Beyond the exam room

FigureNurse practitioners (NPs) are in a prime position to transform our ailing healthcare system into one that gets back to health and caring. We can make a difference with patience, persistence, and politeness. As nurses, our profession is not based on curing illness but rather on helping people find wholeness and health. NPs are making a difference in healthcare today, and we need to make that known. We see patients and give excellent, compassionate, high-quality care. But we need to do something beyond the clinical encounters and beyond the exam room in order to improve healthcare as well as to advance our profession. We need to be part of the bigger picture of healthcare. Collecting data There have been many studies demonstrating that NPs provide effective and high-quality healthcare.1,2 These studies have helped our profession grow and substantiate who we are, but we need to gather more data to show that the care we give, the relationships we build with patients, and the style of care we provide are making a difference. Collecting data about how we practice and the outcomes is a key way to show this. It does not mean you have to be trained as a researcher or even do a research study. Simply collecting some simple data can prove to be useful. Here is how I started collecting data: I have been working with patients on lifestyle changes as a way to avoid or reduce medication use for chronic diseases, such as hypertension, diabetes, and hyperlipidemia.3 Many patients do not realize that there is an opportunity to stop chronic medications if they make lifestyle changes. I keep a spreadsheet on my laptop to track the number of chronic disease medications I stop each day as well as the number of new ones I start. It is a simple process that takes just a few seconds. In the last year, I recorded 144 medications stopped and only 43 new ones started! This represents an outcome related to the lifestyle changes people are making. It is also a baseline number to compare with future years or with other providers. Start simple, but start doing something to measure outcomes for your practice. Tracking smokers Assessing smoking status has become a key component of the Patient Centered Medical Home (PCMH). We assess smoking status and are then supposed to counsel on smoking cessation and/or give a prescription (I believe the former is essential, even if the latter is done). However, tracking those who actually stop smoking is not part of the PCMH criteria. Smoking is a major health concern, and those who quit smoking have a big impact on health. Cessation data are rarely tracked these days. I have a column on my spreadsheet that lists the number of my patients who report having quit smoking. This may not be a daily event, and the numbers may not be large, but the impact of quitting is tremendous and deserves to be tracked. I also like to include a unique identifier for the patient so I can later go back and see if each patient sustained his or her cessation. In the last 12 months, I recorded thirteen patients who quit smoking–thirteen now former smokers living healthier lives. Our data can tell a story Our electronic health record (EHR) systems are constantly collecting data as well. Maybe you can find someone to help you generate a report to display some data about your practice patterns. We often receive quality reports, which show if we are screening certain patients for breast or colon cancer, measuring low-density lipoprotein levels and BP, or how many patients have reached a specific hemoglobin A1c goal. Consider exploring other data our EHRs can show us. For example, in my practice, I found someone who can run a report for me detailing the number of prescriptions I write per “user” or patient annually. She first ran the report 5 years ago, which was before I was emphasizing lifestyle changes as much with patients. She then ran another report of prescriptions per “user” from the past year. It showed a 45% reduction in prescriptions per user since implementing the lifestyle change program. This kind of data will get people listening. I was recently able to use EHR data to support the NP role. On April 29th, 2014, an op-ed was published in the New York Times entitled, “Nurses Are Not Doctors.” The physician author questioned the cost-effectiveness of NPs saying, “Nurse practitioners, though generally praised for being sensitive to patients' psychological and social well concerns, appear to order more diagnostic tests than do their physician counterparts.” He cited a 1999 study in the Journal of Effective Clinical Practice saying NP's patients underwent “more” ultrasounds, computed tomography scans, and magnetic resonance imaging scans than those assigned to physicians and had “25% more specialty visits.”4 I work in a practice of 46 providers: 17 physicians, 10 NPs, and 19 physician assistants. A quick report run from 2013 showed that, at least in our practice, NPs ordered diagnostic tests in 9% of encounters, compared with 12% by physicians. Referrals were 15% per encounter by NPs and 17% by physicians, and prescriptions were written by NPs at 59% of encounters versus 71% with physicians. This is real data that countered the “opinion” article in the Times. We need to use data to tell these stories! Sharing what we do Building relationships in our community is another way to advance healthcare and our profession. Share what NPs are doing and what you are doing with your community. Do you have a unique practice or service you offer, some remarkable outcomes to share (from your data collection), or healthy living tips or strategies you could share? Consider writing about it, perhaps for your local paper or a community newsletter. Maybe you could offer some type of class in your community or lead a health education event hosted by your practice or local hospital. If you or a colleague you know have received an award or accomplished something special, submit a press release to your local newspaper, TV, and radio stations. Writing a press release is easy, and you can find guidelines for writing them on the Intenet.5 Include photos if you have them. We need to shout out what NPs are doing. Writing an op-ed for your local paper is yet another way to share your message. Contact your local paper, or look online for word limits and other requirements for the op-ed. You do not have to be a professional writer or a well-known individual — only someone with a message. Op-eds are opinion pieces for the general public, not scholarly papers, so keep them simple, and you do not need to include references. Consider writing about a healthcare issue, ways to be healthy, things your community could do to improve health, or a piece of legislation that is being debated in your state or locality. Supporting the profession Finally, we all need to support our profession through our state and national organizations. We cannot do all that needs to be done for both healthcare and our profession, but we have member organizations that advocate, support, and represent us. I feel disappointed when I see that only about one-fourth of the NPs in my state are members of our state NP organization. On a national level, we now have one single organization that represents all NPs: the American Association of Nurse Practitioners (AANP). In the past, there were two national umbrella organizations, and NPs were often confused about which one to join. Through persistence, patience, and compromise, dedicated colleagues worked to form a single national NP organization about a year-and-half ago. This organization advocates for all of us and is working toward growing our profession and to improve health and healthcare in our country. We all need this organization, but even more, it needs each of us. Unfortunately, out of over 180,000 NPs in the country, only about 50,000 are members. If you are not a member of your state organization and of AANP, I strongly encourage you to join. The membership fee is reasonable and is one of the best investments you can make. Here is the link to join AANP: www.aanp.org/membership/join-renew-update. Imagine the power NPs would have if our organization could go to politicians, insurers, and patients to say they represent 180,000 NPs! Do your part by joining today. Your state and national organization need you. Invest in NPs It is not enough to be competent, compassionate, and caring clinicians. We must all be part of a bigger picture in healthcare. Look for ways, even small ways, to make a difference beyond the exam room. Consider ways you can collect and share data. Reach out to build relationships with your community. If you do nothing else, join your state and national NP organizations. If you are already a member, find a colleague who is not a member, and encourage that person to join. NPs are making a difference in healthcare today. Together, we can magnify that difference. Do something now to care for your profession the way you care for your patients so well, something beyond the exam room. Invest in our profession!

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