FNP2writer

Not at all. There remains a shortage of providers nationwide. This existed before the pandemic and got worse after. Just make sure you do your due diligence on where you apply. There is likely a reason that one clinic is always hiring. And ALWAYS try to negotiate salary, whether it is in the form of more money or time off. Never forget your value.

I made the transition in 2013 from Planned Parenthood to primary care. There was a steep learning curve with the transition. You go from essentially specializing in reproductive health to the open universe of needing to know at least a little about everything in primary care. The expectations from patients are also different. They come in with lists of problems they want you to address in the 15-20 min visits, and can get frustrated with being asked to schedule additional appointments for their "oh, by the way" they bring up as you try to walk out the door. You will be challenged routinely with things they never taught you in school. I enjoyed my time in primary care, but it was stressful almost every day. I'm happy to be back working primarily with women in menopause care.

The price of higher education leads many new nurse practitioners to look for ways to pay down the debt quickly while gaining experience. Federally Qualified Health Centers (FQHC) through the Health Resources and Services Administration (HRSA) are a way of doing both. These health facilities can be in both urban and rural settings, typically in underserved areas. The goal of the FQHC is to provide services to people who may otherwise have difficulty accessing care. As a provider working in a rural site for over eight years, I can tell you it is rewarding to serve these communities. However, working in a rural location is not without some challenges. Here are some things you should know when considering a rural FQHC job site. Staffing Staff turnover in the FQHCs can be high. Frequently, medical staff seek out these positions solely for the benefit of loan repayment and do not intend to establish roots in the communities. They leave as soon as their service for the repayment is satisfied. This can create a revolving door of providers, nurses, and behavioral health staff. High staff turnover leads to significant patient dissatisfaction. Think about how often you see your provider. If you are healthy, likely just once or twice a year. So imagine if you see your provider a handful of times, then they are gone...again. When there is a lot of staff turnover, the patients constantly have to introduce themselves, explain their conditions, and decide if they like the new person sitting in front of them. For my first few years, patients regularly asked if I was sticking around. Be mindful of this when choosing where you may want to work. It is not only the medical staff that sees high turnover. Support staff, such as billing, front office, and medical assistants, may be hard to come by, especially in rural settings where people with the qualifications are limited. As a provider, you quickly learn good support staff in place affects how well you can do your job. Don't forget illness among staff. If the clinic only has 2-3 providers and one calls off sick, you are going to have a very busy day. If illness occurs when someone is out on vacation, the clinic may be left with no provider. Does the idea of that trigger a stress response in you? It does in me! When looking at potential rural sites, make sure you are considering how well the clinic is staffed. Talk to everyone you can to get a feel for the turnover. Specialists Working at a rural clinic may mean not being connected to a larger hospital system or medical group. These can be stand-alone clinics in remote locations with a two-hour drive for a patient to see specialists. Specialists may be booked out for months. Yes, months. These wait times have worsened following the pandemic due to backlog, ongoing outbreaks of illness, and staffing issues. Providers are left managing potentially complicated patients on their own for months at a time. Another consideration is the patient who is unwilling or unable to see a specialist due to the distance. The boost to telemedicine during the pandemic reduced the need for some long trips just for consultations but not for treatments. The key here for new providers is the ability to forge relationships with colleagues to help guide your work so you can better care for these patients. You are their safety net. Patients As the only clinic for many miles, you will see anything and everything that walks through the door. Living in rural Oregon, injuries related to fishing, construction, hiking, and the rogue chainsaw is not unexpected. Patients in these rural areas tend to be hard-working and used to some level of injuries. Many times they may not come in unless things are bad - such as an amputated finger from the slip of a circular saw, or with orthopedic injuries they have long ignored and now have retracted muscles to show for it. As there may not be another clinic for miles, providers in these settings will likely also see many staff members. In these rural areas, you will get to know everyone's business. Opiates and Addiction Anyone well versed in the opiate crisis knows rural communities where physically demanding jobs are the norm were hard hit with the opioids. The tide is turning, but many patients still struggle with this. You will find patients are still on some form of opioids for long-term pain management or due to addiction. Knowing how to prescribe treatments and a willingness to do so is still needed in these communities. Alcohol abuse is also common. Pain management clinics and rehab facilities can be hard to come by. Benefits The benefits of working in a rural setting go beyond just financial for someone who likes this type of work. The commute is much less stressful than in an urban area. A slower pace comes with living in a rural setting, which can be a change of lifestyle. If your goal in choosing to work in family medicine is to treat whole families, you will not be disappointed. If you are looking for the sense of community gained from providing care to your neighbors, the grocery clerk, and the woman who does your hair, a rural site can be quite appealing. Nurse practitioners are filling the gaps in these communities where doctors have become scarce. The patients appreciate the difference in care nurse practitioners provide. The work presents some challenges but is also satisfying and rewarding.

