Clinic nurse in Primary Care. First responder to every emergency, counselor, friend, advocate, warrior, mom, expert for both clinical and nonclinical issues, clinical lead, form filler, triage nurse and complex care coordinator. A typical day in the clinic.
To me, 30 years as a nurse passed like a fleeting dream at night, but every day brings something new! I go in like a rookie every day wondering what the day will bring and I am never disappointed! Since graduation, I worked a host of jobs in acute care, long term care, school health, teaching, home care, community health nurse and administration. For the last four years, I have been working in a primary care clinic. When I first walked in, I thought, "How hard can this be?" After all, all I would be doing was vital signs and have the patient wait for the doctor. Right? Wrong! Let me take you through a clinic day at my job.
I work as a Chronic Care Nurse Coordinator in a busy clinic in an economically disadvantaged area, in a busy city, in the United States. My patients are mostly Medicaid funded with major medical issues, chronic problems and innumerable social issues including homelessness, poverty, broken homes, inadequate food, access issues, transportation issues, illiteracy, and minimal social support. Let's meet some of my patients.
Jose, a former gang member with skull and cross tattoos on both arms is a forty years old diabetic, hypertensive with depression and alcohol dependence who reads at a fourth-grade level. His biggest supporter is his mother who is battling depression herself. His HbA1C is fourteen and he doesn't understand why I am so concerned. My Diabetic teaching 15 minutes visit stretches to 40 minutes as I ask if he ever sleeps with his front door open at night. Scratching his head he says "No!"
"Why not Jose?", I calmly ask.
"Nurse, that is plain stupid! Anyone can come in! I could get robbed!"
"Jose, you are already doing that!"
"What do you mean Nurse Annie?"
"When you don't take your medications and ignore your diabetes, you leave the door open to infections, high sugars, kidney problems, heart attacks. They are like rival gang members!"
"Oh! I see!" the penny drops as he understands.
"What should I do?"
"Well, Jose! You are a smart man. You need to close your door by taking meds. Let's talk about them----!" I have him hooked now as it makes sense to him and he is ready to listen and learn how to protect himself. After all, that's what he has been doing ever since he was a kid! The last time I saw him, he was back on his medications and his HbA1C had come down to 13! Jose was back on track.
Tanya, 36 years old with a history of CHF, flash pulmonary edema and an ejection fraction of 15%, a frequent flier to the hospital looks bloated as I pass her in the waiting room. I stop to say hello. She smiles at me as I sit next to her in the waiting room.
"Who are you seeing today? "
"The Medicaid worker. I just dropped my papers. My insurance won't start back for two weeks". She looks worried and is short of breath. I inwardly curse as I suspect she has run out of medications.
"Tanya, when is the last time you took your Lasix? "
"3 days ago, nurse. I called the clinic and told them to ask Nurse Annie to call me back, please. It's urgent. I tried calling them again but no one picked up. Didn't they tell you?" I had never got that message as it was the weekend, the call center had taken the message but the clinic was closed. Tanya could not remember the on-call number. I gave her my personal cell number again for emergencies.
I turned to the front desk clerk John and requested that he put her on my panel and took her into an exam room even though, I had 3 other patients waiting. Just like I suspected, she had put on 4 lbs and I could hear crackles at the base of her lungs. She did not want to go to the hospital for admission and we had to negotiate! I got her a same day appointment with one of our providers who titrated her Lasix and scheduled her for a followup and weight check in two days with me. As I left the room after giving a warm handoff to the provider, she called out after me, "Thanks! Nurse! You are an angel!" I smiled at her and walked away to my waiting patients.
Sam looked grumpy when I found him in the waiting room.
"What took you so long nurse?"
"Sorry Sam, I had an emergency."
"Did you bring all your medications?"
