Are Doctors Bribed by Pharma? An Analysis of Data.

An in-depth look at a recent paper that explores correlational data relating opioid prescribing to opioid manufacturer payments.

from The Health Care Blog

Association studies that draw correlations between drug company-provided meals and physician prescribing behavior have become a favorite genre among advocates of greater separation between drug manufacturers and physicians. Recent studies have demonstrated correlations between acceptance of drug manufacturer payments and undesirable physician behaviors, such as increased prescription of promoted drugs. The authors of such articles are usually careful to avoid making direct claims of a cause-effect relationship since their observations are based on correlation alone. Nonetheless, such a relationship is often implied by conjecture. Further, the large number of publications in high profile journals on this subject can only be justified by concerns that such a cause-and-effect relationship exists and is widespread and nefarious. In this article, we will examine a recent paper by Hadland et al. which explores correlational data relating opioid prescribing to opioid manufacturer payments and in which the authors imply the existence of a cause-and-effect relationship.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

More Nurse Practitioners Now Pursue Residency Programs To Hone Skills

There is a growing cadre of nurse practitioners who tack on up to a year of clinical and other training, often in primary care.

Michelle Andrews

The patient at the clinic was in his 40s and had lost both his legs to Type 1 diabetes. He had mental health and substance abuse problems and was taking large amounts of opioids to manage pain. He was assigned to Nichole Mitchell, who in 2014 was a newly minted nurse practitioner in her first week of a one-year postgraduate residency program at the Community Health Center clinic in Middletown, Conn.

In a regular clinical appointment, “I would have been given 20 minutes with him, and would have been without the support or knowledge of how to treat pain or Type 1 diabetes,” she said.

But her residency program gives the nurse practitioners extra time to assess patients, allowing her to come up with a plan for the man’s care, she said, with a doctor at her side to whom she could put all her questions.

A few years later, Mitchell is still at that clinic and now mentors nurse practitioner residents. She has developed a specialty in caring for patients with HIV and hepatitis C, as well as transgender health care.

The residency program “gives you the space to explore things you’re interested in in family practice,” Mitchell said. “There’s no way I could have gotten that training without the residency.”

Mitchell is part of a growing cadre of nurse practitioners — typically, registered nurses who have completed a master’s degree in nursing — who tack on up to a year of clinical and other training, often in primary care.

Residencies may be at federally qualified health centers, Veterans Affairs medical centers or private practices and hospital systems. Patients run the gamut, but many are low-income and have complicated needs.

Proponents say the programs help prepare new nurse practitioners to deal with the growing number of patients with complex health issues. But detractors say that a standard training program already provides adequate preparation to handle patients with serious health care needs. Nurse practitioners who choose not to do a residency, as the vast majority of the 23,000 who graduate each year do not, are well qualified to provide good patient care, they say.

As many communities, especially rural ones, struggle to attract medical providers, it’s increasingly likely that patients will see a nurse practitioner rather than a medical doctor when they need care. In 2016, nurse practitioners made up a quarter of primary care providers in rural areas and 23 percent in non-rural areas, up from 17.6 and 15.9 percent, respectively, in 2008, according to a study in the June issue of Health Affairs.

[khn_slabs slabs=”790331″ view=”inline”]

Depending on the state, they may practice independently of physicians or with varying degrees of oversight. Research has shown that nurse practitioners generally provide care that’s comparable to that of doctors in terms of quality, safety and effectiveness.

But their training differs. Unlike the three-year residency programs that doctors must generally complete after medical school in order to practice medicine, nurse practitioner residency programs, sometimes called fellowships, are completely voluntary. Like medical school residents, though, the nurse practitioner residents work for a fraction of what they would make at a regular job, typically about half to three-quarters of a normal salary.

Advocates say it’s worth it.

“It’s a very difficult transition to go from excellent nurse practitioner training to full scope-of-practice provider,” said Margaret Flinter, a nurse practitioner who is senior vice president and clinical director of Community Health Center, a network of community health centers in Connecticut.

“My experience was that too often, too many junior NPs found it a difficult transition, and we lost people, maybe forever, based on the intensity and readiness for seeing people” at our centers.

Flinter started the first nurse practitioner residency program in 2007. There are now more than 50 postgraduate primary care residency programs nationwide, she said. Mentored clinical training is a key part of the programs, but they typically also include formal lectures and clinical rotations in other specialties.

