Careers in Nursing: An Interview with Nurse Practitioner Joyce Knestrick

Careers in Nursing: An Interview with Nurse Practitioner Joyce Knestrick

Many physicians’ offices, hospitals, and urgent care clinics often have nurse practitioners (NPs) working in them. Although it’s usually the patients who aren’t sure what this kind of nurse does, we know that some of our readers may not know as well—at least not all the minutia involved with this kind of job and career path. Considering that more nurses are choosing to become NPs, knowing this information is important—especially in helping you decide if this is where you want to go next.

We interviewed Joyce Knestrick, PhD, APRN, C-FNP, FAANP, a family nurse practitioner and president of the American Association of Nurse Practitioners (AANP), to learn more about what exactly a nurse practitioner is and does. An edited version of our interview follows.

What is a nurse practitioner and what type of work does s/he do? What additional duties and responsibilities are they able to do because of their additional education?

The first thing to know is that NPs provide primary, acute, and specialty health care to patients of all ages and walks of life. We operate in all types of care settings from hospitals to home care, and urgent care clinics to the VA.  NPs conducted over a billion patient visits in the last year alone. Many of your readers have probably seen an NP at some point, and we have developed a solid reputation of being close to our patients. The profession’s track record of patient-centered health care and outstanding outcomes have been well established over 50 years of research. NPs assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans—including prescribing medications.

NPs complete a master’s and/or a doctoral degree program, along with having completed advanced clinical training beyond their initial professional RN preparation. If an NP wants to go on to specialize in an area of care, it requires additional education and training.

With over 234,000 NPs across America, each having to undergo rigorous national certification, periodic peer reviews, clinical outcome evaluations, as well as adherence to a code for ethical practices, we’ve quickly become the primary care provider of choice for millions of Americans from rural areas to dense urban ones. About 16% of the profession works in communities of less than 10,000 and over 36% work in communities with a population less than 50,000.

Are there currently any barriers to practicing as a nurse practitioner? If so, what are they?

Yes, there are several barriers to practice for NPs all across the country. Currently, 22 states, plus the District of Columbia, allow NPs to practice to the full extent of their education, training, and licensure. While that may be over 40% of the country, AANP believes every state should enact laws enabling what we call “full practice authority.”

Every state is unique with its own set of public policy and political challenges, but we are committed to removing the barriers between NPs and their patients by drawing on the expertise of NPs who serve at the intersection of health care policy and patient care with the goal of achieving better health and improved access to care, at a lower cost.

We’ve identified several states as priorities this year. Any of you readers who are interested in helping to reduce barriers to practice for NPs should visit and look for our state policy guide.

To make it easier for people to understand many of the nuances surrounding the FPA issue, we’ve assigned each state a color (see our map here).

Green states, which we’ve already mentioned, allow NPs to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications and controlled substances—under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and National Council of State Boards of Nursing.

Yellow states are called “reduced practice states,” and they reduce the ability of an NP to engage in at least one element of NP practice. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care or limits the setting of one or more elements of NP practice.

Red states are called “restricted practice states,” and they restrict the ability of an NP to engage in at least one element of NP practice. State law requires career-long supervision, delegation, or team-management by another health provider in order for the NP to provide patient care.

There are many reasons why states fail to modernize regulations to enable NPs to practice to the full scope of their education and clinical training, not the least of which is pressure from organized medicine. That’s not to say that there aren’t similarities between yellow and red states’ barriers, but each state requires its own approach, and we actively identify legislation, support state-level NP organizations’ policy initiatives, and develop policy resources that cultivate strong NP leaders and sound health policy in every state.

What states are the best to work in as a nurse practitioner? Why?

Of course, any state colored green on our map will be more favorable to NPs than ones colored yellow or red. As the map demonstrates, western and northeastern states have chosen to enable NPs to practice to the fullest extent of their clinical training and licensure.

Why is it important for NPs to be able to practice fully? What do they bring to the health care table, so to speak, that benefits the health care system as a whole?

As clinicians, NPs blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management. We bring a comprehensive perspective to health care.

Yes, You Can Have It All

Yes, You Can Have It All

You can have it all. Decrease the stress in your life. Stop to smell the roses. Be in the moment. Great words of advice, but how does that happen? I don’t know about you, but I have found it almost impossible to accomplish! Almost.

I am the manager of a group of neonatal nurse practitioners in a level 3+ NICU of a large, urban Midwestern university hospital that provides care to an underserved population.  Yikes! Talk about stressors.