"Yes, nurse". He pulled out 3 bags! I inwardly groaned as I painstakingly went over his medications. He was taking Metoprolol that had been discontinued, had not picked up his Lisinopril, was taking over the counter garlic pills with his blood thinner Coumadin and had left his inhalers and insulin pens at home---. I called his pharmacy, updated them, educated him about the dangers of bleeding by mixing a blood thinner with garlic pills, turmeric pills alongside his aspirin 81mg and ibuprofen for pain! I made another appointment for him to come back with the rest of his medication and eye drops in one week. I was running over every 15-minute visit on my panel today.
I went to my office as my next patient was in an hour. I had 12 messages waiting in my inbox in our EMR for a callback, 7 forms waiting to be filled, staff schedules for the next week to be reviewed and was covering my partner that was on lunch for all triage calls. I got through 2 forms and 3 calls before I had to go and triage an asthmatic that walked into our clinic requesting to be seen. I started the 18-year-old on a Combivent treatment and found an empty slot with a provider and asked the provider to put in the order. It was time for my next patient.
My next patient was from West Africa, spoke only French, was 21 pregnant and had a six-year-old child. The translator phone service put me on hold twice for 20 minutes each till I got fed up and went looking for the video translator in the clinic. I found it in the 12th room I checked and did a prenatal visit asking her a whole bunch of preset questions and taught her about breastfeeding and how to prevent and manage nausea in pregnancy. I wished my visit slots were at least 30 minutes instead of the fifteen a sure setup for not keeping time.
I had to then, call a complex care patient who was paraplegic, and who self catheterized. He was running out of supplies as his prior authorization for supplies was not approved and now I was on the phone trying to get him approval----left messages for his care coordinator and the durable medical equipment store that had an automated system.
All throughout the day, I was paged multiple times when the front desk had questions, the LPN needed help, the doctor needed me to call a 14-year-old with abnormal results (positive STD) and a new order for medications that needed to be picked up by the patient and started. I called the 14-year-old patient and her mother picked up the phone-------could not tell her. Told her to have her daughter call back the doctor or me, fielded and avoided giving specific answers to the mother's questions and sent a private message via the patient portal to call the clinic and ask for me or the doctor. Documented all conversations in the chart.
I then had to call a hospital discharge patient and get a Spanish translator on the phone to ask our lengthy hospital discharge questions about her CHF management and coordinate calls between her primary care provider, the cardiologist and myself and work around her schedule as she was watching her grandkids while her daughter worked. I was unsure if she knew what medications to take and asked her to come in for a med reconciliation. The earliest she could come was a week later on her daughter's day off. I sent a note to her doctor.
It was almost time to go home. The rest of the work would have to wait for tomorrow. I sat down and said a quick prayer of thanks. At the beginning of the day, I had sent someone who was short of breath and fatigued via 911 to the nearest hospital. I was pretty sure he was having some kind of blockage in his heart. I called the hospital to find out and finally was transferred to the ICU. Turns out he had a 100% block in his LAD and had been taken straight to the cath lab and stented. He was stable and in the ICU being monitored. I left work feeling good!
My years in the telemetry and ED had helped me spot that pt and also Tanya's CHF exacerbation. My home care training had prepared me for the discharge calls, the med reconciliation and many of the triage calls. My teaching and long term care experience helped me with grumpy Sam and Jose my ex-gang patient! Every day of my nursing experience has been put to use in this job. I feel privileged to be a front line worker making a difference. I might not be recognized for my work and sincerity to my job, by a manager or coworker but in my heart, I know, I make a difference every day in someone's life. I have been blessed by my patients a thousand times over like many of you who work tirelessly no matter what the odds stacked against us! We are blessed to be nurses and have a special mission on earth! It is to touch lives from birth to death and be there for our patients and one another when no one else does! If no one has thanked you for being a nurse, let me say thank you! I am blessed and proud to be a nurse!
So true.It is like a PE! If you are not looking, you may miss the boat! You hit the ground running and most days are fast paced. You also have to know what to do and how to stabilize a patient while waiting for 911. I once had a patient on Coumadin with a non healing foot ulcer and a tendency to bleed. He went to the bathroom and turned his wheelchair hitting his foot against something and bleed like crazy. Luckily he pulled the emergency cord and we went in to a blood bath and called 911! Between the doc and I, we tied a tourniquet, lifted his leg up and put an IV in, all in the bathroom. I walked out of the bathroom feeling like I was in a murder scene! Lol! Later he came back and thanked us as they transfused him with 2 units in the ED! I joked with him that I was a blood relative at this point!