One of the best pieces of advice I received regarding salary as a new grad came from a mentor who told me always to negotiate. I reminded the same mentor of this advice when I applied for a job at her organization. The advice served me well as I negotiated a higher salary for myself, which triggered a salary increase for all of the nurse practitioners in the company because they were unionized. As crucial as salary is, there are other ways to get compensated for your value. Most nurse practitioners know to ask for salary and loan repayment benefits when negotiating a new job contract. But these are not the only perks you should bargain for. Here is a list of five other benefits you should consider when negotiating a new job offer. Vacation and Paid Time Off Most companies have a set amount of paid time off based on years of service. However, like so many things this is a guideline and not a rule. Asking for more vacation allows you to take time off to refresh your mind or spend time with your family. Paid time off is valuable not only for your mental health but also for your pocketbook. Consider paid time off free money as you get paid for not working. For example, four weeks of vacation is an entire month of salary without any work and is essentially a boost to your salary. Continuing Education We all need continuing education to keep licensure and education up to date. Continuing education dollars and time off to spend those dollars are common perks you need to ensure are included in your contract. When education benefits are offered, take the time to review these perks to ensure you are not getting shortchanged. Administrative Time Getting paid to keep up on the endless chart notes, phone calls, refills, and emails should be standard, but frequently is not. Anyone who has spent hours at home trying to catch up on work understands having administrative time is one of the most valuable benefits. More companies are recognizing this and including admin time in their offer. Make sure it is in yours. How much should you ask for? Admin time should be based on patient load. A new provider may need just two hours a week. A provider with a full panel likely needs more. Asking for a little time every day is reasonable. Hours Are you a morning person? Do you like working just three days a week? Need to be off every Wednesday for your child's soccer games? Many clinics need to cover hours outside the standard 9 to 5. Use this to your advantage to get a schedule that works best for you. Call Taking call may seem like a difficult area to negotiate as call is a common expectation for many clinics. Aspects to ask for include pay for the call time, frequency of call, and taking call for other clinics. Ensure you know how many providers the call covers as this can provide leverage for the bargaining. Negotiating for benefits can be stressful and uncomfortable. However, it is easier to hammer out details at the start of a new position than go back when you realize things are not going well for you six months or more down the road. The most important thing to remember is that you are advocating for yourself. No one else will do this for you, so make sure you end up with something you are happy with in your contract. Determine what is most important for your work-life balance and fight for it.

Congrats on the engagement! Changing your name will always be challenging as it is expensive and time-consuming. I know many nurses who kept their maiden names due to this. If you are set on wanting to change your name and are considering eloping, I suggest doing that.

