In the press of caring for patients, family nurse practitioners (FNPs) must tend to a patient’s physical well-being and mental health. Caring for a patient’s mental status can be vital to meeting healthcare needs.
As primary care providers, FNPS play a significant role in tending to mental health concerns. The American Association of Nurse Practitioners (AANP) reflected that 88% of the nation’s NP workforce are certified in an area of primary care, with over 70% delivering primary care services, notes LaMicha M. Hogan, PhD, APRN, FNP-BC, associate dean/department chair for APRN Programs for the Texas Tech University Health Sciences Center School of Nursing-Graduate Program.
In this article, we’ll offer ways to ensure you’re attending to your patient’s mental health needs and touch on how FNP programs should educate students about mental health.
Great Impact
Though stigmatizing societal attitudes regarding mental healthcare have improved, a patient’s initial encounter with a healthcare provider will likely have the most significant impact on self-perception of a mental health complaint as well as willingness to seek continued treatment, notesHogan.
Early detection and intervention lead to the best outcomes, in conjunction with a trusting, collaborative rapport between the patient and FNP to reduce stigma present with having a mental health condition, according to Hogan. FNPs must be aware that a patient’s mental health status has a greater impact on chronic physical health conditions if undiagnosed or left untreated, she notes.
It’s imperative for FNPs, especially those in primary care settings, to prioritize the screening of conditions such as depression and anxiety, notes Amanda Ringold, DNP, FNP-BC, CRNP, SANE-A, assistant professor at the University of Pittsburgh School of Nursing. “To ensure effective mental health assessments, FNPs must address and overcome organizational barriers, including time constraints, a lack of a universal screening policy, and providers’ feelings of inadequacy in conducting mental health screenings. FNPs are poised to take on leadership roles within clinical settings to address and mitigate these challenges,” she explains.
Screening Strategies
Various strategies exist for dealing with mental health during patient care visits. For instance,
Ringold notes that not every screening needs to be done face-to-face with the FNP. Instead, screenings can be conducted with pen and paper in the waiting room or via an app before the appointment. She notes that other team members, including nurses or medical assistants, can be trained in administering the screenings.
Lisa Johnson, DrNP, CRNP, ACNP-BC, associate professor and DNP/NP Program Coordinator at Gwynedd Mercy University, agrees that patients can complete questionnaires in the waiting room or before the visit. However, “we have to be cautious not to fatigue patients with questionnaires and to ascertain their reading level and primary language prior to requesting a mental health assessment be completed by the patient,” she warns.
In an interview, Irene W. Bean, DNP, FNP/PMHNP-BC, FAAN, FAANP, FNAP, CEO of Serenity Health Care, P.C., and Tennessee State Rep for AANP, says to pay attention to a patient’s body language once in a patient encounter. Watch for poor eye contact or note whether a patient has been crying.
She says to pay attention to slurred speech and be aware of signs such as a patient who typically speaks loudly suddenly speaking in a whisper or a normally talkative patient now being reserved.
FNP Programs
Johnson says NP educational standards emphasize assessing mental health in varied patient populations. Healthcare providers and institutions of higher education need to focus on the cultural considerations of mental health disorders and further emphasize collaborative communication between primary care and mental health providers, she notes.
Hogan says clinical competencies are best attained via a competency-based educational model throughout the FNP curricula. Specialized courses on mental health, simulation training, interprofessional education, and clinical rotations in primary care settings can develop competence. She says that after graduation, FNPs should maintain continuing education specific to FNP’s scope of practice and evidence-based care for mental health concerns.
Ringold notes a growing trend of students at the University of Pittsburgh School of Nursing opting for dual FNP-PMHNP degrees.
Scope of Practice
While FNPs can treat mental health conditions such as basic anxiety and depression, they need to be mindful of their state’s scope of practice, says Bean. For patients with conditions such as bipolar disorder or schizophrenia, you may be stepping outside your practice scope and may need to refer the patient to a specialist, Bean says
“One thing that I would stress, and I stress to my students, is that you want to protect your license. You want to ensure the patient is safe while protecting your license,” Bean says.
Calling on Compassion
When you realize your patient is anxious, depressed, or dealing with a mental health issue, “What you don’t want to do is rush that patient from that conversation,” says Bean. “You’re going to miss a lot of things when you rush patients who have a mental health crisis through your clinic,” Bean says.
