Online Health Chat with Meredith A Lahl, MSN, APRN, PCNS-BC, PPCNP-BC, CPON – Executive Director/ACNO of Advanced Practice Nursing at Cleveland Clinic

Friday, July 14, 2017


Description

Today we will be discussing and learning more about the career path of advanced practice nursing. Some common topics for discussion are: choosing an APN role, searching for available jobs, choosing which career path to take and the current climate.

Meredith Lahl, executive director/ACNO of Advanced Practice Nursing at Cleveland Clinic is here to answer questions about the profession. Meredith has had a leadership focus in her own career path and now has the privilege of helping develop others. Cleveland Clinic supports advanced practice registered nurses throughout all the Institutes within the Cleveland Clinic Health System. The Office of Advanced Practice Nursing provides scope of practice oversight, maintains the credentialing and privileging process, and provides educational opportunities for APRNs as well as graduate students.

Advanced practice registered nurses are key providers of high quality, safe, patient-family centered care. APRNs work in collaboration with physicians to provide care including: histories, physical exams, diagnoses and treatment plans. They are able to diagnose and treat illnesses, order diagnostic tests and prescribe medications. There are many opportunities available to APRNs today and with the right approach, you can build a great career and make a tremendous impact on the profession. If you have any interest in learning more about the profession, are looking for opportunities or are interested in the current climate, we hope you enjoy today’s informative web chat.

About the Speaker

Meredith A. Lahl, MSN, APRN, PCNS-BC, PPCNP-BC, CPON, is executive director and associate chief nursing officer for Advanced Practice Nursing at Cleveland Clinic. In her role, Ms Lahl is responsible for the oversight and supervision of the scope of practice, recruitment, quality, credentialing and privileging of Cleveland Clinic Health System’s more than 1,200 advanced practice nurses.

Prior to her current position, Ms. Lahl served five years as senior director of advanced practice nursing, also providing strategic leadership for Cleveland Clinic’s advanced practice nurses, as well as direct supervision for the health system’s inpatient clinical nurse specialists. Ms. Lahl’s Cleveland Clinic career experience also includes six years as a pediatric CNS and a staff nurse in the pediatric intensive care unit. She has also worked in various nursing positions at Rainbow Babies and Children’s Hospital in Cleveland, Ohio and Children’s Hospital of Philadelphia.

With a passion for nursing advancement, Ms Lahl is a dedicated professional whose expertise is noted throughout the health care industry through organizations such as the Association of Pediatric Hematology/Oncology Nurses (APHON) and American Nurses Credentialing Center (ANCC). She is the Ohio chapter president for APHON, involved with several national APHON committees, and is the 2012 recipient of the organization’s Jean Fergusson Excellence in Pediatric Hematology/Oncology Nursing Practice Award. Additionally, she serves as a content expert and chair for the ANCC’s pediatric CNS exam and role definition study and is chairperson for the Cleveland Clinic nursing organization’s image and branding council, and legislative and health policy council. She holds a dual certification as a CNS and as a nurse practitioner in pediatrics, and has served as clinical faculty for advanced practice nursing students at several colleges and universities.

Ms. Lahl has presented nationally on a variety of clinical and professional topics, and has been a featured speaker at many industry conferences. Ms. Lahl earned her BSN and MSN from the University of Pennsylvania and holds an MBA degree from Case Western Reserve University’s Weatherhead School. Welcome to our chat, "Advanced Practice Nursing 101" with Cleveland Clinic’s Meredith Lahl, executive director/associate chief nursing officer of Advanced Practice Nursing.

Meredith, thank you for taking the time to be with us and sharing your thoughts and expertise on advanced practice nursing. With so many exciting possibilities in the nursing profession these days, it is great to chat with you and get your insight.


Let’s Chat About Advanced Practice Nursing


APRN ABCs

kels: How do you define an advanced practice registered nurse (APRN)?

Meredith_A._Lahl,_MSN, APRN: An advanced practice registered nurse is an RN that is educated at the graduate level (either a Masters or doctorate) and nationally certified in an APRN specialty role. APRNs can diagnose, treat and prescribe. They work with patients and families in all care settings. There are four sub-roles of APRNs, certified nurse practitioners, certified nurse midwives, certified registered nurse anesthetists and clinical nurse specialists. There is also the option to focus on a specialty patient population such as pediatrics, neonatal, women's health, psychiatry and health across the lifespan.