Not everyone is as gung-ho about the need for nurse practitioner residency programs, though.

“There’s a lot of debate within the community,” said Joyce Knestrick, president of the American Association of Nurse Practitioners. Knestrick practices in Wheeling, W.Va., a rural area about an hour’s drive from Pittsburgh. She said that there could be a benefit if a nurse practitioner wanted to switch from primary care to work in a cardiology practice, for example. But otherwise she’s not sold on the idea.

A position statement from the Nurse Practitioner Roundtable, a group of professional organizations of which AANP is a member, offered this assessment: “Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high quality, competent care. Additional post-graduate preparation is not required or necessary for entry into practice.”

“We already have good outcomes to show that our current educational system has been effective,” Knestrick said. “So I’m not really sure what the benefit is for residencies.”

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Headaches in the Community

An NP with decades of experience discusses diagnosing and treating patients with headaches, based on what she’s learned by specializing in pediatric headache and pain medicine.

by Victoria Karian

Headache is one of the most common problems seen in the primary care office. It is often a chronic complaint, not easily managed, and often an unsatisfying experience for families and providers. You can’t cure headache like an ear infection, it will always come back in some form or another. And while headache is technically a neurological problem, at its heart, headache is a chronic pain problem. It is not as glamorous or interesting as many neurological conditions. Many neurologists are not as interested in headache as they are in other conditions. Patients and families are often challenging and the issues are often multi-factorial, comprehensive and complicated. Chronic pain is a field that takes a certain mindset and approach, not for the faint-hearted. I believe that a multidisciplinary wellness approach to care is best, and our job is to guide the families to adopt that approach. This is time consuming, requiring a lot of counselling and coaching, to achieve good results, and most importantly to prevent disability.

Fortunately, for those of us who work in the headache field, there are many wonderful patients and families, more than happy to work as a team to achieve good results. You can have your chronic migraine patient with several comorbidities including inadequately treated psychiatric issues and significant disability as your first patient of the day. Then you can have a patient with episodic migraine or menstrual migraine, with many family members with migraine, has learned their triggers, has a rescue plan, and is doing well overall. It’s really a mixed bag in the headache world, which makes it a bit different than the usual chronic pain patients, especially in pediatrics. It is also more enjoyable.

I think the most important thing is being able to accurately make the diagnosis, identify appropriate treatment, and obtain buy-in from the patients and families to accept the multidisciplinary approach to care. Since I work in a tertiary care outpatient clinic setting, our patients have already been evaluated, tried some medications or treatments, and have not had success. Patients may have had inadequate medication trials, been given incorrect diagnoses and treatments, and establishing trust is difficult. In these days, instant gratification is desired, and this is just NOT a hallmark of headache care. Daily medications can take a month to see effectiveness (or not). Lifestyle changes take time. Learning cognitive behavioral skills take a while to become effective. Establishing a healthy headache lifestyle along with adequate treatment options is a marathon, not a sprint. There’s a lot of trial and error. Without the families’ trust, this journey is made even more difficult.

For the community provider, having some good baseline knowledge of headache, is a great starting point. In the next posts, I will review the primary headache in pediatrics. Learning to recognize the specific headaches and common treatments, both preventive and rescue, is the bread and butter of headache medicine.

Victoria Karian has been a nurse for 38 years and a PNP for 21 years, most recently working in pediatric headache and pain medicine. Her blog, headfirstpnp.com, was started to share information and common sense insights into acute and chronic headache management with other pediatric providers.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Retooled Vaccine Raises Hopes As A Lower-Cost Treatment For Type 1 Diabetes

The increasing cost of Type 1 diabetes, one of the most common serious chronic diseases, has created heavy financial burdens for families, with insulin prices more than doubling in the past decade.

By Carmen Heredia Rodriguez, Kaiser Health News

For Hodalis Gaytan, 20, living with Type 1 diabetes means depending on an assortment of expensive medicines and devices to stay healthy. Test strips. Needles. A glucose meter. Insulin.

The increasing cost of Type 1 diabetes, one of the most common serious chronic diseases, has created heavy financial burdens for families and generated controversy, with insulin prices more than doubling in the past decade.

Without her parent’s insurance, “I would not be alive,” said Gaytan, a student at the University of Maryland.

