Advanced Practice Registered Nurse (APRN)

Campus Health Center
Johnsonville, SC

As a school nurse in a rural South Carolina district, Gaye Douglas, MEd, MSN, APRN-BC, noticed that many students she treated also would show up for primary care at the hospital emergency room 22 miles away, where she worked weekends. So in 2006, a year after becoming certified as a family nurse practitioner, Gaye took “a huge leap of faith” by securing a $496,000 Duke Endowment grant to operate a health clinic on the campus of Johnsonville’s three adjacent schools serving K-12.

“It was a mission,” says Gaye of Campus Health Center, built by the school district and run by Gaye, who oversees a staff nurse and a billing administrator. “I knew as a nurse practitioner I could choose an area I was passionate about and build a program to impact the community. I’m interested in school and adolescent health. I was able to pursue that and make my own job.”

Campus Health Center, which is now self-sustaining financially, serves not only the 1,600 students, but also the district’s teachers and community residents, including adults. The clinic teaches preventive care and provides acute care, treating such conditions as ear infections and viral illnesses. It administers the state’s vaccine program for students. Gaye helps adult patients manage chronic diseases, such as diabetes and high blood pressure. She is authorized to prescribe medications.

With health care providers scarce in the area, many of Gaye’s patients would miss school or work to go to the hospital emergency room, travel long distances for a doctor visit, or wait days for an appointment at one of the few local providers’ offices. Gaye’s clinic usually can accommodate same-day appointments, and designates a walk-in time every morning.

With her school district better equipped to provide timely health care, Gaye is now planning her next mission – a mobile health service, financed by a $500,000 federal grant.  The health clinic on wheels, scheduled to launch in January 2012 and to be staffed by a nurse practitioner, will travel to three other rural schools in towns with health care provider shortages.

Atlanta Birth Center
Atlanta, GA

Atlanta-area women would travel long distances to receive prenatal, postnatal and primary care from Anjli Aurora Hinman, CNM, MPH, FNP-BC, and her mentor, Margaret Strickhouser, CNM, MS, at their midwifery practice within a physician’s office. When the physician closed that service in 2009, Anjli followed Margaret, who had a strong patient following that spanned generations, when she opened Intown Midwifery, one of the only midwife-led clinics in metropolitan Atlanta. Within six weeks, the practice contracted with a collaborating physician and attained clinical privileges at the nearby hospital, Atlanta Medical Center.

Business boomed immediately. The high demand and enthusiasm of community volunteers have led to plans to establish the Atlanta Birth Center by 2013.

“Support of normal birth with low intervention is hard to find,” says Anjli, adding that midwives’ holistic approach has been shown to lower rates of infant mortality, prematurity, low-birth weight infants and Cesarean section births, and increase rates of breast-feeding and positive birth experiences. “Patients were telling us daily that Atlanta needs a birth center. It quickly became much bigger than the providers and patients in our practice; it has become a movement in the community. We were seen as leaders because we were providing that care.”

The Atlanta Birth Center is planned as an independent, integrated care model that will bring together a network of providers to care for women and families who “guide the ship.”  The center will provide primary care and connect patients to a range of services from pediatrics and mental health to acupuncture and chiropractic care.

Anjli and Margaret’s model of care at the Intown Midwifery practice has had an impact at their hospital. Water births are now an option for women, doulas are part of more births, and healthy newborns now are allowed to have minimal separation and be assessed while staying with their mothers from birth until discharge.  The practice has added four more midwives and also begun training midwifery students to ensure this type of care continues for the future.

“I believe in transformative change because I see it in birth and the women I care for every day,” Anjli says. “I hear from women their fears and hesitations about birth and becoming a parent, and to see women rise past those fears, climb their highest mountains, and let go and trust the process is truly inspiring. Birth matters, and I believe the way a child is brought into the world has an important impact on the rest of life. Helping with that transition is an honor.”

For Janice Miller, CRNP, MS, CDE, a big advantage of her job as a nurse practitioner is the 40-minute block she spends with diabetes patients to educate them about managing their condition.  As the only nurse practitioner along with 12 physicians in a Philadelphia internal medicine practice, Janice meets with the diabetes patients to discuss diet and nutrition, review exams of their eyes and feet, evaluate and order lab tests, start insulin regimens, prescribe medications and chart progress.

“I can do a lot of teaching with a patient,” says Janice, a diabetes educator who instructs third-year medical school students for Thomas Jefferson University, with which her Jefferson Internal Medicine Associates is affiliated.  “I like having some autonomy and feeling the things I do impact people and can change the course of their health.”