Brink: As a nurse, how do I go about picking an APRN specialty area? And which types of options are available?

Meredith_A._Lahl,_MSN, APRN: When choosing the type of APRN you wish to be, a few considerations must be taken into account. First off, do you want to remain in direct patient care? If yes, an APRN career path is for you. As for the type of APRN, considerations I suggest include: What type of patients do you most enjoy caring for? Do you want a fast paced environment such as an ICU? Do you want to care for families across the continuum from wellness to illness? Do you like to teach? Would you want to work with underserved patient populations? APRNs at Cleveland Clinic work in all practice settings, all hospitals. The opportunities are endless, but you must know where your passion as a nurse lies. I do not recommend you choose a role for the work schedule or the pay. Think about the work you are doing, if you enjoy the patients and feel as though you are providing high quality care.

Jackie: How are the APRN licenses different among states? Are APRNs internationally recognized to practice at similar levels?

Meredith_A._Lahl,_MSN, APRN: All states are different in their practice acts, so you have to look at those to determine the practice. Some states are full practice. Some recognize all four roles, some do not. Ohio is a collaborative state and recognizes all four roles. Internationally, there is growth as well. The United Kingdom and Australia are the two highest utilizers of APRNs. Cleveland Clinic Abu Dhabi was the first Middle Eastern country to use NPs, and they are replicating the practice of Ohio.

jane: In your opinion, what APRN specialty is the best one to get into right now (in regard to job availability, opportunity for career growth, interesting patient cases, etc.), nurse practitioners, anesthetists, nurse-midwives or CNS?

Meredith_A._Lahl,_MSN, APRN: There are great opportunities in all of the roles, but if you ask me today (which you are), we have a great need for acute care NPs.

tjess: With so many organizations make recommendations, writing standards and guidelines, how do you know who to follow?

Meredith_A._Lahl,_MSN, APRN: My first source of truth for what you should follow is your state's Nurse Practice Act. What the state says you can do is first and foremost. From there, I would look to your national certifying body and then your specialty professional organization.

Moderator: The majority of our web chats are geared toward the lay person, educating about different diseases and conditions. This is one of the first that we have done primarily for professionals. Thank you for being so engaged. If you would like information about our other chats to share with patients, go to clevelandclinic.org/chats to view upcoming topics.


Personal Experience

WmS: What was your trajectory to becoming an APRN?

Meredith_A._Lahl,_MSN, APRN: I was fortunate when I started my nursing career. I was exposed to APRNs, had a good understanding of what their role was and I loved my specialty of pediatric oncology. My passion for the patient population led me to the role. I started graduate school shortly after becoming a nurse, but at a slow pace, one class per semester. By the time I graduated, I had three years of experience as a RN. I chose to focus on the CNS role because I really enjoyed working with patients, nurses and on system work. I have worked both as a CNP and CNS in pediatrics, and have had lots of opportunities with my specialty. I spent about eight months looking for my first APRN job, and I’m happy I did. If I could offer one piece of advice, it would be to think of the patients you enjoy caring for, then the role. From there, I think my natural "take charge" attitude led me to leadership. I believe it is important to still practice clinically, so I do work in clinical practice still. I worked too hard for that MSN and certifications to let them go unused.


Job Journey

schUS: Why is the APRN role taking off today in terms of job growth?

Meredith_A._Lahl,_MSN, APRN: The health care arena is dramatically changing; the way people receive health care and who they receive health care from is very different. The APRN role can serve the needs of patients and their families, and provide a great boost for health care delivery systems that utilize these types of providers. Because APRNs can diagnose, treat and prescribe, and are trained to care for various patient populations, they are able to work in various settings as members of the entire team.

dlayy: What kinds of jobs are available for advanced practice nurses?

Meredith_A._Lahl,_MSN, APRN: There are various job opportunities throughout Cleveland Clinic, in the state of Ohio and nationally. In my role as ACNO at Cleveland Clinic, I see a growing need for acute care NPs. We have a large need for ACNPs who can work and want to work in the hospital setting, in our EDs, ICUs and other nursing units. The Express Cares are growing as well, and true primary care will be a future need. What I often tell new graduates is to be patient, think about the specialty and workplace, and do not rush to "just get a job." Think about where and what you want to do.

