Transcription:
Life as a New Graduate Advanced Practice Provider

Trisha Williams: Hi guys. Welcome to the third season of the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien: And I'm Toby O'Brien. This is a podcast created by advanced practice Providers for advanced practice providers. Our goal is to provide you with education and inspiration. We will be talking with pediatric experts on timely key topics. And giving you an inside look at the various advanced practice role at Children's Mercy.

Trisha Williams: We are so glad that you're joining us today. So sit back, tune in. And let's get started.

Today, we are pleased to have Natalie Heim joining us. She is a pediatric nurse practitioner in the emergency department here at Children's Mercy. We're gonna spend some time talking about transitioning from being an RN to an APRN and her life in the ED. Hi, Natalie. Thanks for joining us.

Natalie Heim: Hi. Thanks for having me.

Trisha Williams: Can you tell our Listeners a little bit about yourself?

Natalie Heim: Yes, I am a nurse practitioner in the emergency room. I started my nursing career about five and a half years ago as a nurse in the emergency room, actually at Children's Mercy. I graduated from the University of Arkansas and then wanted to come up to Kansas City, knew I wanted to do pediatrics, and kind of fell into emergency medicine on accident. Never would've thought that that's where I would land, would've thought that it was too intense.

But that's kind of the job that I got presented when I was a new grad nurse and then ended up hanging around there, saw some of the amazing nurse practitioners that I worked with, and kind of learned more about their role. And then over time just was able to see how they were able. Patients lives better and improve care and make plans. And I was interested in their line of work and realized that I could go back to school and do the same thing. So went back and got my masters from UMKC, and then when I graduated, landed back in the emergency room as a nurse practitioner.

Tobie O'Brien: Oh, well we are so excited that you did that and to be talking with you today. So tell us a little bit about so you worked in the ED as a nurse, and then you got your masters, and now you're back in the ED as an advanced practice nurse. So can you tell us a little bit about that transition for you from becoming an RN to an APR and you did it within such a short amount of time. So tell us a little bit about that experience for you?

Natalie Heim: Yeah, so it was a, pretty big learning curve. I would say one of the hardest transitions when you go from nurse to nurse practitioner is just the way that you have to think about problems, changes. When you're a nurse, you have to do constant assessments and you're continuously checking on the patient. And when you're the nurse practitioner, you're kind of anticipating the care and putting in the orders and what comes next and consoling some of the parents and what their concerns are. So your thought process really changes.

Since I stayed in the same department that I was a nurse in, I felt like was able to observe a lot of the different plans of care that different nurse practitioners and even physicians were able to come up with. And that kind of helped me understand the thought process of becoming a nurse practitioner. But it's definitely a different thought process from when you're a nurse, cause you're just thinking about different outcomes and thinking about, okay, if this is true, then what does that mean next? And you have to look through things from a different lens. And I feel like that's one of the hardest parts of switching your brain off from nurse mode onto this futuristic thinking kind of mode.

Trisha Williams: Yeah, like developing that list of differential diagnoses and then coming up with what, assessment tools we could use or diagnostic testing to rule out those differentials to come up with an actual diagnosis. Yeah. I've had a very long nursing career, and I found it when I transitioned, like the hardest thing was I was an expert at the top of my level as an RN. And then going to an APRN, I was now back at a novice level. And being an adult in a career for such a long time to be back to a novice was a big transition. Did or have you found that to be difficult kind of to your psyche and what have you done to kind of help curtail that thought process?

Natalie Heim: Oh, definitely. I mean, exactly to your point. You go from being this expert in one area where you're fairly comfortable with your nursing job, you know what your roles and expectations are to a totally new career, and you're a novice at best. I mean, there's a lot you don't know. So I think for me, what helped a lot, especially staying in the same department, is approaching that new role with a lot of humility and knowing that I wasn't gonna get it right a hundred percent of the time.

And knowing my resources, knowing when to ask for help and just kind of realizing that, okay, you knew how to do your nursing job, but now you're in this new role and you're not gonna know every answer to every question. And some really good advice I got actually when I was a nurse, but it applied even more when I was a nurse practitioner. The only time you're gonna be dangerous is when you think you know everything. And so if you ever get to a point where you don't know something, not being afraid to ask questions, and then that way you learn.