“You have to have compassion for patients dealing with a crisis. Their crisis may not be something you feel is a crisis, but to them, it’s everything. You can’t discount their feelings, and you can’t discount what you’re seeing in that patient.”
Are you the tech-savvy nurse on the unit? Do your colleagues seek you out with questions about the quirks of your electronic health record (EHR)? If so, consider turning that know-how into a career in nursing informatics.
A background at the bedside is critical for a successful nursing informatics role. “There’s typically some kind of clinical experience involved before jumping into an informatics role,” said Christy St. John, MSN, RN, NI-BC, CPHQ, president of the American Nursing Informatics Association (ANIA), in an interview. “To come straight from your studies into informatics is fairly rare.”
A combination of clinical nursing experience and education in informatics is essential, according to Melinda L. Jenkins, PhD, FNP, associate professor and director, nursing informatics specialty, Rutgers School of Nursing. Experience with patient care in the clinical setting is essential to the nursing informatics role because this role is the connection between the clinical setting and the technology piece of healthcare, says Lori Martone-Roberts, DNP, RN, CHSE, director of simulation and professor of the practice of nursing, Wheaton College.
Although training and hands-on experience with technology is important, Michael Mickan, chief nursing informatics officer at Memorial Hermann Health System, looks for experience using the tools on hand and a natural curiosity that leads to self-teaching. He feels that a nurse with that kind of informal experience is usually more successful as a nurse informaticist than those who wait to be formally trained before exploring a new technology.
Range of Skills
You’ll need to bring many skills to a nursing informatics role. Mickan outlines a variety of abilities:
Communications: Nurse informaticists must be able to provide “translation” of patient care, and clinician needs to technology partners as well as technology concepts and requirements to clinical users and communicate with various disciplines.
Problem-solving: Informaticists must be able to identify the real problem with astute observation and critical thinking encompassing people, processes, and technology.
Change management: Nurse informaticists must understand change management strategies and be comfortable facilitating, guiding, and managing change.
Project management: Often, a nurse informaticist facilitates collaboration between clinical and technology partners to solve problems and support the optimal use of technology. To do this effectively, proficiency in project management is a must.
Data analytics: Nurse informaticists must have a solid grasp of the data that validates the problems to be solved and provides the baseline for measuring progress.
Day-to-Day Projects
What kind of work will you do on a daily basis? An example, notes Martone-Roberts, could be to evaluate workflows or improve usability and streamline processes, leading to improved functioning and efficient data capture.
She notes that nurses in the nursing informatics role will work with EHRs in various ways, including managing information and troubleshooting issues when healthcare professionals use the system. Other projects involve training, validating, and reporting data and ensuring the collected data is useful.
She suggests that one example of a project could involve using chatbots to keep a patient engaged and decrease re-hospitalization. Similarly, Mickan outlines workflow analysis and optimization projects, working with clinical decision support systems and EHR implementation and optimization.
Growing Field
When it comes to future demand for nursing informaticists, “I see it as a growing sector,” says St. John.
“I think sometimes it’s a matter of being a little bit more broad in the way we think about nursing informatics,” she notes. Instead of simply searching for the term on a job site, a job search can be more about “opening my eyes to things that might include AI, analyst, or health informatics roles. I think nurse informatics roles will be more in demand in the bigger picture of health technology.”
Education and Certification
According to Martone-Roberts, you’ll need an RN and BSN to serve in a nursing informatics role. Also, she says, a nurse with a master’s degree in healthcare informatics, nursing informatics, or data management will be better positioned to succeed.
Although one of the more technical roles in nursing, nursing informatics still has patient care as the end goal. “At the end of the day, what we’re after is better outcomes for the populations that we’re serving, whether that’s in the inpatient setting, whether that’s in an ambulatory setting, whether that’s in our communities,” says St. John.
Basing your nursing practice on the latest evidence and research remains critical to providing optimal patient care. Practicing nursing based on tradition, “how we’ve always done it,” or outdated research can lead to poor patient outcomes, inappropriate care, or serious errors.
No doubt you studied evidence-based practice (EBP) in school, read it in journals or attended in-service sessions about using evidence in practice. You no doubt have every intention and desire to base your nursing practice on the latest research. But how can you do that when your days quickly spin into a whirlwind of patient admissions, procedures, and more?
In this article, we’ll offer a few perspectives and approaches on ways to help base your practice on the latest evidence. But first, a quick refresher on the importance of EBP.