I have a patient I am confident has bladder cancer. They first came to me when their urine turned dark red, and they could not urinate without self-catheterizing. I have explained my concerns to this patient multiple times. Unfortunately, their response is staunch disbelief that cancer could possibly cause their symptoms. Instead, the patient remains convinced their symptoms are a side effect of the single dose of the COVID-19 vaccine they received two years ago. The basis for this belief is information regarding the harmful effects of the COVID-19 vaccine the patient read on the internet, saw on television, or heard from peers. None of this information comes from a medical professional. Any evidence I present contrary to the knowledge the patient gained from these sources is immediately dismissed as if I am too ignorant to understand the medicine I practice. This is just one example of the alarming effect of social media and misinformation disseminated by traditional media on patient care. Daily, patients say to me, “I’m not a doctor, but I did some research online.” Countless patients have come to me asking for prescriptions for ivermectin and are angry when I do not provide what they want. I never discouraged patients from using the internet as a tool. However, I do encourage the use of reputable websites and guide them to sites with accurate information, as this can help guide informed discussions regarding their care. Patients turning to the internet for medical advice is not new, and neither is “fake news.” Since the inception of the first medical websites in the 1990s, people search the internet for answers to their health concerns. The internet, as a source of all information, is constantly growing relatively untethered. This includes information with a questionable basis in fact. Ideas once considered fictional, outlandish, or conspiracy theories found in supermarket tabloids are now accepted as mainstream. Healthcare is not immune to conspiracy theories treated as factual information, which has led to growing mistrust of healthcare professionals. Widespread mistrust of healthcare can be traced to the beginning of medicine and seen with the long-term trend of vaccine hesitancy, which goes as far back as the inception of the smallpox vaccine. Unfortunately, with the pandemic, the effects of misinformation found online and presented by the media have widened the distrust patients have regarding medical care overall. This makes providing the highest quality of care to patients difficult across all aspects of medicine and puts the lives of patients at risk when they doubt or refuse to accept evidence-based health care. When the pandemic started, the idea of “fake news” was already ingrained into much of the population. The pandemic provided the perfect storm for distrust and misinformation to take hold, spreading like wildfire. The efforts to control the spread of the COVID-19 virus led to major changes to everyday life, affecting the entire world. As the impacts of the changes challenged “normal” life and led many people to struggle, mistrust of health professionals moved to an all-time high. Videos were posted online by people at hospitals trying to dispel the fact of the locations being overwhelmed. Dangerous treatments like the ingestion of bleach became touted as cures. Rumors spread that health professionals received payments for every patient they could get a positive COVID-19 test on. Misinformation continues to be so rampant that reputable medical sources like the World Health Organization, The Centers for Disease Control and Prevention, Mayo Clinic, and Johns Hopkins continue to post and update information regarding the myths surrounding COVID-19. Unfortunately, with the increasing distrust of what is traditionally regarded as acceptable sources of healthcare knowledge, patients are no longer willing to consider these sources as reliable and continue to turn to internet videos and online advice from questionable sources. Pew Research indicates trust in medical professionals dropped from 89% in April 2020 to 78% in December 2021. As healthcare providers, the frustration we experience when patients come to us with questionable science and doubt what we know to be sound becomes burdensome. The problem lies in how to turn this around to keep patients from causing more harm to themselves. Research published in Health Psychology revealed people with lower education levels, interest in alternative medicine, and existing distrust of healthcare are more likely to believe medical misinformation such as ineffective cancer treatments and false information regarding vaccine safety. The researchers found participants who accepted one source of inaccurate information were more likely to believe additional sources of misinformation. There is no easy answer to the pervasive misinformation and “fake news.” Nurses remain the most trusted profession, and we need to use this to our advantage. Continue to educate with factual information. Provide compassionate patient care in ways that continually build and grow that trust. As always, we will not be able to save everyone. But the ones we save will be worth the effort. References/Resources Americans’ Trust in Scientists, Other Groups Declines Education level, interest in alternative medicine among factors associated with believing misinformation

There are never enough admin hours. I am granted 2 hours a week and had to fight for those. Admin hours are becoming more popular as a "benefit" to ask for when negotiating the job. It is reasonable to ask about this when interviewing or when talking with other staff.

Great article Delta! Look forward to reading more from you.

I routinely talk with patients about what they do for their physical activity, and walking is a frequent response. However, the amount of walking my patients report is highly variable. I had one patient tell me they get up to open the door and let their dog out. Conversely, I have patients who walk up to 4 miles every day. Most of my patients fall somewhere in between this range. Commonly, people, these days have the goal of walking at least 10,000 steps every day. This number is so common that many of the wearable devices we use for tracking fitness have this number preset as a fitness goal for the wearer. But where did this mythical number come from, and is it really what the goal for improved health should be? Where 10,000 steps came from Many sources point to the Japanese company as the source of the 10,000 steps. The Yamasa company released a pedometer in 1964 with the name Manpo-kei. Translated this means "10,000 steps meter". When Fitbit launched in 2009 the company chose to promote 10,000 steps as a fitness goal because this number satisfies the recommendation by the Centers for Disease Control to be physically active for 150 minutes a week. With the popularity of Fitbit, many of the other wearable devices also took up this fitness goal. However, recent research is showing that 10,000 steps may not need to be the standard. Studies reported in JAMA Internal Medicine and Nature Medicine indicate walking 10,000 steps daily is not based on any proven research. Researchers in these studies looked at how many steps are really needed to maintain health. Decreasing mortality Harvard researchers published a study in the journal JAMA Internal Medicine in May 2019 that looked at the connection between the daily number of steps along with the intensity of steps in relation to the causes of mortality in older women. The researchers found that, on average, 4,400 daily steps decreased the overall risk of death in older women. This risk reduction continued to improve with the more steps taken. Researchers found the benefits of walking leveled off at about 7,500 daily steps. The researchers also found the level of intensity involved with walking did not have a significant impact on risk reduction. Preventing chronic disease A more recent study published in the journal Nature Medicine in October 2022 looked at the role daily steps play in chronic disease. This study was not explicitly aimed at women's health, but the majority (71%) of the participants were women. Researchers found the number of daily steps taken directly related to several chronic health issues. Low step count contributed to: Gastroesophageal reflux disease Diabetes Hypertension Obesity Sleep apnea Depression The more daily steps taken correlated with a lower risk of developing these chronic health issues. The findings indicate the optimal number to ward off these chronic diseases is about 8,200 daily steps. Unlike the Harvard study, these researchers did find the level of intensity of the activity also affected the risk of developing chronic diseases. Keep on moving Staying physically active and keeping the body moving has long been known to improve overall well-being. These studies help define the range of walking needed to optimize health by reducing the risk of chronic disease and death. Walking 10,000 steps may not need to be the ultimate daily goal, but the amount of walking should definitely be more than just letting the dog out. Walking is a great low-impact activity that can be done by most individuals almost anywhere. So get up and go for a walk. Your life may depend on it. References/Resources Association of Step Volume and Intensity With All-Cause Mortality in Older Women Association of step counts over time with the risk of chronic disease in the All of Us Research Program Why is 10,000 steps a day the goal? Fitbit's CEO has some answers