And I'm lucky, I work with a lot of really good peers that have helped me and taught me some really good tricks. And you don't know what you don't know, so being able to seek out their opinion and get more information and realize that it's okay to not know everything right at the beginning. And just, like you said, kind of humbling yourself and being willing to ask questions and admit if you've made a mistake.

Tobie O'Brien: Oh, you're so wise for being so new. So I love all of that advice.

Trisha Williams: Yeah.

Tobie O'Brien: I love that. Can talk about the APP fellowship program? We have had Kathy Cartright on and we love chatting with her, but will you tell us your experience? I understand that you recently did complete the APP fellowship program because that is something that I believe all new APPs that at are new graduates at Children's Mercy do this APP fellowship program. So can you tell us about that?

Natalie Heim: Yes, so exactly what you said, everybody that is a new nurse practitioner gets automatically enrolled in the fellowship program and it ends up meeting about once a month for four hours, and it's basically a group of other new nurse practitioners and you get to. Meet and kinda learn different ins and outs of the hospital. So at the beginning of every session, we would meet with the Center for Wellbeing and we would learn meditation tips and coping with the new job. And we actually would read a book together and we would go over tips to help in a new role and workplace stress.

And in addition to that, we would meet with experts in the field of legal and experts in the field of. Different practices and they would help give us tips to help apply to our practices so that we could try to learn some tips and tricks and ins and outs of the hospital. And also got familiar with some of the resources that were available to us as new nurse practitioners. And then one of my favorite parts about it is obviously you get to connect with different colleagues in different fields and have a friend that you can call on if you know I know somebody from surgery clinic and then I need something from them. Like having a face to the name and being able to say, oh, hey, we hang out once a month for four hours. Don't you remember me? It's nice just to have that comradery.

Trisha Williams: Well, it's good to have that collaboration too. Like, oh, I have a surgery question. I have a postop kid in the er. Call that person for that collaboration. Yeah, that's fantastic. I think at Children's Mercy we're so fortunate to have a lot of resources available to us as APPs, that I think other institutions would really benefit from and maybe could reach out to us for the tips on the fellowship program and the, academy for professional development. And I think we're very fortunate.

Natalie Heim: Yeah, it definitely helps make some of those transitions smooth.

Trisha Williams: Absolutely. A couple of episodes ago we had the privilege of talking with, a UMKC faculty member about ways to help students that are in a APRN school or new graduate, a seeking jobs at Children's Mercy and how to help them be successful. Are you able to shed some light on your feelings in ways as a new nurse practitioner, how seasoned APPs can help newer nurse practitioners grow in their role and become better and to help facilitate their learning experience.

Natalie Heim: Yeah. So I think the most important thing is remembering when you yourself are in that role, because especially when you're walking into clinical rotations, you're walking into an office and you don't know who anybody is, you don't know their expectations, you don't know their personality, and so you're kind of walking in not knowing what to expect. So remembering how intimidating that can be. And then I always appreciated so much when either my preceptors or my peers that I work with saw unique things and then sought me out to teach me.

Because it goes back to that you don't know what you don't know if you've never seen some sort of weird skin rash, and then here it is and someone in clinic has it, and you're able to see that. That helps you connect the dots. And anytime someone does that knowledge sharing, they introduce you to something new that helps you become a better nurse practitioner as well. So I always appreciated when people would reach out to me with unique cases or unique opportunities because that just helped me learn better, and then it helped me feel more included in their group and their practice, and helped me feel like they valued my learning as well.

Tobie O'Brien: Absolutely. Those are really good points. Can you think about any like specific experiences that you remember that you were like, oh, this was like an aha moment in my, like when I was a student that really made a difference and helped you in what you're doing now?

Natalie Heim: Yeah, so the, one of the trickiest things I always feel like for students is the otoscope exam. That's just always so hard for nurse practitioners to get down when they're first starting out. So I had one preceptor that really pulled me aside and took the time to show me how she was able to pull back the ear and barely even had to insert the otoscope to get her exam done. And then it was way more tolerable for the child. And that was so helpful to me because obviously that's just intimidating when you feel like you can't nail that skill and you're embarrassed to ask because it's such a common skill that you feel like you should have.