Karen: What is the current climate for APRNs?

Meredith_A._Lahl,_MSN, APRN: The climate is hot. In any media arena you see APRNs, specifically NPs. Yahoo Jobs has rated NPs as one of the top jobs for several years now. It is also geographic as the need and the ability to practice in states varies.

nformer07: Good afternoon. What would you suggest is the best way to find a position after APN school? I am currently enrolled in a FNP program and finding a preceptor has been difficult. I am wondering if finding work within Cleveland Clinic after graduation will be just as difficult.

Meredith_A._Lahl,_MSN,_MBA,_APRN,_PCNS-BC,_PPCNP-C,_CPON: Patience. Patience. Patience. When previously asked about my trajectory, I said it took me eight months to find my first APRN job, and it was worth it. When you graduate, prep for your national certification, get your license and look for jobs at the same time. I will say there are a lot of new graduate FNPs out there. We also need acute care NPs in the hospital.

sj123: I love health and fitness. I love teaching, managing and educating. I also have a passion for youth and young adult development and empowerment. With all this being said, what options do I have? Can I open a youth center within my community, become an APRN health coach and personal trainer? That’s a lot, but if there was one role I could combine it all into, my job would be perfect.

Meredith_A._Lahl,_MSN, APRN: There are many growing opportunities for APRNs in the community. In Ohio, there are APRNs who have their own businesses, too. I think using your nursing profession and your advanced degree in that way are definitely possibilities. You would have to work as a clinician first to build your base as a practitioner, however.


Education Exchanges

kels: What should I consider when returning to an APRN graduate program?

Meredith_A._Lahl,_MSN, APRN: That’s a great question. Here are some things to consider: 1) What kind of flexibility do you have with work and school? 2) Where do you like to work? For example, if you have always worked in a hospital, you might want to shadow other practice locations before going back to school. 3) Can you work full-time and go to school full-time? 4) Is the program accredited? This is very important! 5) How do the programs support clinical rotations? 6) Most importantly, know what the role of an APRN is before returning to school. Many people get to a program and don't know what to expect in the role.

avery: What types of nurse practitioner programs are available?

Meredith_A._Lahl,_MSN, APRN: There are many nurse practitioner programs out there. There are traditional programs, online programs, and RN to MSN and RN to DNP programs. Pretty much any type of program you can think of is out there. Here are some points I would definitely consider: 1) Is the program accredited? 2) Can you go full- or part-time? Is there a time from start to expected completion? 3) What kind of support is there for clinical placements? (This is key.) 4) Look at the faculty of the program and determine if they have expertise in the areas of practice. For example, are the faculty for the pediatric NP program experienced as pediatrics NPs? 5) Consider where you went to undergraduate school and continuing on. You know the school and the style. Lastly, do not necessarily take the easiest way to the end degree. Think about the quality of the program and how prepared you will be when you do graduate to independently care for patients.

dale: You said you worked as both a CNP and CNS. What is required as far as education and licensure to transition from one role to the other?

Meredith_A._Lahl,_MSN, APRN: I was very fortunate. The program I attended was a dual APRN program, so when I finished I was able to certify as both a CNS and CNP. (Very few of these programs exist anymore.) In terms of going from one to the other, if you have one, you can easily return to a post-Masters program for the other. It usually involves some course work and definitely clinical hours. The basic “three Ps” as they call them: pathophysiology, pharmacology and physical assessment are the cornerstones of all APRNs programs.

Steve: Is a doctorate in nursing practice necessary? Will nurses continue to get their DNPs?

Meredith_A._Lahl,_MSN, APRN: This has been a question for some time. Several years back, there was some talk of making APRNs have a doctorate. That has not become the standard. A Masters is still the standard the majority of the time. The doctorate will be required for CRNAs starting in 2020, however. As far as nurses continuing to get DNPs, they absolutely will; nurses are lifelong learners. At Cleveland Clinic, we have hundreds of nurses and APRNs either with their doctorates or currently in DNP programs. I just got an email from a NP today who finished.