The burden of treatment is why a small study that shows promise for a simpler, cheaper alternative treatment to Type 1 diabetes is being met with hope — but also with caution and skepticism.

The research, published June 21 in the journal Nature Partner Journal Vaccines, showed that an older generic vaccine may help lower the blood sugar level of patients with Type 1 diabetes, decreasing their need for insulin. The vaccine, BCG, is used in a number of countries to prevent tuberculosis and has long been known to stimulate the immune system as well. That vaccine is relatively cheap, costing about $157 per dose in the United States, according to the health care technology company Connecture.

In the study, participants with long-standing Type 1 diabetes were injected with two doses of Bacillus Calmette-Guerin tuberculosis vaccine — known as BCG — four weeks apart. Three of the patients were observed for eight years. Nine participants were followed for five years.

The blood sugar levels — known as A1c — of those followed for eight years dropped by more than 10 percent three years after the injection and were sustained for five more years.

While the trial involved a tiny number of patients, the researchers — led by Dr. Denise Faustman, director of the Immunobiology Laboratory at Massachusetts General Hospital — are conducting a much larger Phase 2 trial of BCG to treat diabetes to see if the results hold up.

JDRF, a leading nonprofit organization that provides funding for research on Type 1 diabetes, and the American Diabetes Association issued a joint statement shortly after the new study was released, cautioning against misinterpreting the findings and stating that they “do not provide enough clinical evidence to support any recommended change in therapy at this time.” Both groups have partnered with drug manufacturers and device makers in the industry.

Still, Dr. Camillo Ricordi, director of the Diabetes Research Institute at the University of Miami, said he is “cautiously optimistic” about the findings, noting the “incredibly high price tag” for patients with diabetes. But he warned against generating “too much hype” among families before the treatment is proven to be effective.

Dr. Joseph Bellanti, professor emeritus of pediatrics and microbiology and immunology at Georgetown University Medical Center in Washington, D.C., was also encouraged by the studies’ findings. While he acknowledged the skepticism surrounding Faustman’s research, scrutiny is a necessary part of the scientific process, he said.

“We’re seeking the truth, and we want to make sure that the results and the interpretations are correct, Bellanti said, “and that requires healthy debate.”

Faustman said her findings are important because they suggest that the vaccine could have positive effects in the treatment of diabetes, similar to what has been seen in previous research on other autoimmune diseases, like multiple sclerosis, that involve an immune system reaction against normal tissue.

“It also opens up a host of new possible treatment avenues,” Faustman said, adding that it could help in developing interventions for other groups suffering from chronic illnesses.

Type 1 diabetes, which typically is diagnosed in childhood, occurs when the immune system destroys the cells that produce insulin. People with Type 2 diabetes produce normal levels of this vital hormone, but their bodies don’t respond appropriately.

These findings surface as the country grapples with soaring insulin prices — a rise so significant it has prompted attorneys general in several states and at least one federal prosecutor to launch investigations targeting insulin makers Eli Lilly, Novo Nordisk, Sanofi and pharmacy benefit managers.

The United States already pays a steep price for its diabetes burden. According to the American Diabetes Association, the 24.7 million Americans living with the diagnosis last year spent $237 billion in direct medical costs.

For patients like Gaytan, the prospect of new medications to simplify and reduce the costs of her treatment is tantalizing. She injects herself with insulin and checks her blood sugar level about five times a day. And she attends therapy to help deal with the burden of living with a chronic condition, and worries about how she’ll afford it in the future.

“I know diabetics [whose] families pay for everything,” she said, adding they “just can’t afford it.”

According to Connecture, the list price for Apidra SoloStar — an injectable insulin product that Gaytan uses several times per day — increased from $33.24 per pen in early 2009 to $104.28 per pen in early 2018.

Faustman said her research has documented the mechanism by which the old vaccine reduces blood sugar levels. In the Phase 2 trial, she will attempt to replicate her findings by following 150 participants with the disease for five years. It will be at least another four years until results are published.

Ultimately, if BCG works to treat Type 1 diabetes, its current cheap price could rise, said Gerard Anderson, professor of health policy and management and medicine at Johns Hopkins University in Baltimore, who, like Kaiser Health News, receives money from the Laura and John Arnold Foundation. Though BCG is generic, pharmaceutical companies can raise the price by altering the drug and issuing a new patent.