3 hours ago, NotFlo said:I'm a clinic nurse in primary care. Just an LPN but I'm the only nurse they have. I relate to a lot of what you wrote. I have, over the past few years, been burned by some patients who take and take and take. People I am up at night sleepless worrying about. People I have spent hours and hours for on the phone trying to help out. Finally I realized one day I can't fix everyone's whole life and I had to start setting some limits and start expecting people who are able to do some things for themselves. Personally, I would never give my phone number to anyone. I know someone who gave hers out a lot and she did end up getting texts and calls day and night and got so overwhelmed and burnt out.
I also envy the access your clinic has. My clinic has no appointments and I spend so much time struggling to get people in that need to be seen. I am happy to take a look at someone's wound or edema or take a listen to their lungs...but if I identify a problem I am left with a major dilemma with no way to actually diagnose or treat the patient as often their PCP just cannot see them for a same day.
I also have to be responding phone calls constantly all day and be available for the MD to do the shots, med administrations, wound care, ear flushes, spirometry etc that they need done during clinic. People on my schedule I have to keep moving as much as possible because the docs are waiting for me and so many people need phone calls. Everything documented in EMR of course. I also do a lot of prior auths, refills, all the home health referrals and communications (and they call a lot!) And write most of the docs letters and do all the FMLA etc paperwork that comes in. Also do all the ordering and stocking (down to the toilet paper and garbage bags) and manage the stare vaccine program and OSHA stuff.
So anyway yeah clinic work is definitely busy! A different busy than when I worked the floor but still busy.
Wow! That's a lot you are doing super nurse! Thank you for helping your patients in spite of all the work they throw your way! I have to stand my ground and ask them to put patients on my schedule if they want me to see them that day. I am not afraid to say no. I say it nicely though! When I am scheduled to attend interviews for new staff and they put pts on my schedule, I skip the interview as I can only be at one place at one time.It is a tough job but I am glad I can make a difference. Don't underestimate the good you can do where ever you are. It does sound like a lot for one LPN.
We don't have access all the time and sometimes I send pts to the ED or Urgent care the same day. If they can wait for one more day safely, I put them on the next available slot. Sometimes I speak to the doctor and overbook them if it is urgent but does not warrant an ED visit or is unstable for Urgent care like an asthma exacerbation.
I had no idea.
I am glad you enjoy your work, but you should not be giving out your personal cell number. This is violating professional boundaries and will not be good for you or the patients in the long run.
I am exhausted just reading your article. I think clinics are understaffed just as badly as the inpatient facilities after reading your article.
Bless you, but tighten up on that personal phone number business.
Thank you Kooky Korky! Will definitely tighten up as I know you all have good intentions.I honestly do not give my number to every patient, just 1 in 3000! Lol! Did not mean to exhaust you with details of a clinic day but you are right. It is understaffed as even the management that runs the place do not get what the nurses do! Most people have this "all they do is vital signs attitude "and I am guilty of that too before I started working in a clinic.I guess, when you don't work in a place, you don't realize the details whether it be inpatient or outpatient.
Clinic UC nurse here... yes that sounds like a typical day! And for the "new grad" comment, the clinics are constantly short-staffed just like the hospitals. Moving to the clinic requires a salary decrease, no overtime and no holiday pay. Sometimes they have to take the staff they can get. The shortage is only going to get worse. We need to get past the "new grad" prejudice and figure out how to get them up to speed!
We are undervalued and almost everything we do is behind closed doors. Administration doesn't have a clue.
56 minutes ago, spotangel said:I would rather a new grad that I could train but that will happen only i f you have input into the hiring process!