Sage Advice

racheileen: I'm about to start the last year of my pediatric nurse practitioner program. Is there anything I can start doing now to make sure I find a great job and my first year of practice will be a success?

Meredith_A._Lahl,_MSN, APRN: This is a great question. I suggest you consider every clinical hour and clinical experience as a job interview. Trust me, the preceptors you are working with are doing the same. The success and impression you make as a student can definitely impact your ability to get a position with that group if you want one. That being said, also make it a point to interview them as well (on the sly). What do they like about their roles in the practice? How long have they been there? What would they change? It's a two-way street.

To make your first year of practice a success, I give this piece of advice that was given to me: consider feedback a gift. Ask for feedback on your assessments, histories, differential diagnoses and demeanor with patients. Ask those teaching you how you are doing, and ask for some constructive ways to improve. It will only make you a better practitioner.

leslibeth: I started my career as a med/surg RN (four years) and have since transferred to clinical research. I am interested in returning to school for an FNP. What advice do you have for someone who has been away from the bedside for a few years? What do you expect my biggest challenges would be? What schools in this area would you most highly recommend for an FNP program?

Meredith_A._Lahl,_MSN, APRN: Your four years as a med/surg RN is great experience, as is your research nurse experience. You may want to consider returning to direct patient care before you return to school or while you return to school. What I tell most new NP graduates is that your biggest challenge is going from taking the orders to giving the orders. You need to be confident in your decision making and be able to make a plan for a patient with the evidence to back it up. As for schools, there are many great programs. What I recommend is talking with the program faculty. Ask about clinical placement support and where their graduates work.

katie.l: Hi Meredith. I am currently in an FNP program online, and just started advanced pathophysiology. Do you have any tips on the best way to tackle all of this information? Thanks.

Meredith_A._Lahl,_MSN, APRN: First off, good luck! I am a visual learner. My strategies were a lot of flashcards and a lot of looking at those flashcards over and over. I used pictures, anything I could find. Also, another trick for me was finding questions (such as old test questions) on the subject, which I would review over and over. Lastly, try not to stress. Don’t leave it all to end, tackle a little at a time and build on it.

BearintheWoods: What is your advice to becoming the best APRN you can be?

Meredith_A._Lahl,_MSN, APRN: My advice to becoming the best APRN is listen, accept feedback and grow. I think the two most important aspects for anyone in health care are good relationships with people, all of your patients and colleagues, and great communication. It all boils down to relationships and communication. One more thing, no role is less or more important. Respect the whole team; everyone plays a part.


School Suggestions

mbrow: Many of us need to work full-time while attending school. How does Cleveland Clinic accommodate employees looking for clinical time outside of normal work hours? This has been my main fear and reason for not applying to a program. Thank you.

Meredith_A._Lahl,_MSN, APRN: I think that the flexibility of being a nurse makes going back to school ideal. At Cleveland Clinic, you can work various shifts, days and as much or as little as you want if you go back to school. As you know nursing is a 24/7 operation, so there are definite opportunities to work flexible hours. I think you have to open yourself up to potentially different locations or different specialties sometimes to make it work. There is also CCSR, which offers a great deal of flexibility. If that is your fear, trust me, you can find a way to work and go back.

GraceM.: What challenges exist with the increased presence of advanced practice nurses?

Meredith_A._Lahl,_MSN, APRN: If I had to identify a challenge in the APRN world, it is basic supply and demand. (I did just finish my MBA. HA!) We have continual growth, but the growth of APRN students and having adequate preceptors for them is the biggest challenge. So, when considering returning to school, consider the program's support in your clinical education.

Lene: I am working an eight to five, Monday through Friday job and want to go back for an APN degree. How difficult is it to find clinical areas in the evenings or weekend for FNP versus acute NP? Thanks.

Meredith_A._Lahl,_MSN, APRN: There are opportunities to do clinicals in the evening and weekends, but they are usually non-traditional practice areas such as Express Care. There are some primary care office hours during that time, but probably not enough for a rotation. As for the acute care NP role, if you like the hospital setting, I would look into that more.

roxy2: I have completed two years of online FNP program. As FNP students, our focus is outside the hospital setting. We are responsible for securing our own preceptors, which is turning out to be a real challenge. I work in specialty ambulatory care. I know Cleveland Clinic has an onboarding process; however, I heard the request for preceptors is at such a high demand that it may be a year or longer to precept at Cleveland Clinic even if I do find a willing NP to serve as a preceptor for me. Is this true as to the length of time to onboard? Thanks.