Janice sees many more patients with other chronic conditions, such as congestive heart failure, arthritis, kidney disease and sickle cell anemia, who need comprehensive treatment plans and care coordination to avoid costly hospitalization. Her practice focuses on preventive care and uses electronic health records to determine how to improve the quality of care.

“I like getting to know the patients in an ongoing care setting,” says Janice, who worked as a critical care nurse and a pulmonary researcher before becoming a nurse practitioner. “They really open up and you get to know things about their lives that aren’t readily apparent when you meet them. A sense of mutual trust develops.”

Janice recently has become engaged in political advocacy, talking with her congressional representative about removing barriers to APRN practice and writing to Pennsylvania state legislators in support of bills. “I’m trying to raise consciousness about the role of nurse practitioners in health reform and in increasing access to care, quality of care and cost savings. As a group, we need to be more vocal.”

Operative Care Division
Portland Veterans Administration Medical Center
Portland, OR

As a clinical nurse specialist in the surgical division of Portland’s veteran’s hospital, working with patients is only a part of Stephen Patten’s job. Sure, he helps prepare patients for surgery and recover post-operation. But he mostly focuses on two other spheres of influence – working with nurses to improve the quality of care, and developing systems and procedures to make surgery safe and effective.

Stephen’s role is akin to systems engineer of the surgical process, or, as he describes it, planning “how to do business in the O.R.” For a surgical procedure, he may interact with nurses from multiple departments, hospital clinics, surgeons, anesthesiologists, or pathologists -- any personnel that affects surgical outcomes.

For example, through checklists and consultations, Stephen ensures that:

• The correct antibiotics are given to a patient within one hour of a surgical incision, and discontinued within 48 hours
• Catheter use is discontinued within 48 hours after surgery to avoid infection
• Patients have taken necessary medications, such as beta blockers to protect  their heart

Stephen works with 120 nurses in his division, which handles 8,000 surgeries annually. He incorporates research findings into the division’s policies, procedures and best practices to improve care. When nursing problems arise, Stephen’s on point.

“In the CNS role, you can be an expert within a specialty. It’s taking nursing to its highest level,” Stephen describes. “Through my education and 32 years’ practice as a nurse, I have had the opportunity to become an expert in the peri-operative setting and can help nurses from the youngest to the most mature to achieve the goals they want for their patients.”

Before becoming a CNS, Stephen worked at a trauma facility, where getting a patient out of the O.R. alive was an “adrenaline rush.” He’s traded that thrill for the satisfactions of teamwork and a thorough knowledge of operative care. "It’s a little mystifying. The doors close and no one else comes in. It’s fun knowing the mystery."

Meridian Health Group
Carmel, IN

Nurse anesthetist Jackie Rowles sees patients whose chronic pain has devastated their lives, forcing them from jobs and affecting their relationships. At Meridian Health Group, an inter-disciplinary pain management clinic in Carmel, Ind., Jackie works as part of a team that develops treatment plans to minimize pain and wean patients from addictive medications.

“A lot of people may never be pain free, but if we can keep their pain down, they can be productive members of society and get back to work. That’s our goal,” says Jackie, CRNA, MBA, FAAPM, who collaborates with psychiatrists, physicians, podiatrists, therapists, and other health professionals at the integrative clinic. 

Jackie evaluates patients and provides pain treatment therapies, such as spinal injections with fluoroscopy (for imaging guidance), joint injections and peripheral nerve blocks. The difference between this job and her previous work in hospitals is her ability to work with patients long-term and monitor complex conditions to find the best multidisciplinary treatment pain management regimen. 

“I like being part of a team and being a member with a lot of responsibility,” Jackie says, adding her job requires high-level assessment and decision-making abilities. “My education, knowledge and skill set have provided me the opportunity to have that level of responsibility. I always have to keep up on [clinical] education, new drugs, equipment and research. We’re working with patients at a time that’s very scary for them.”

Challenges include evaluating patients with a 20-year history of chronic pain with little success from past treatments, and engaging them in treatment plans. Insurance reimbursement policy causes frustration, especially when a medication is working but lack of insurance coverage makes the drug unaffordable.
A challenge for the profession is educating the public about what nurse anesthetists do, and their skill level and competencies. “People think we’re just helping a doctor, but we’re really providing the care for our patients, administering their anesthetics and managing their pain, putting them to sleep, and most importantly, waking them up."