Drugmakers are expert at retooling old drugs to treat new conditions, he said, adding: “It could result in no cost savings at all — and, in fact, a higher price.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Fifteen Years of Progress: Biopharmaceutical Industry Survey Results

Take a look at highlights from 15 years of changes in biopharmaceutical manufacturing.

from BioPharm International

Since 2003, BioPlan Associates, Inc. has published an extensive annual survey of bioprocessing professionals. Since the first survey, which was started in collaboration with the American Society for Microbiology, critical bioprocessing issues have grown. The annual report has expanded to include 60 questions with nearly 500 pages of analysis and data. Manufacturing capacity issues have always been at the core of the annual survey, but as the industry has matured, the factors impacting capacity have become more complex.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Trying Physical Therapy First For Low Back Pain May Curb Use Of Opioids

A study published in the journal Health Services Research suggests trying physical therapy first may may cost patients less in the long run, as well as curb reliance on opioids.

from NPR

Though Americans spend an estimated $80 billion to $100 billion each year in hopes of easing their aching backs, the evidence is mounting that many pricey standard treatments — including surgery and spinal injections — are often ineffective and can even worsen and prolong the problem.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

How to Become a Continuing Education Instructor

Being a therapy professional doesn’t have to be limited to clinical practice. One alternative is to take on the non-clinical role of a Continuing Education Instructor.

from The Non-Clinical PT

Therapists, by nature, are educators, and that is a skill that provides a great deal of success in a clinical setting, as well as opportunities outside the clinic. One area of education that intrigues many therapists is continuing education. Becoming a continuing education instructor is a great way test out the waters of the education world, without the commitment of a full-time role. Being a con-ed instructor can also provide a good deal of flexibility and autonomy. 

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: One of the Worst-Ever Days of My Career… and Advocating for Patients

by Kimberly Spering, MSN, FNP-BC

Think about the worst-ever day of your career. Do you have one? Can you recount, in excruciating detail, the episode that you ranked as your “worst-ever?” I’ve had a few… but this experience rates in the top-3 of all time.

My day started as any other routine day…but I paused when I reviewed the chart of a younger male, Spanish-only speaking dementia patient.

He had seen his PCP earlier this week, where his wife recounted that he had increased agitation, hitting her in the head so hard, that she had chronic headaches (and likely a concussion).

His wife had recounted to me that he refused to wash, refused to clean up after using the bathroom, and the only way she could make him change his clothes was to cut them off.

She shared a long history of their decades of married life. His dementia worsened several years ago, but significantly so in the past six months.

At my last visit, he became significantly agitated when I took his blood pressure. He paced non-stop; I assessed his heart rate and lung sounds while he walked. He hit me when I tried to check his temperature, pulse, and oximetry. As a result, I gave up on his assessment.

Today, I came to his home to find him asleep – for about 5 minutes.

His wife admitted that he started to hit her, even when she didn’t try to provide skin care or clean him up. This was a change from his baseline, where he would only become agitated with his wife trying to do personal care.

His risperidone had run out several weeks prior to my visit. His wife felt it caused lower extremity edema, so she did not restart it — and the edema improved. His PCP started him on low-dose Seroquel for his agitation about one week before my visit.

His wife flatly said, “he’s much worse now.”

I recognized signs of violence today. He was pacing, staring and swearing at me in Spanish. I asked his wife what he was saying, via an iPad Spanish interpreter. She wouldn’t tell me. I chose to focus on his wife and not engage him, as it made him worse. I found out later that he was threatening me in Spanish.

His wife admitted to being very afraid of him. After all, he hit her before, and he could not be reasoned with.

Desperately, I contacted our office social worker. She recommended that we call Protective Services.

Well…that person told me to call 911 and the police.

So, after doing so, stressing that the patient was acting erratically, threatening us, and that I was concerned about our safety…the first officer arrived 20 minutes later. Meanwhile, all of the preventative measures that our safety officers had discussed about our safety in the home was foremost in my mind.

And the officer? Well, he he was oh-so-angry at this call he was forced to take.

I explained the scenario. Oh, and remember, the patient/family was ONLY Spanish-speaking, which I mentioned to the dispatcher.