Meredith_A._Lahl,_MSN, APRN: There are many schools out there, and trying to meet all the demands of all the students is what keeps me up at night. We do our best to support our own caregivers in school while recognizing we have many learners in our health system.


Deliberating Direction

Lucy in the Skies: Is the APRN pathway primarily focused on the clinical practicing nurse, or is this something the more administrative-focused RN should consider?

Meredith_A._Lahl,_MSN, APRN: The APRN roles are focused on direct patient care, so that is why thinking about what you love about nursing is so important. There are opportunities for APRNs to be leaders and do administrative work, but in my experience APRNs want to be able to do both. At Cleveland Clinic, we have developed a structure where APRNs are leaders of their peers. They have the best of both worlds; they are clinical and get to be leaders in the administrative arena.

gas: Hello Meredith. As someone with a MSN degree that is looking forward to continuing to develop professionally and contribute to change in practice, policy and education, can you advise whether a post-Master's certificate as a CNS or NP versus a doctorate in nursing would be more valuable to pursue now, both for the organization and employment opportunities? Can you elaborate on opportunities that APRN's at Cleveland Clinic have in public health? Thank you for your time.

Meredith_A._Lahl,_MSN, APRN: I would look for programs with a DNP that can also allow you to certify as a APRN (either CNS or NP). They are out there. Rather than a post-Masters, find the program with the DNP that will make you eligible for APRN certification. The growth of population health is going to be significant in the coming years, and Cleveland Clinic has a great opportunity to work with the community and partnering organizations to ensure public health needs are met.

dale: I'd like to get an MSN, but I'm not certain which path to take. At different times, I've thought about going down many different pathways: NP, CNS, education or leadership. I'm just never sure what I want to be doing in five or 10 years. Which degree do you think is the most versatile in the current health care climate/market?

Meredith_A._Lahl,_MSN, APRN: This all comes down to what you love about nursing and what you enjoy about your work. I also think your passions and interests change over time. In my own example, I loved the pediatric oncology patient population, so I pursued a MSN in a dual program so I could be a CNS and a CNP. To me, it was a focused patient population, but I had two options of roles. Over time, my interest moved toward leadership and health policy, so I recently got my MBA. There is a great need for educators, especially in the academic settings. I know it is cliché, but it has to be about what you love to do within nursing.


Practice Points

tjess: Hi. I am a new graduate. I have concerns about the expectations for patient management in my new role. I've learned so much in school and feel like I could benefit from an internship. Is that available through Cleveland Clinic? How long is the typical orientation period?

Meredith_A._Lahl,_MSN, APRN: We know that this is a concern of new graduates entering the practice world. They’re entering a new role and a lot of responsibility. We know that we need to transition new graduates better, so we are developing a transition-to-practice program. It is very exciting, but also a lot of work. The first cohort is launching this summer in primary care, and we have to continue to build the other curriculums, but we will get there. At Cleveland Clinic, the departments know there is a huge need to support the transition and onboarding of new graduates. We are working to ensure new graduates learning needs are met.

tjess: I was concerned about the incentive pay. If I do not meet the expectations, what happens? Will I be penalized?

Meredith_A._Lahl,_MSN, APRN: I’m not sure what you mean about incentive pay. If you are referring to an employer paying you to meet metrics, that is very specific to the employer.


Clinic Considerations

katie.l: Hi Meredith. Can you please share some information about the new APN fellowship at Cleveland Clinic? Thanks.

Meredith_A._Lahl,_MSN, APRN: I would love to share this work. It is a work in progress, and we are calling it a transition-to-practice because we want to retain all the great new graduates we hire. We are creating curriculums to meet the needs of new graduates in various clinical areas. The first one to launch is primary care. It will be a full year-long program, but with intensive clinical faculty involvement in the first three to six months. It includes simulation, baseline assessments, ongoing feedback, professional activities, such as QI projects, and mentorship. It is a work in progress, but we launch the first group this summer.


Closing

That is all the time we have for questions today. Thank you, Meredith, for taking the time to discuss advanced practice nursing.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.


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