So I really appreciated her taking that time out to slow down in the clinic and show me her trips and tricks of how to do that. Another time was when I was in gynecology clinic and they have a unique clinic at Children's Mercy called the Young Women's Clinic and it's paired with hematology and. They follow with girls that are starting their menstrual cycles and they have bleeding disorders and they're able to help them manage it in that clinic better. And I thought that was such a cool experience because I, one never knew we had that clinic. And two, it's such a cool opportunity to meet with girls in such a vulnerable time and kinda help them through that.

And just the way of the science behind it, how they look at the hematology behind the illness that they have and then they help them manage their monthly cycles, I thought was really cool.

Tobie O'Brien: I did not know that we had that clinic either, which is why I love doing this podcast because I meet so many people and they tell me so much about, the work being done at Children's Mercy that I have no idea about. So I love hearing about that. Yeah. And that Autologic skill is, while it is, seems like just so commonplace, it's somewhat difficult to nail down, but like so important to nail down. And so especially with you working in the ED, that is one skill that is super helpful to have had someone take their time to make sure that you felt comfortable with it.

Trisha Williams: I love too that you said that about the Otologic exam with Toby and I being ENT nurse practitioners. I find it a very valuable exam to be able to do appropriately and I think that it's, some of those simpler exams we think are simple, but really an ear exam is hard and to take the time. It is to like, how do you hold the otoscope? What do you do? What do you do with this hand? What do you do? How do you tell the patient to turn their head?

That we have to remember that these things that we think as seasoned nurse practitioners are, physician assistants are routine. When we start out, they're not. We had to learn and now it's muscle memory for us. But if we don't ever obtain that starting point, we can't get that muscle memory. So thank you so much for pointing that out and.

Natalie Heim: Well, and then the moment that it finally clicks, you're like, okay, I get it now. I see what they were saying. I'm not just seeing the back of somebody's ear anymore. I'm actually able to visualize the membrane.

Trisha Williams: That's what it looks like. Yeah.

Tobie O'Brien: Yeah. I remember specifically doing my clinicals, and this was like 20 years ago. I remember doing my clinicals and when it finally clicked, I was like, oh, that's what we're looking for. Okay, so isn't that funny? I still remember. So it was like a pivotal moment for me as well.

Natalie Heim: Yes.

Tobie O'Brien: Well let's talk a little bit about what resources you have found helpful and maybe to other new a that are at Children's Mercy. What have you found helpful as far as resources that we can offer to make your job a little bit easier?

Natalie Heim: So in the emergency room, obviously you see a wide variety of things and the kind of caveat is you're like, you know, a little bit about a lot of things. And so number one, the best resource always is my peers. I'm so amazed with how knowledgeable my peers are and how much information they can just spat out. So they're number one my favorite to get information from, but obviously they're not always available. So sometimes you have to turn to your own resources and Children's Mercy has their library services on the scope and my hands on favorite is visual diagnosis.

It's so awesome. You can plug in the symptoms that your patient is having specifically for rashes, because rashes are just always tricky. I feel like you can plug in the location of the rash. You can plug in if they have a fever, you can plug in all these various things, and then it pulls up a differential for you and it includes pictures. And so I find that resource so helpful because if I can physically see the rash and then compare it to what my patient has, that makes me more confident in making a diagnosis.

And then it also has diagnostic pearls too. And so I feel like that's helpful. I also find Red Book is really helpful to help with antimicrobial management of patients. And then also of course up to date, up to. A really quick resource that you can just put in almost any diagnosis, I feel like, and it'll pull up management, plurals, diagnostic tools, treatment options, and I found that to be really helpful as well.

Trisha Williams: I think up to date is a fantastic tool. I did not know about what was it? The visual diagnosis or visual diagnostics?

Natalie Heim: Yes, it's my favorite, awesome.