He rolled his eyes and scowled at me. “You should have called Crisis Intervention.”

I explained, through my gritted teeth, that I had done so, and only called 911 at their request. It didn’t matter. With a furrowed brow and muttered words under his breath, he radioed into his precinct, looking for an officer that spoke Spanish. He then informed me that, “no one working today speaks Spanish.”

Um, OK. I use an iPad for my Spanish-speaking patients. It’s required in health care. He refused to use my medical interpreter, who was still online from our earlier encounter. Finally, he reached one of the police department secretaries who spoke Spanish, who was instructed to talk to the patient. I reiterated that he had dementia and no ability to communicate. It didn’t matter; he told her to talk to him.

After many failed attempts, along with my pleading to have his person speak to the patient’s wife, he finally told the office person to speak to her. She clarified the issues, and agreed to complete his involuntary commitment admission paperwork. The patient’s daughter arrived, speaking some English, and the officer requested that she convey he needed to go to the hospital. She did. The patient balked. The officers walked him outside, then determined that he needed handcuffs to take him to the hospital… “for his safety.”

And let’s not overlook the nosy neighbors, congregating in their yard, noticing his predicament.

So let’s look at the global picture here.

1. Spanish-only speaking male with advanced dementia
2. Patient hitting his wife at random, argumentative, and a risk to himself/others
3. Heightened safety issues in the home…and a police force that took 20 minutes to respond to my call for a critical situation
4. A police officer who appeared to refuse to communicate with a Spanish-speaking family, until this NP insisted repeatedly that this happen
5. Need for medication management and placement in a long-term facility – which could only occur in the inpatient setting
6. Significant family trauma, as they witnessed their loved one being hauled off in handcuffs to the hospital

I think, without a doubt, this was one of the hardest issues I’ve felt in 27-plus years of nursing/NP practice. The grandson threw himself down in the yard, wailing. His wife sobbed non-stop, watching her husband being carted away like a criminal. And, let’s remember, he has Alzheimer’s Disease dementia with agitation.

He is not a criminal. He is not a derelict. He is not an “illegal immigrant.” Oh, but he just-so-happens to be Spanish-only speaking in a county that is predominantly Caucasian. And…oh yes, he has a NP who is a fighter and advocates for folks like him.

There HAS to be a better way to manage these situations.

A way without using restraints.

Not handcuffing folks who don’t have the ability to understand what is happening. Handcuffing patients should be an absolute LAST resort – not one that is convenient. And frankly, it will agitate dementia patients more if handcuffed.

Increasing education to our law enforcement about treating folks with dignity. These patients don’t understand, nor control their reactions. That doesn’t mean that they should be treated with harshness or lack of understanding.

Let’s imagine, if you will, having a relative with advanced dementia. One who is acting out more, being argumentative, resisting care. Would YOU like your loved one to be arrested and hauled away? Or would you advocate for those in the first response team to use compassion and try to understand the issues?

I’d bet, you would want the latter option.

It is our responsibility to advocate for these patients. Support their needs in declining cognitive function. Be their support when times get tough. Figure out ways to make life easier for them.

Wouldn’t we all want the same? Think about it.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

A Day in the Life of a Rural Nurse Practitioner

While the exact daily responsibilities vary according to the type of clinic or office where an NP works, most rural NPs enjoy a great deal of autonomy while performing a wide range of tasks.

from NP Schools

Currently, only about 20 percent of physicians working in rural areas are under 40 years old, and 30 percent are rapidly approaching (or have already passed) retirement age. Due to an aging population and a lack of experienced and trained professionals, there is increasing demand for healthcare professionals in rural areas, leading to a significant opportunity for nurse practitioners to pick up the slack. Take a look at what a typical day in the life of a rural NP looks like.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Should I Quit This Darn Nursing Job?

Have you ever wondered when it’s time to quit your nursing job and move on? Are you stuck in a job, uncertain where to go next as a nurse? Or do you just need a change of scenery?

From Nurse Keith’s Digital Doorway

Have you ever wondered when it’s time to quit your nursing job and move on? Are you stuck in a job, uncertain where to go next as a nurse? Or do you just need a change of scenery? It’s all about timing, self-care, finances, lifestyle and workstyle, career development, and other factors that impact how long you stay and when (and why) you go.

Ready to Move On or Not?