The Importance of Evidence
“By integrating the latest and most robust evidence into our day-to-day nursing practices, as nurses, we ensure that our interventions are grounded on the most recent or latest advancements in healthcare and patient preferences and values, thus promoting safe, effective, and high-quality care,” according to Meredith Padilla, PhD, RN, CCRN-CMC, clinical practice specialist for practice excellence at the American Association of Critical-Care Nurses (AACN). “Moreover, EBP fosters a culture of continuous learning and professional development and elevates the standards of nursing practice. Additionally, a recent study reports that EBP culture and mentorship increase job satisfaction and intent to stay among nurses.”
Highlighting the importance of bringing evidence into practice, an entire field of research is now dedicated to determining the best methods and strategies (or interventions) for facilitating the implementation of research evidence in healthcare decision-making, including day-to-day nursing practice, according to Jennifer Yost, PhD, RN, FAAN, professor, M. Louise Fitzpatrick College of Nursing, Villanova University. She notes that this is commonly referred to as implementation science, knowledge translation, or translational science.
Culture of Inquiry
In bringing evidence to the bedside, nurses must cultivate a culture of inquiry, notes Padilla. “Asking questions is the initial step toward EBP,” she says. She suggests using the PICOT format (Patient/population, Intervention, Comparison, Outcome, Time) to frame the question.
Emphasize the importance of identifying and defining specific clinical questions that require EBP solutions and utilize the PICOT format guide to search for evidence.
Share a step of conducting a systematic and thorough review of the best available evidence related to the clinical question.
Have a common goal of the translation of evidence into clinical practice.
Emphasize evaluation of the implementation process and continuous improvement.
Tap your resources, Padilla says. Collaborate with a colleague, nurse leader, or interdisciplinary team member who can provide support and mentorship as you explore the evidence behind a clinical question.
Along those same lines, cultivating a culture of peer review and mentorship is pivotal, says Sandra Russo, PhD, RN, director of nursing and chairperson of the nursing program at Touro University. She notes that peer-reviewed journal club meetings and mentorship programs can provide a platform for exchanging knowledge and developing critical skills.
Access to Resources
Having easy access to EBP resources is key. Hospitals and healthcare agencies should support EBP by providing nursing staff with easy access to reputable nursing journals, online databases, and institutional access to academic resources, says Russo.
In addition, don’t neglect to consult your institution’s policies and procedures, says Pamela Barnwell-Sanders, EdD, MBA, MSN, RN, associate professor of practice at Egan School of Nursing and Health Studies, Fairfield University. She says that even if you’re performing a procedure regularly, you may discover that the policy or procedure has been updated to reflect the latest evidence.
Resources to help nurses identify the best available evidence, notes Padilla, include published clinical practice guidelines research databases like PubMed, CINAHL, and the Cochrane Library.
When it comes to searching for evidence, starting a search for the already-synthesized evidence (for example, systematic reviews or clinical practice guidelines based on systematic reviews) can improve search efficiency, according to Yost. Searching repositories of evidence syntheses (for example, Epistemonikos) and databases, such as PubMed, that allow one to limit searches to systematic reviews is also helpful, she says.
Continuous Improvement
As with most aspects of healthcare, analysis and feedback are critical. Regular audits of nursing practices are necessary to assess adherence to evidence-based guidelines, notes Russo. She says constructive feedback, recognizing positive behaviors, and addressing areas requiring improvement is the cornerstone of a continuous improvement cycle.
The nurse at the bedside should always be asking why, says Barnwell-Sanders. With a firm understanding of and grounding in EBP, you’ll have a solid knowledge of why a practice or procedure provides the best evidence-based care for your patients.
As in most things, getting off to a good start as a nurse can help ensure a long, successful, and satisfying career. With nursing shortages and nurse burnout still taking a tremendous toll on the profession, hospitals must do all they can to ensure new nurses have the tools to succeed.
Organizations help ensure success for new nurses through nurse residency programs, also called transition to practice or new grad programs. These structured learning experiences can be of great benefit.
readiness for practice improved significantly for nurse residents, as did nurse retention perceptions, indicating that nurse residents were more likely to be retained at the study organization. The 1- and 2-year nurse retention rates during the 3 years of the study showed notable improvement.
In this article, we’ll offer specific suggestions on what to look for in a nurse residency program so that you can find a good fit. But first, let’s look at when you should start investigating those programs.