Trisha Williams: That's awesome. I know. I'm gonna check it out. the one thing that I love that we have at Children's Mercy is also our clinical practice guidelines. tha have been evidence based driven, and I feel like we have a ton of clinical practice guidelines to follow as well that we're blessed to have with some of our resources. But that visual diagnostics, I'm gonna have to go take a look at it.

Natalie Heim: Yes. That's awesome.

Trisha Williams: Yeah, . So let's talk a little bit about your role in the emergency department. Give us some insight about what your daily role looks like in the ED?

Natalie Heim: So in the ER it's fun because you can see a wide variety of things. So you might be helping the brand new parent whose kid is clinically well appearing, but they're just really nervous about a very small thing. Or you could be seeing in appendicitis or a broken arm or a seizure. And so you see a lot of wide variety, which I like the variety because it helps me kind of keep up to date on my skills. But it's interesting because the trickiest part about the ER is you have to be able to differentiate stick versus not sick. So going into that first time parent and looking at their kid and realizing, okay.

They're not sick, they just need a lot of education. But then also going into this other kid who has similar symptoms, maybe like fever and vomiting and recognizing, Hmm, something's off here. I think they have appendicitis. Cause it's tricky in the emergency room because you could in theory, do every single test for every single person, but obviously that's not using good stewardship of your resources. So being able to differentiate who needs the resources and who doesn't is the trickiest part of the emergency room.

Trisha Williams: I could totally see that. And so it leads me to my next question. How are you facilitating your learning? Because to me it sounds like and it's not, to me, it just is what it is. Like you see everything. You have the potential to see every type of subspecialty patient in your emergency department, so how are you facilitating your education to be able to jump back and forth between a broken arm and feel confident in taking care of that patient with a broken arm to the patient that just had a febrile seizure to the patient that's now having appendicitis?

Natalie Heim: It is a little tricky to kind of switch your brain from one thing to another. I. Being a nurse in that department kind of helped me be able to switch my brain that quickl. But I would say knowing your resources again is huge. You know, knowing your peers, knowing your own limitations. So knowing that if I walk into a room and I'm presented with a problem and I have no clue what to do with it, being able to go to those resources that I spoke to or call on a colleague and get their opinion and knowing your limits.

Because you will never know everything out there. You will never be able to know every single diagnosis and every single treatment and every single problem. So being able to call on your resources when you're really stuck and you just don't know, I mean, that's how you learn it. It took someone pointing out to me like, oh, this is actually eczema on a rash. Until I learned him, I was like, oh yeah, it looks a little bit different. But I see what you're saying here. It does look like eczema in this area. It. Someone teaching you that in order to get more familiar with it.

So I think knowing your limitations and also in the emergency room, we also have to do like a risk benefit assessment. Patient presents with a problem. I could do all of these tests. What's the risk of harm to them versus what's the risk of not finding this out and kind of weighing those options and seeing if I let this kid go home, am I gonna be able to sleep at night? Am I gonna feel comfortable with their plan? Do they have strict return precautions just to kind of cover, if you weren't able to discover exactly what was going on?

Tobie O'Brien: That sounds really interesting, and I'm sure you are learning a ton. I'm sure the learning curve for that is just, is so high. But how long have you been doing it now? A year? Is that what I heard?

Natalie Heim: It'll be a year in just a couple weeks. Yeah, just coming up on a year.

Tobie O'Brien: Okay. I'm sure you have just learned this past year has it just been total overload, but now are you starting to like get your groove and kind of feel good about things like, like you said, you're never gonna feel completely good, but like you feel like you're in a great space with knowing your resources and such.

Natalie Heim: Yeah, it's funny, whenever I was in the fellowship program, one of the very first weeks, they presented this graph to us and it was new job satisfaction in a, or it was, let me backtrack. When I first started in the fellowship, they presented us this graph. And it was about confidence and enjoyment in a brand new physician. And it kind of started off on like a really high peak. And then the peak drops drastically after the first couple weeks because I think everyone hits that. I don't know anything. I don't know what I'm doing. I shouldn't be in this role kind of feeling. And it makes me feel like you're not very good at your job.