Making the choice to move on from a nursing job you’ve had for a while is not always an easy choice. There are multiple reasons to move on, just as there may be a myriad of reasons to hang in there.

What has led you to quit jobs in the past? Was it money? Was it health insurance or other benefits? Were you mistreated, overworked, burned out, or underpaid? Did you receive an offer you simply couldn’t pass up? Did you need to relocate? Were there other reasons you left for greener pastures?

Sometimes we feel we should move on but something stands in our way. Is it the money or the benefits? Is it pressure from our spouse or family to not undergo the stress of a job change? Or is it just regular old lack of motivation and career lethargy?

Whether you currently need to move on or not, it’s always good to be prepared for the eventuality that a change may be on the horizon.

Some Reasons to Quit That Job and Move On

How many reasons are there to quit your nursing job? Let me count the ways.

Poor leadership/management: One of the top reasons that people leave jobs is poor management and leadership. When you don’t feel supported by those who you report you, the game’s over and it’s time to jump ship.

Your nursing license is endangered: If your work environment is such that you feel that your nursing license is at risk, leave that job today and don’t look back. No amount of money or benefits or prestige is worth the risk of losing the license that you’ve worked so hard to earn and maintain. An untold number of circumstances or conditions can endanger your license, patient care, and perhaps even your safety. My advice: don’t compromise on this ever! It’s just not worth it.

You are physically unsafe: An unsafe environment where you’re physically in danger and have little or no protection is a workplace that simply doesn’t deserve you. If your workplace doesn’t offer the resources to be physically safe from harm, grab your parachute and leap from the plane before you experience unnecessary and wholly preventable injury.

Mistreatment/bullying/harassment/etc: Mistreatment and aberrant behavior thrive in nursing and healthcare for some reason. Bullying is rampant, and discrimination and harassment are common. The presence of such behavior, when it goes uncorrected, is a sure sign that you need to exit, stage left as soon as possible. In the presence of persistent on-the-job bullying or harassment, I generally advise clients to leave their job immediately since that type of toxic environment eats away at the soul and psyche in very unhealthy ways that can be more damaging than being unemployed for a period of time between jobs. Bullying can cause you to make errors and lose confidence, and no one needs that kind of energy running in their work lives.

Overwork/staffing issues/burnout/unhealthy environment: This is so common it’s almost laughable if it wasn’t so tragic. California is the only state in the U.S. with mandated nurse-patient ratios, although some other states are moving in that direction. Legislation to mandate safe ratios nationwide makes its way through Congress every year but has yet to come down for a vote. Burnout often results from overwork, the pressures of mandatory overtime, long hours, high ratios, and unsafe staffing that can result in nurse or patient injury, medication errors, and many other less than positive outcomes.

Pay and benefits: With the cost of living as it is in the 21st century, it’s understandable that some nurses choose to leave their jobs in pursuit of more pay or improved benefits. Health insurance and your personal healthcare can be expensive, and some employers offer much more robust health benefits that others. Healthcare and childcare savings accounts help employees shelter more of their money from taxation, and other benefits like time off and money for continuing education can be attractive.

A better opportunity: Sometimes we leave jobs because something better came along. You never know when a new opportunity may cross your path, so be ready to jump when the jumping is good. New opportunities can lead to more responsibility, new clinical skills, a shot at a new circumstance that lends itself to career-building, or a host of other potential positive outcomes.

Relocation: Moving to a new home in a new town, city, or country is a common reason to leave your job. Relocation is common, and sometimes we just have to move for a variety of reasons, even if we’re happy in our work.

How to Leave Gracefully (or Not)

It’s almost always preferable to leave on a good note in the interest of relations and your reputation. If possible, you also may want to line up your next position before handing in your resignation. Of course, this is an optimal situation, and sometimes optimal is just not what presents itself. Here are some pointers for how to exit as gracefully as possible:

Give ample notice: I always recommend telling your boss that you’re leaving before you tell your colleagues (unless you have a peer in whom you’ve been confiding your plans). In terms of avoiding the unnecessary burning of professional bridges, try to give at least 2 weeks’ notice. However, it’s my humble opinion that giving notice isn’t totally necessary for a variety of reasons. For example, if you’ve documented bullying and reported it to your supervisors or managers, you deserve to leave stat if they’re consistently unresponsive. When you first report the situation, consider telling them that you’ll need to leave forthwith if the situation isn’t addressed appropriately and quickly. If you report it more than once and nothing happens, you’re in your rights to get out of there.