Start Early
To discover if a nurse residency program is right for you, don’t wait until you pass your licensure exam. “Waiting until they pass their NCLEX many times is too late,” says Sheri Cosme DNP, RN, NPD-BC, director, Practice Transition Accreditation Program (PTAP), Advanced Practice Provider Fellowship Accreditation, American Nurses Credentialing Center (ANCC).
Nursing students should “use the time that they’re in school to start identifying those organizations that they want to work at sooner rather than later,” notes Cosme. Many programs start only two to three cohorts a year, so they have very specific recruitment timelines for when they accept applications from new graduate nurses, she says. “My biggest piece of advice to a new graduate nurse is not to miss that window.”
Cosme says to take advantage of your time at your clinical rotations and interview the facility. “That’s going to give them a good sense of what the organization is all about.”
In addition, Cosme suggests checking social media to learn what nurses say about the organization. Also, reach out to employees. You might also ask to speak to a nurse who has recently completed the program to find out how they balanced class time with working off-shifts, suggests Sara R. Grieshop, MHI, BSN, RN, practice excellence supervisor, American Association of Critical-Care Nurses. “Don’t hesitate to interview the programs as much as they are interviewing you,” notes Grieshop.
Make sure, says Cosme, that the organization has a specific plan in place for the program. For instance, the organization should tell you how much time you will spend with a preceptor or the milestones you need to hit to reach full competence.
What to Look for in a Nurse Residency Program
As you research nurse residency programs, consider the following areas:
Accreditation. Find out if the nurse residency program carries accreditation. As of mid-November 2023, some 250 programs in 831 healthcare sites were part of the ANCC Practice Transition Accreditation Program.
Accreditation helps ensure that programs provide a rich educational experience. “Accreditation validates that the programs are consistently following evidence-based standards that support nurses in their transition to nursing practice,” according to Christine Young, MSN, MBA, RN, NEA-BC, DNP, chief of hospital-based services and chief nursing officer, Akron Children’s Hospital.
Length of time. Cosme says a nurse residency program will run between 6 and 12 months. “A majority of the time, the programming is front-loaded,” she notes so that during the first part of the program, the nurse gets more concentrated professional development and support.
Seek programs that provide at least 6 to 12 months of program support and a preceptorship, which will help you acclimate to your intended specialty with a structured orientation and clinical training at the bedside, suggests Laura Douglas, MSN-Ed, RN, NPD-BC, CCRN-K, manager of the transition to practice programs (nurse residency, fellowship, and respiratory residency) at Memorial Hermann Health System.
While clinical orientation may last only 3 to 6 months, depending on specialty, a residency program supports the new graduate first through orientation, then through the initial phases of independent practice for up to a year, according to Young. Support into the second year is also ideal, she notes.
The nurse residency program should provide opportunities for participant feedback and evaluation, including regularly scheduled formal meetings to examine strengths and areas for growth, as well as provisions for individual self-assessment/self-reflection, according to Karen T. Pardue, PhD, RN, CNE, FNAP, ANEF, associate provost for strategic initiatives and professor, School of Nursing and Population Health, University of New England. Also, the program should dedicate attention to activities and interactions that build a sense of community and provide peer support, heightening the new employee’s sense of connection and belonging, she suggests.
Preceptorship. It would help if you were working with a preceptor, and ideally, one or two preceptors through the orientation phase of your residency program, notes Cosme. You should also check if you will have a mentor. While those two roles intersect, they provide different support, notes Young. The mentor, Young notes, could be a previous nurse resident who remembers what it was like to be a new grad in the specialty area they are working in and is willing to connect with the new nurse regularly to offer support, identify resources, and so on. The preceptor must evaluate the new nurse’s ability to demonstrate competency in practice and provide feedback during orientation.
Specialty experience. Determine if the nurse residency program will provide education in your specialty area, notes Cosme. If you’re unsure which unit is best for you, look for a residency program that allows you to work in various units, notes Grieshop. “This will allow you to broaden your horizons beyond what your clinical hours achieved,” she notes.
Never-Ending Learning
Nurses in a residency program, notes Cosme, should “be a sponge, soak it all up, wring themselves out, and soak up even more because they will be learning in nursing every day. I think the biggest blessing in healthcare is that things are constantly changing. We’re always learning.”