Exactly! If you have input. I didn't!!! Sometimes it worse having bad help than no help at all, because you have to clean up after them. I have a nurse who was kicked out of 3 jobs before coming to my office, she has been barely a nurse for over a year. It really depends on how savvy and intelligent the new nurse is.
On 6/17/2019 at 12:44 AM, spotangel said:Wow! That's a lot you are doing super nurse! Thank you for helping your patients in spite of all the work they throw your way! I have to stand my ground and ask them to put patients on my schedule if they want me to see them that day. I am not afraid to say no. I say it nicely though! When I am scheduled to attend interviews for new staff and they put pts on my schedule, I skip the interview as I can only be at one place at one time.It is a tough job but I am glad I can make a difference. Don't underestimate the good you can do where ever you are. It does sound like a lot for one LPN.
We don't have access all the time and sometimes I send pts to the ED or Urgent care the same day. If they can wait for one more day safely, I put them on the next available slot. Sometimes I speak to the doctor and overbook them if it is urgent but does not warrant an ED visit or is unstable for Urgent care like an asthma exacerbation.
I do work with some awesome medical assistants who help tremendously. The doctors I work with are also great, I can always discuss concerns and triage calls with them. Some doctors will allow overbooking if it is really necessary and a couple just can"t or wont. So I do have to use walk in and ED if not walk in appropriate more than I would like to.
Finally!! Someone who feels the same way I do at the end of the day! It’s a tough job! Rewarding but tough. I worked ER and trauma for 20 years half adult and the last half pediatric and also did pediatric flight. Those jobs ended at the end of shift. Clinic nursing continues on day to day you are never finished with everything. In addition 75% of my patients don’t speak English so communication is very difficult and we are a free clinic so resources can be scarce. It definitely takes a village. Keep on keeping on! ✌???
Sara! You are not alone. I wish there was a way to capture the time we spend especially with care coordination and translation and a way to ping each interruption that requires more of our time.Unfortunately, the attitude is that more and more can be done as our schedule shows empty slots and we must have a lot of "free time". The visits spill over the allotted slots between the 80 year old Spanish speaking patient who has the beginnings of dementia, is hard of hearing that has brought all his meds in a pillbox for med reconciliation , the 16 year old pregnant girl who lives in the shelter and needs WIC and the non compliant 35 year old man who feels that if he ignores his HbA1c of 14, it will go away! The reward is when you are working through your lunch hour but manage to get them the help they need and they are truly grateful that you care enough. At least I do have resources that I can hook them up with and for that I am truly grateful!
NotFlo
353 Posts
I'm a clinic nurse in primary care. Just an LPN but I'm the only nurse they have. I relate to a lot of what you wrote. I have, over the past few years, been burned by some patients who take and take and take. People I am up at night sleepless worrying about. People I have spent hours and hours for on the phone trying to help out. Finally I realized one day I can't fix everyone's whole life and I had to start setting some limits and start expecting people who are able to do some things for themselves. Personally, I would never give my phone number to anyone. I know someone who gave hers out a lot and she did end up getting texts and calls day and night and got so overwhelmed and burnt out.
I also envy the access your clinic has. My clinic has no appointments and I spend so much time struggling to get people in that need to be seen. I am happy to take a look at someone's wound or edema or take a listen to their lungs...but if I identify a problem I am left with a major dilemma with no way to actually diagnose or treat the patient as often their PCP just cannot see them for a same day.
I also have to be responding phone calls constantly all day and be available for the MD to do the shots, med administrations, wound care, ear flushes, spirometry etc that they need done during clinic. People on my schedule I have to keep moving as much as possible because the docs are waiting for me and so many people need phone calls. Everything documented in EMR of course. I also do a lot of prior auths, refills, all the home health referrals and communications (and they call a lot!) And write most of the docs letters and do all the FMLA etc paperwork that comes in. Also do all the ordering and stocking (down to the toilet paper and garbage bags) and manage the stare vaccine program and OSHA stuff.
So anyway yeah clinic work is definitely busy! A different busy than when I worked the floor but still busy.