But then the graph shows that it starts to even out and trend back upward because you get a little bit more confident, you get to see a little bit more things. You get to trust your ability a little bit more. And I would say that graph was definitely true for me. I started off the job and I was like, this is gonna be awesome. And then you hit a point and you're like what am I doing? I don't know of anything. I feel like I don't know the answer to simple questions. And so you kind of plummet. And then as you start to get back into it and learn more and use all those resources, you turned back up.

And then you're, you get to a point where you at least feel competent to handle the basic things. And then again, like you said, you know your resources, you establish relationships with your peers. feel comfortable asking them questions,

Trisha Williams: That is exactly how I felt, but didn't know that I wasn't alone. It's good to know there's a grafh in this statistical data that supports There is the truth to what I was feeling.

Natalie Heim: Yeah. That was definitely a benefit of the fellowship as well, was seeing that graph and being like, okay, so this is normal to be feeling this way.

Trisha Williams: Yeah, absolutely. So as we kind of conclude things today, I would love kinda one piece of advice that you could give the season to nurse practitioners? I know that you had said like, remember what it was like, to be that new person, but I think, with all of us, with the onset of the pandemic and now we went straight into the high census with RSV and bronchiolitis and people still need to learn. We still need to orient, we still need to precept, we still need to do these things to grow our future colleagues. So do you have like one piece of advice for us as seasoned nurse practitioners and physician assistants to be able to do that, to foster good, future colleagues.

Natalie Heim: I think the best advice I could give is that experience is the best teacher. So if you have somebody that's interested in going back to school or just a nurse that's really interested in learning, giving them the opportunity to experience something really cool and unique because that's how people learn. And then I feel like it helps you as a seasoned nurse practitioner feel really good about sharing your knowledge about a subject. And then obviously the novice is really excited to receive the knowledge. So anytime you get the opportunity to share a unique experience with someone, go ahead and do it. Because I just feel like that's how people learn and then everyone feels good about that.

Trisha Williams: I'm in awe of you. That was amazing. That was a beautifully said. And experience is the best teacher, so we all need to be able to foster the love that I feel coming from you for our practice as advanced practice providers. So thank you so much for sharing your love for our practice and your love for your work in the emergency department with us today.

Natalie Heim: Thank you for having me. I love any opportunity to talk. If anybody knows me, I rarely am quiet, so is perfect.

Trisha Williams: You're in company.

Tobie O'Brien: Yeah. Oh yes, you are. Well, I agree with Trisha. It really has been a delight to have you on. I agree there's so much excitement that I can just hear in your voice about your new role. And so I'm sure the ED is super happy to have you joined them. So speaking of the ED department, we kind of like to each episode, with the same question. So I want you to think about your colleagues that you work with in the ED. And I want to know in what way do you love to encourage them, because I bet you're an encourager. Just hearing from your voice, it sounds like, you are excited about life and I want to hear how you like to encourage others.

Natalie Heim: Well, one of the ways that I feel like it's really easy to encourage coworkers during a, tough shift is playing music. One of my colleagues always does it, and it just brightens the mood because when you've got a random Pandora station on and it plays some old hip hop song, everyone kind of starts laughing about it and it kind of lightens the mood and so that's not even specific. It's just having music on in the background kind of helps, I think, bring everybody up. And then I think the importance of listening to, if a colleague's having a really bad day and they just wanna talk about it, they don't want your opinion, they don't want, your assessment of this, the problem.

They just need somebody to listen to that. I think that goes a really long way, especially with the high census season that we've been having, somebody that can relate to you, that can just sit and listen is huge. And then, like you said, just, verbally encouraging coworkers when they do a good job or whenever they have a good catch. We have all these great programs for that at Children's Mercy too, but I think verbal encouragement goes a long way as well.

Trisha Williams: Yeah, I agree. I love that. And Natalie, it has been a true pleasure having you on our podcast today.

Natalie Heim: It's been so fun. I've loved it.

Tobie O'Brien: Well, yes, I agree. Thank you for coming on today. And listeners, thank you for listening in. If you have a topic you wanna hear about or you are interested in being a guest, please email Trisha or myself, TD O'Brien@CMH. Edu or TWilliams@CMH. Edu. And once again, thank you so much for listening to the Advanced Practice Perspectives Podcast.