Read the January issue of Minority Nurse focusing on RN-to-BSN and Nurse Residency Programs here.
Burnout can steal the enthusiasm, satisfaction, and joy that prompted you to become an NP. It can rob you of the joy of caring and potentially deprive your patients of the care they need.
As a nation, the U.S. can ill afford to have NPs burn out. A national survey of U.S. adults conducted by the American Association of Nurse Practitioners (AANP) in April 2023 found that more than 40% of respondents have experienced a “longer than reasonable” wait for healthcare. In a press release, 26% of those surveyed reported waiting more than two months to gain access to a healthcare provider. NPs, notes the AANP, can help fill that void.
delivered by NPs and physician assistants (PAs) increased from 14.0% to 25.6%.
We’ll look at some factors that cause burnout and ways to prevent it from diminishing your enthusiasm or leaving practice entirely.
First, let’s take a brief look at the signs of burnout.
Signs of Strain
Burnout is characterized by emotional, physical, and mental exhaustion, notes April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the AANP. A practitioner can feel less valued and lose interest in their work.
You may have trouble sleeping, experience tension and stress, and potentially have prolonged feelings of depression, according to Sunny G. Hallowell, PhD, APRN, PPCNP-BC, associate professor, pediatric nurse practitioner, M. Louise Fitzpatrick College of Nursing, Villanova University.
COVID Makes it Worse
While blaming the pandemic for NP burnout would be easy, burnout was a phenomenon before COVID. “What happened during the pandemic is the phenomenon of burnout, which has been consistently well documented in the healthcare literature for decades before COVID. Those events were exacerbated by the pandemic,” according to Hallowell. “It was already there. It just got so much worse.”
One data point of burnout before the pandemic comes from a study conducted in early 2018, which examined advanced practice registered nurses, including NPs and PAs. It found that 59% of respondents experienced or formerly experienced burnout. The pandemic “really blew everything up,” says Kapu, the study’s lead author, published in the Journal of the American Association of Nurse Practitioners.
Forces of Stress
Besides the pandemic, unhealthy work environments can lead to burnout. In those environments, notes Kapu, staff shortages continue to take a toll, overtime may be needed, and there needs to be more opportunity for professional growth, development, or change.
Furthermore, the back-and-forth involving full practice authority for NPs may also cause stress. During the pandemic, various states provided temporary waivers allowing full practice authority for NPs. Since then, some states have reverted to reduced or restricted practice laws. This sends a “mixed message,” notes Hallowell, breeding mistrust, uncertainty, and confusion.
“In states that have moved to full practice authority, we’ve seen an increase in the workforce; NPs enjoy working there,” says Kapu. “We’ve seen those states move up in terms of overall healthcare outcomes. The top five states in the U.S. in terms of healthcare outcomes are all states where nurse practitioners can practice to what they’ve been educated and trained to do.”
NPs might also suffer from stress in dealing with inexperienced healthcare colleagues. “The distribution of healthcare delivery has shifted in such a way that we have a lot of inexperienced folks at the frontline now,” Hallowell notes.
“We need to create a structure to onboard and train and bring these new workers into the work environment, help them develop confidence in their skills, make sure that they’re competent in what they’re doing,” notes Kapu .” We’ve done this as nurse practitioners for years. We have onboarding, orientation, and training programs, and we support them through that so that they feel competent and integrated into the team. They have a supportive environment where they can reach out and ask questions as needed.”
Self-care is Key
When it comes to preventing burnout, tactics involve self-care, notes Hallowell. They include:
Rest.
Asking for help. Hopefully, you can call on experienced colleagues who can provide emotional support to offset the stress, demands, and mental load of patient care.
Requesting training. If you are doing something unfamiliar, ask for education.
Exercise.
Good nutrition.
Having interests outside the profession.
Socializing with friends and family
Mindfulness.
“We need to make sure that we recognize the signs and symptoms and then determine what will be our change,” says Kapu. “Do we need to work in a better environment? Can we help contribute to making our work environment better? What are we doing in terms of self-care?”
Addressing the exhaustion that can lead to burnout is similar to exercising a muscle, notes Kapu. “You work a muscle to a critical mass and then recover. That’s how it gets stronger. It’s the same thing with stress,” she notes, where some stress is good, but it may get to a point where you have to take time away.
“We have to give ourselves time to recover, to refuel, to constantly check in and say, Am I taking care of myself so I can bring my very best self to my patients?”