Request an exit interview: Exit interviews happen routinely in many industries, but I don’t really hear about them much in the healthcare setting. When preparing to leave, request an exit interview where you can give your employer or your supervisors feedback. If no exit interview is granted, put it all in writing, keep a copy for your records, and distribute it to as many key players as you like (e.g.: CEO, CFO, CNO, nursing director, charge nurse, supervisor, etc).

Connect with colleagues: A big order of business is connecting with friendly and supportive colleagues on LinkedIn throughout your career. It’s advisable to keep in touch with colleagues and peers over time for a variety of reasons, and LinkedIn is a great way to organize them all in one place. If you’re planning to quit or resign, begin connecting with your colleagues who you like and respect the most. Your ongoing job will be staying connected with those peers with whom you have the most positive rapport — you may need each other in the future. A nice gift to your best colleagues is to write them a recommendation on LinkedIn, which may be reciprocated. You can even ask to exchange recommendations with those with whom you share mutual respect and admiration. You can also ask certain individuals to serve as references in the future.

Offer to train your replacement: If you’re in a position with unique responsibilities, offer to train your replacement (if it’s at all possible). Sometimes we’re the holders of important knowledge or skill that needs to be passed on to the next person when appropriate.

Be self-contained: When you’ve decided to leave, play your cards close to your chest and don’t blurt it out everywhere at once. Be sensitive to your colleagues who may want to leave but can’t yet do it — they may be envious of your escape plan. Be empathic with those you’re leaving behind, especially if it’s a toxic or difficult work environment. Share the news of your leaving quietly and gracefully.

Document: If you wrote articles, co-authored studies, took part in committees, or otherwise got involved at work, save copies of anything you were a part of (unless, of course, it’s protected proprietary information that can’t legally leave the workplace).

Pat yourself on the back: You deserve it. Period.

As you can see, there are plenty of things to do in order to move forward into a brighter future.

Summing Up

Once you decide to leave, update your resume and LinkedIn profile with your new data. (If you’ve been following my advice all along, the job you’re leaving has been on your resume and LinkedIn profile since you first started that gig.) If you’re starting a new position right away, add it now.

If you’re leaving without the safety net of another job, you may have some budgeting to do. If you have a spouse or partner, make some plans — if you’re single, you’ll have to be even more diligent in terms of managing a period of unemployment on your own.

Once you start a new gig, begin forming relationships with fellow colleagues, connect on LinkedIn, and otherwise set the table for success.

When interviewing for your next position, you’ll most likely need to explain why you’re planning to leave your current job or why you already left. Have your authentic story ready — every circumstance is different, so there are no cookie cutter answers here.

If you need help in such an important transition, make use of a career coach, mentor, trusted colleague, or counselor. It can be a lonely and stressful time, so ask for support from whomever would be most effective at being present for you when you need it the most.

Leaving a job is a potentially stressful time, especially if you don’t have anything else lined up quite yet. Be thoughtful, circumspect, kind, strategic, organized, and gentle with yourself, and things will fall in place as you do your due diligence and move forward into an even more promising future.

Keith Carlson, RN, BSN, NC-BC, is the Board Certified Nurse Coach behind NurseKeith.com and the well-known nursing blog, Digital Doorway. Please visit his online platforms and reach out for his support when you need it most.

Keith is co-host of RNFMRadio.com, a wildly popular nursing podcast; he also hosts The Nurse Keith Show, his own podcast focused on career advice and inspiration for nurses.

A widely published nurse writer, Keith is the author of “Savvy Networking For Nurses: Getting Connected and Staying Connected in the 21st Century,” and has contributed chapters to a number of books related to the nursing profession. Keith has written for Nurse.com, Nurse.org, MultiViews News Service, LPNtoBSNOnline, StaffGarden, AusMed, American Sentinel University, the ANA blog, Working Nurse Magazine, and other online publications.

Mr. Carlson brings a plethora of experience as a nurse thought leader, online nurse personality, podcaster, holistic career coach, writer, and well-known successful nurse entrepreneur. He lives in Santa Fe, New Mexico with his lovely and talented wife, Mary Rives.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.