There are 18 women all ages, experiences, and personalities in our group. The question is: How do you create a cohesive, compassionate, supportive, and clinically excellent group of practitioners? Well, it took years of trial and error, strong faculty support, and the unexpected loss of our previous beloved manager—and then to find our feet again over the next three years. I hate it when people say “it’s a process.” Really? Of course it is, but it’s hard to see it in the beginning. We all want instant gratification, whether it’s from new sources, TV, retail, or work. I want it NOW! Yeah, well, that’s not going to happen.

First, you must have individuals of amazing talent, drive, personality, and intelligence. No short order for anyone. I’m not sure how we achieved this dynamic, but we did. Every person in our group is unique in their interests and skills. We foster and encourage the differences. We celebrate the differences. Thank goodness there are NNPs that are the ultimate in PICC insertion skills—not me! I will do anything for you if you get my line in—I will see all the other babies! (Just a note, my other procedural skills are awesome.) Thank goodness we have some young energetic women that love to go on transport. I am getting too old for climbing in and out of ambulances.

Second, you must have the unwavering support of the faculty of neonatologists. Without the clear dedication of the physicians it’s like fighting upstream in the spring run off.  I’m not talking about money or time off or even the gift at Christmas. I’m talking about standing for you and beside you to the bureaucracy of administration. We all face shortages of staff, long hours, and extremely difficult patient care situations, but when you know that the medical staff is with you—and you with them—it means everything.

Third, and most important, you need to see the problems that cause discord, anxiety, and anger within the group. In my first ten years here, the NNP group was growing in numbers and responsibilities, especially when we moved into our new, larger NICU. Often when a need arose in the unit the response was ”the practitioners can do it.” Sound familiar? Five years ago we unexpectedly lost our manager. This was a stunning blow to our group and unit. The next two and half years were a struggle as the section and department leadership changed, thus leaving the NNPs in limbo for their own leadership. In many ways the group was rudderless. We had no goal or focus. We reacted to the needs of the unit without any professional growth for any of us.

Last, you must have a manager/leader who believes. Believes in themselves, the members of the group, the faculty, the staff nurses, and staff support members. I know it sounds hokey, but it is absolutely essential. When I became the manager, I held a dinner at my home so we could come together as individuals to talk, laugh, cry, and plan.  I met with every practitioner to discuss their goals, aspirations, and what they wanted from me as the manager. Since we cover the unit 24/7/365, the NNPs are never all together at an event. I insisted that the NNP group have an annual retreat so that we could all be together to continue the discussion for our group. With a facilitator, we identified several issues that had been troubling us for many months. We designed a plan to address these issues. We also affirmed our commitment to each other as colleagues and friends.

We continue the “process” to grow and change. But it is not all the big stuff, the retreats and meetings. It is the seemingly small things, like making our collective office a little more cozy, posting funny and inspiring quotes, putting a seasonal wreath on the office door for all to enjoy, and remembering that this is our job, not our life. We are not always perfect, but we strive to be. You can have it all — just not all the time.



How to Deal with a Traumatic Situation at Work

How to Deal with a Traumatic Situation at Work

At some point in every nurse’s career, they will experience a traumatic situation such as a hemorrhage, code blue, or even the death of a patient. It is important to know how to deal with the aftermath of this type of event so you can begin the healing process. Failing to take care of yourself or pushing away emotions could lead to burnout and potentially end your nursing career. Here are a few tips on how to process and recover after a traumatic situation at work.

1. Debrief with your coworkers.

During an emergent situation, your perception of the events that took place may be skewed due to adrenaline and anxiety. It is important to take time to debrief with others who were involved in the situation with you, so you can begin to process the situation. As you discuss how everything unfolded and begin to understand everyone’s role in the event, you will be able to process what happened. Be sure to address any questions or concerns you have about how or why things occurred the way they did.

2. Take time off from work.

After experiencing a stressful situation at work, ask yourself how you are feeling about returning to work for your next shift. If you are feeling anxiety or dread, it might be a good idea to take some time off. Talk to your managers about these emotions and see if they can help you to arrange some time off. Having time to process your emotions and refresh yourself will help prevent burnout.

3. Spend time with loved ones.

It is important to spend time with the people you love most after a traumatic event. You may not be able to discuss the details of what happened due to HIPAA, but you can express how you feel emotionally. Your loved ones will be able to comfort you and provide you with the support and space you need to begin healing.

4. Practice self-care.

It is always important to practice self-care, but it becomes absolutely necessary to do so after the emotional and physical stress of a traumatic event. Check in with yourself about the emotions you are feeling and what could help you to process and relieve them. For example, if you are feeling overwhelmed or anxious, try going on a walk or doing a workout you enjoy. If you are feeling physically or mentally exhausted, try getting a massage or taking a nice, warm bath.

