    When we as nurses evaluate a patient's pain it's based on what the patient says and how s/he presents. It's based on the amount of knowledge the individual nurse has on the anatomy and physiology (and psychology) of pain. That amount of knowledge varies. It's also based on the medical history available to us and it's also definitely affected by our own personal experiences and biases. It's important to be aware of the last part and how it might negatively impact our patients.

    Russianbear, the way I interpret your posts is that you think that the least desirable outcome is that we as healthcare professionals inadvertently (or because of indifference) enable an addict and give them a "free high" by administering opioids without any verifiable medical indication. My take on this is different. My least desirable outcome is that we fail to properly treat even one single patient in pain. To me that's failing the patient.

    As has been mentioned in this thread, the acute care setting is not the place to cure a problem with addiction. If I withhold a pain med because I suspect that the patient is "a seeker" I run the risk of undertreating someone's pain. If I was actually correct in my guess and the patient was actually "just seeking", I haven't really accomplished anything (apart from whatever satisfaction I/ a nurse might derive from denying someone their "fix"). It won't "cure" the addicted person, they'll find another way to get their desperately needed drug. From my earlier experience those ways often involve; mugging someone for cash to buy drugs, selling one's body for money to buy drugs or in exchange for drugs, stealing from department stores/businesses or stealing from family members or perhaps even robbing a pharmacy. All these are methods that result in some type of collateral damage. Since I can be quite certain that my withholding the med won't result in the addict saying; oh, this didn't work. With that in mind, I don't really see what good I will have accomplished. I think I'll just quit my habit" That won't happen before the addicted person manages to find the motivation to want to become clean.

    In the case that OP described, giving Jake his medication is a no-brainer (providing his vital signs permit it). He's had a surgical procedure known to cause post-operative pain.

  • Mar 20

    Quote from CG1979
    Here's the thing: Jake may have the "same right" to pain meds and your time as other patients, but management of his behavior will take time away from other patients care. Not exactly equal or fair, is it?
    By this measure, the patient who is intubated, on 5 pressors and an IABP is taking time away from the patient who got their finger stuck in a door. Is it fair that the first patient gets more nursing time? These days we use individualized patient care models that reflect the needs of the patient. If that patient's needs manifest as mental health needs then that's what the time is spent doing. Being an addict doesn't make them any less deserving of time. You're stepping over a line when you determine that a certain patient is worthy of less time because of their social and psych history.

  • Mar 19

    Quote from BostonFNP
    Self-reflective practice is a vital component to providing good care, at any level.

    If nothing else, hopefully this thread has engaged everyone reflecting on how we individually approach patients that have been labelled "seekers".
    That was my goal in writing this.

  • Mar 18

    Quote from russianbear
    Again, I am trying to distinguish between people with medical issues versus those who do not.
    So, how do you deal with people who have both medical and addiction issues? This is the point that PPs are trying to make, I think. It's not a strict either/or algorithm. Which issue gets prioritized?

  • Mar 18

    Quote from madglee
    We need all NPs to have doctorates from 2015 out.
    I needed some satire this morning. Well done!

  • Mar 16

    There is a rationale for pain meds. Coke & Meth don't do anything for pain.

  • Mar 16

    I have never quite grasped the thought process behind holding/rationing pain meds for an addict when they are in hospital for some acute process which results in pain. We have a lot of addicts (heroin is a HUGE issue in our area, one of the highest rates per capita in our state) that come to us for whatever reason. Cutting someone open will result in pain whether you're an addict or not. Acute bouts of pancreatitis result in pain whether you're an addict or not. The only difference is that an addict may require higher doses of pain meds to control/cut through the pain.

    These are my issues: The patient who shows up religiously every three days in ED for pain. Said patient is with pain management. Patient knows darn good and well we will not go outside the parameters of the pain management contract. Same patient knows that #1, "chest pain" gets them to the front of the line in ED, and #2, no matter who they demand to see (all the way up to hospital president) they will not get any pain meds outside of their pain management contract. But they try every. single. time. and waste the time of RNs, supervisors, etc.

    My other issue is the patient who decides to bring their illicit drugs to the hospital and shoot up in their room when no one is in there. Or you remove a patient's socks and needles and baggies fall out. Or flip a pillow and have a syringe with God knows what go flying across the bed. I'll admit it pisses me off to no end to walk into a room to find a patient gray and not breathing because they took something.

  • Mar 8

    Quote from Strugaaa4eva
    I guess you're right. I will take this as a lesson learned but will not be seeking anything else at this time.
    I am looking at the responses and I sit and shake my head at the responses and I am reminded once again at the present culture of nursing. Frankly I feel we all need to take a look at ourselves and develop a sense of humor....we need to learn to laugh at ourselves.

    I don't think your phone call was a terminating event. If this facility fired you for this and the person in orientation flipped out....which I feel is extreme....and they fired you for it.....count your blessings. IMHO this would be an extremely difficult environment to work in...keep this experience in your mind but don't let it deter you from what you want.

  • Feb 18

    Quote from brownbook
    Wile E Coyote Could you please sight your source for this statistic?

    The above is a quote, I can never use the quote function correctly!

    Sorry, no I can't. I am pretty certain that most violence is committed by someone the victim knows personally as in a close personal acquaintance or relative.

    I am sure you can find cases of psychiatric patients stalking, even killing, their care provider after they have been discharged.

    I am sure you can find cases of medically ill (no psychiatric diagnosis) patients stalking even killing their care provider after they have been discharged.

    I have no statistics but I believe these cases are extremely rare.

    Fearing mentally ill patients is perpetuating a stigma that professional medical health care workers should be striving to end.

    It is exactly the same as fearing all Muslims or any "group" you want to label as dangerous.
    A simple Google search can be enlightening.
    Violence toward mental health staff has been receiving national attention in the face of diminishing resources to treat what appears to be an increasingly violent patient population. Assaults by psychiatric patients against mental health care providers are both a reality and a concern, as the effects of violence can be devastating to the victim. Some staff rationalize that violence is an occupational hazard and believe that they are equipped to cope with it. Despite these beliefs, these victims suffer from many of the same physical and psychological sequelae as victims of a natural disaster or street crime
    Violence Against Mental Health Professionals: When the Treater Becomes the Victim


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