I worked at PP in Oregon for several years both as an RN and then as NP. They do take new grads. It is a great place to work in reproductive health. Salary and benefits are going to vary by each state as some locations are unionized.

US News and World Report recently reported a sharp increase in the number of teenagers seeking more reliable forms of birth control due to the overturning of Roe versus Wade by the Supreme Court. As many states change laws banning or severely restricting abortions, teens just do not want to risk an unplanned pregnancy with the use of less reliable birth control methods. Additionally, the US News article also notes teens and young women are concerned about pregnancies from sexual assault or rape because their state may no longer allow abortions in these instances. As health care providers, we know teenagers' bodies are still developing and carry a higher risk with pregnancy. We can provide a valuable role in counseling teens on the most reliable birth control methods available, known as LARCs (long-acting reversible contraceptives). What are LARCs? There are two types of LARCs currently available in the United States, intrauterine devices (IUDs) and the single-rod implantable device. These forms of birth control are frequently referred to as “forgettable methods” as there is nothing routinely done by the user to keep them effective. This lack of daily or weekly maintenance of the birth control method is why the LARCs are considered more effective than other methods. Once placed, these methods provide dependable birth control for 3-12 years, depending on the method, with greater than 99% efficacy. IUDs IUDs were first introduced in 1909 and have undergone many design changes to the highly effective, safe options in use today. The current devices available are all T-shaped and are either hormonal or non-hormonal. IUDs are placed in the uterus through the lady parts by a trained medical provider, including midwives and nurse practitioners. The hormonal IUDs release levonorgestrel which prevents pregnancy by significantly increasing the amount and thickness of mucous in the cervical canal, making it nearly impossible for sperm to penetrate. The four IUDs available release different amounts of levonorgestrel which affects the duration of use: Mirena - 20 mcg per day is FDA approved for five years of use Kyleena - 17.5 mcg per day is approved for five years of use Liletta - 18.6 mcg per day is approved for four years of use Skyla - 14 mcg per day is approved for just three years due to its smaller size The amount of the levonorgestrel hormone released daily with these devices is small, but some women will still experience side effects of the hormone. These include: Headaches Nausea Mood changes Breast tenderness Ovarian cysts Decreased menstrual bleeding The Paragard is the only non-hormonal IUD. The device is made with copper, and the copper itself is the birth control. It works by decreasing sperm mobility keeping the sperm from reaching eggs. Because it does not contain hormones, women do not experience negative hormonal side effects. However, the Paragard has side effects of its own. Commonly women using the Paragard will experience heavier menstrual bleeding and cramping. This device has FDA approval for ten years of use, but is shown to be effective for up to 12 years of use. Complications with the IUDs are uncommon. Risks include pelvic infection, expulsion of the device, failure of the method, and perforation of the uterus. None of the IUDs induce abortion. Implant The implant is considered the most effective method of birth control as it cannot be forgotten or accidentally removed. Hormonal implants were first developed in 1966 and, like the IUDs, have gone through design modifications. The current devices are Nexplanon and Implanon. They consist of a porous vinyl rod encapsulating etonogestrel. The porous nature of the vinyl rod allows the release of the hormone slowly over three years. The implant prevents pregnancy by suppressing ovulation and possibly some thickening of the cervical mucus. The matchstick-sized device is placed subdermally in the upper inner arm. Like the IUD, the implant must be inserted by a trained medical provider. Unlike the IUD, providers are required to go through training from the manufacturer before inserting or removing these devices. Complications with insertion and removal are very rare. The commonly reported side effects include: Changes in menstrual bleeding GI upset Headache Breast pain Vaginitis LARC methods have few contraindications and are safe to use. With their high efficacy and low risk, the LARC birth control methods are ideal for helping teens and young women prevent unplanned pregnancies. As healthcare providers, we are in a unique position to help educate teens and young women on these highly effective birth control options and can guide teens and young women in making informed decisions regarding their reproductive health. Additional information regarding reproductive health to help guide your counseling is available through the CDC. References Teen Interest in Long-Lasting Birth Control Soars After Roe Long-Acting Reversible Contraception: Implants and Intrauterine Devices