5. Seek professional help.

In some cases you may not be able to work through the aftermath of a traumatic event on your own. It is perfectly normal to need additional help from a therapist. Ask your employer if they have reduced cost or even free therapy sessions for employees needing assistance.

It is important to remember that you are not alone and that at some point, every nurse has struggled in the aftermath of a traumatic event. Every day it will get easier and one day you will wake up and feel completely healed.

5 Tricks to Slash Your Sugar Intake

5 Tricks to Slash Your Sugar Intake

As many of us become more aware of what we should and shouldn’t be doing to improve our health and wellness, we’re continually searching for new ways to improve our diets, eat nutrient-dense foods, and cut out the bad stuff (We’re looking at you, sugar!). We want to maximize our energy so we can sustain our activity levels throughout the day, rather than having the quick surge of energy that sugary snacks or beverages give us, followed by the inevitable crash.

Although there’s no one-size-fits-all approach to nixing sugar from your diet and curbing a sweet tooth, there are some tricks to make the process less painful. Read on to find out how to cut back on this sweet substance once and for all.

1. Stay hydrated.

Sure, sugary drinks will temporarily put a little spring in your step, but a few hours later, you’re likely to feel a bit lethargic. Maintaining adequate hydration levels is essential to help your body function; even mild dehydration can leave you feeling sluggish. Rather than reaching for sugary sodas or fruit drinks, consider herbal teas or no-sugar sparkling waters like LaCroix or Polar. This way, you can drink great tasting beverages and stay hydrated without the extra sugar.

2. Watch out for low and nonfat foods.

In many cases, when a manufacturer reduces fat from a product, they increase the amount of sugar in it, so the products remain tasty—but, they’re not doing you any favors to reduce your overall intake of sugar. One example of this type of product is the low or nonfat, fruit-flavored yogurt, which can be a handy snack when you’re pressed for time. Instead, a better option is to buy plain yogurt and add fresh, antioxidant-rich fruits like strawberries and blueberries to it. You’ll have a filling snack, the benefits of anti-inflammatory superfoods, and you’ll forgo the added sugar.

3. Combine protein, healthy fats, and fiber for a power-infused meal.

Simple carbohydrates and sugars cause a surge in your blood sugar, then it plummets. But foods high in protein, healthy fats, and fiber keep your blood sugar steady, so you won’t experience such highs and lows in your energy levels. Plus, eating meals rich in protein, fats, and fiber will keep you feeling fuller longer, so you’ll be less likely to indulge in those donuts in the breakroom.

4. Bring healthy snacks with you.

When you’re in a hurry, but you’re hungry, vending machines are a quick and accessible way to satisfy an immediate need for food. However, with just a few minutes of preparation each day, you can bring healthier snack alternatives to work that will truly feed your body.

Not sure what to bring? Consider protein-packed hard boiled eggs, healthy fats like nuts and avocados, or vegetables with hummus. With time, you’ll begin to notice your tendency to reach for the sweets lessens, and your sugar cravings start to subside.

5. Take small steps towards change.

Going full throttle into a new diet is tempting. But, if things don’t go smoothly (which they often don’t), you may find yourself slipping back into old patterns. As a substitute for banning sugar from your diet all at once, pick one meal a day and make it a sugar-free meal—like a breakfast omelet loaded with fresh veggies. This nutritious meal will fuel your body and start your day off on the right foot.

If you fall back into old your old routine—no big deal! We all do it from time to time. Just restart your healthy habits the next day, and don’t be too hard on yourself. If sugar has been a mainstay in your diet for a long time, it’s going to take several weeks to months to get used to a diet without it.

On the Move: What It’s Like to be a Critical Care Transport Nurse

On the Move: What It’s Like to be a Critical Care Transport Nurse

When patients need to be moved from one location to another, and they’re in critical condition, every second counts. The transport team caring for them during these moves provide crucial care that can sometimes mean the difference between life and death. Today we celebrate them in honor of Critical Care Transport Nurses Day, held annually on February 18th.

Kristen PonichteraKristen Ponichtera, BSN, RN, CFRN, CTRN, CCRN, is a Critical Care/Emergency Nurse at University of North Carolina at Chapel Hill Medical Center. She knows firsthand the importance of being a critical care transport nurse. “As a transport nurse, no two days are the same. The job entails a lot of planning and preparation, as well as constant maintenance of didactic and clinical proficiencies. The ability to perform at a high level at a moment’s notice is a key element of the field because, for majority of the patient population, minutes matter,” Ponichtera explains.

After she spent years working in critical care and emergency medicine, Ponichtera became a critical care transport nurse because she says, “I was ready to expand my scope of practice and test my knowledge and skills to the fullest. Critical care transport nursing was the appropriate step. I then fell in love with the specialty.”

Like every health care position, critical care transport nursing has both challenges as well as rewards. “The biggest challenge of the job, which doubles as the most exciting, is to expect the unexpected. Every patient assumed under your care during transport is remarkably different from the last, and it is the responsibility of the transport nurse to be able to anticipate the needs of each individual patient,” says Ponichtera.

As for the best parts of the job? “The greatest reward of being a transport nurse is being able to give a patient and their family peace of mind by providing care marked by precision and exactitude when they are in their most vulnerable state,” Ponichtera says. “Practicing with autonomy and earning collegial respect is an additional reward in being a transport nurse. Finally, recognizing the impact made each day on the lives of patients and their families adds value to the career.”

If you are interested in looking into becoming a critical care transport nurse, Ponichtera says that “This is one of the greatest jobs in the field of nursing. Confidence coupled with humility are characteristics every transport nurse must possess, as our patients demand the best in care. But we also must recognize there is always more to learn. Luck is where preparation meets opportunity. Getting the right experience, asking the right questions, and never giving up are the ways I was lucky enough to get into this field, and I suggest you do the same.”

“Although small, the transport nurse community is always willing to lend a hand to those looking to break into the field,” says Ponichtera. “Seek us out and we will be happy to assist our fellow nurses in any way we can.”

4 Ways to Set Work Boundaries

4 Ways to Set Work Boundaries

Do you find that it’s difficult to separate your work life from your home life? Are you more accustomed to saying yes to people rather than no? Have you noticed that you often bring your work home with you in some capacity? If you feel like your work life is becoming indistinguishable from your personal life, maybe it’s time to rethink your boundaries.

Here are four ways to do just that.

1. Establish boundaries at work.

When you’re at work, what things make you feel frustrated, anxious, or overtaxed? Maybe you said you’d come in early, stay late, or take an extra shift when you didn’t want to? Take note of when negative feelings arise and the circumstances that may have caused them.

Next, think about the parameters you need to do your best work. These “parameters” are potential areas to consider for boundaries, and the feelings you experience when you disregard them are likely your body’s way of telling you to set some limits.

Then, examine how you’d feel if you’d made a different choice. Perhaps you’d have more time with your family or participate in the activities you enjoy. The boundaries you create for yourself in the workplace will make your job more enjoyable—give yourself permission to stick to them!

2. Acknowledge your limits.

When your profession involves caring for people, it’s easy to put others before yourself. But your abilities, whether emotional, mental, or physical, have limits. Acknowledge those limits, and don’t shy away from saying no if you’re stressed out, overwhelmed, or uncomfortable with something.

One way to know you’ve reached your maximum capacity is to think of your feelings on a spectrum, according to Dana Gionta and Dan Guerra, authors of From Stressed to Centered. The authors suggest rating your level of discomfort about a situation on a scale of one to ten. A rating of one to three tends to have a minimal effect on you, while ratings of four to six cause a medium impact on your emotions. Furthermore, a circumstance with a score of seven to ten will likely cause a high degree of distress. The authors recommend taking inventory of interactions or situations that produce a medium to high degree of distress and setting a boundary so that you can preserve your well-being.

3. If someone tries to push past your boundaries, discuss it as soon as possible.

Eventually, someone will push past the boundary—the safeguard—you’ve put in place for yourself. When that happens, try to address the interaction or circumstance at that moment, rather than waiting until a later time. If too much time passes, the person may not get the complete picture of your level of discomfort. But if you confront the situation as soon as possible, it can help you avoid unnecessary job drama and feeling overwhelmed, overworked, or resentful down the road.

4. Be mindful of your boundaries at home.

Sometimes, you may not be able to avoid bringing work home with you. But if that’s the case, try to stick to a planned schedule. For example, designate a specific amount of time to address work issues, then, stop when that time frame is up. While it may be tempting to ignore the timer, doing so can leave you feeling exhausted and drained.

As a health care professional, it’s essential that you honor the boundaries you’ve established for your home life as well, so you can feel refreshed and be at your best when you’re helping others.

Creating healthy boundaries doesn’t happen overnight; it takes time and practice. And, if your boundaries get a little off track now and then, you can always refocus your attention and reaffirm your commitment to the limits you set to maintain a healthy work-life balance.

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