Charles Yingling, DNP, FNP-BC is who I want to be when I grow up. This is not said lightly, since in most (okay, all) cultures I’m considered completely grown up. However, there is no other nurse practitioner I respect more. He is fighting the good fight to elevate the nurse practitioner profession by example and through education. Dr. Yingling is a clinical assistant professor in the Family Nurse Practitioner program at University of Illinois at Chicago. In addition to teaching, he maintains an active clinical practice at PCC Community Wellness, a federally qualified health center (FQHC) in Chicago. I recently interviewed him to gain his insight on teaching, avoiding burnout, and the future of our profession.
1. Why did you become a nurse practitioner?
I graduated from nursing school in 1999, and my mom was a nurse. She told me about nurse practitioners, but I never met one when I was in school, though I knew they existed. I loved community health in school and I knew that I didn’t want to work in a hospital, but everyone always tells you that you need to work in the hospital. So I worked in the hospital for a few years, paying my dues, and I don’t regret it. But I loved the idea of becoming a primary care provider – where the role of the provider is to maintain a normal state of health. In nursing theory class, I learned Virginia Henderson’s theory that the role of the nurse is “to be as dispensable as possible as early as possible”, meaning that we assist people to take the necessary steps to maintain and improve their health that they would otherwise do on their own if they had the strength, will or knowledge. The normal tendency of humans is to stay as healthy as possible, and that sums up my philosophy of healthcare. The medical model presumes that an illness has occurred and we will remedy that illness. The nursing model is a complement to the medical model, like a yin-yang. I felt that as a nurse practitioner I could embody that nursing model’s role. So that’s why I became a nurse practitioner. Also, I resented working in hospitals. And I liked the autonomy. Not to diminish the role of the inpatient RN at all, but I knew that as a hospital nurse I could be easily replaced. If I didn’t show up one day, someone could easily just take my place.
2. You are a fantastic clinical instructor at UIC and an expert advanced practice nurse. I’m hoping to one day go back and teach as well. Can you tell me how you started teaching and how you got to where you are at now?
I got my first job out of NP school at UIC’s Integrated Healthcare. The model of that clinic is a nurse-managed health center that was built as a partnership with Thresholds, a community-based mental health service provider. I dreaded that rotation as a student, but as I was there longer I turned out to love it. When I graduated they were looking for an NP and I applied and got the position. It was a great fully mentored first year of practice; it was challenging intellectually and I had very complicated patients. Students would rotate through there because of the UIC connection, so I slowly took on a precepting role. Gradually, I was doing more and more teaching, and I had reached a point where I needed to figure out if I wanted to be a clinical instructor or a clinician – I was doing a 50/50 split, but that’s not really possible, it was more like 75/75. It was not a good balance at all, so I changed my schedule and decided I would focus more on education. Now I’m doing 80% teaching, 20% clinical, which is working out so much better. I feel like I’m making a bigger impact as an instructor, and I feel like this gives me the balance that I need. As you know, being a clinician is a high burnout position.
3. Indeed! Speaking of burnout, how do you prevent burnout?
Clinically it’s all about boundaries. When I first started all of my patients had such high needs. They needed housing, food, they were struggling with substance abuse problems, and they all had very real physical health problems. I didn’t know how to navigate the boundaries. I didn’t know how to say emotionally, “Your problem is your problem, and not my problem.” Not to sound callous, but I was burning out after only two years, always worrying about my patients and fretting about their needs. It was only when I saw my own primary care doctor, who was one of the most compassionate providers I have ever encountered, when it finally became clear to me. By the way, he always referred to himself as a nurse practitioner extender; he is such a great man! Anyway, he and I were talking about my job and he said to me “it seems like you are doing so much good for your patients, but what is it like for you when all your patients are receiving all of your energy, and you’re not receiving anything back?” It dawned on me that what he was asking was so true, that it was a one way flow of energy, with no real energy return. I had been getting demoralized at work because I couldn’t make my patients stop doing what they were doing, be it destructive health behaviors or using drugs. So I started to become very self-aware, knowing when I was starting to see my patient’s problems as my own. I had to remind myself that it’s not a failing of the clinician if the patient continues to make poor decisions for themselves, it’s their right to do that. It was a slow process to learn to do that, but it has served me well since.
Another way to avoid burnout was sharing responsibility. This just happened last Thursday, I was seeing a woman who was very actively suicidal. Long story short, we had to decide whether to let her stay at home and see the psychiatrist the next day, or call 9-1-1 and hospitalize her involuntarily. I made the decision to let her stay at home, but I involved the entire team in making that decision. I involved all the other clinicians in the decision making, I had the MA call her in the morning, I notified the psychiatric NP immediately to let her know that she was seeing my patient in the morning, I basically shared the responsibility so it wasn’t only my burden to bear. There’s a team at most facilities and you can bear that burden together instead of having to bear it yourself.
Lastly, when choosing a job, do not accept anything that gives you less than four weeks of holiday. I really believe in a quarterly break to acknowledge self-care. You don’t have to go to Mexico, but you just need one continuous week of not working. There was a time when I was working overtime and trying to save up all my PTO because I knew we were going to adopt soon, so I just kept working continuously. One of my coworkers took me aside one day and just told me “you need a vacation, you have been working non-stop!” She was so right, it’s not worth it. This is partially why I teach too, there’s natural breaks built into the year.
4. You have seen many new nurse practitioners come and go. What are some of the biggest mistakes you see up-and-coming nurse practitioners make? How can they avoid those mistakes?
I think the biggest mistake I see is accepting a job because it’s the first thing that came along. It’s like that phrase “A bird in the hand is worth two in the bush,” people act on just that, never mind that there’s other potentially more fitting positions out there. Of course there’s practical considerations, but sometimes I see people accepting less than what they’re worth. There’s things like pay but also things like vacation times are important to look at.
The other thing is related to boundaries and letting patient’s social and medical problems encroach onto their own. That happens with presuming you have more control than you actually do on your patient’s health. My friend, who is a marriage and family therapist, said it best as I was lamenting my inability to effectively help a patient make health behavior changes. She said, “Really, Charlie? You have the ability to control people’s thoughts and actions?” It’s like the old adage “you can take a horse to water, but you cannot make him drink.” We do not have control over patients’ decisions that they make for themselves, and you need to learn to not beat yourself up over it. It’s like when you look at a patient and think “oh my goodness, they’re a complete train wreck!” You rush to fix everything, however you have to remember that this is a slowly unfolding train wreck that’s been opening up slowly before they met you, and it will continue to unfold for probably several more years. I think it is easy to get caught up in thinking that things need to be fixed immediately, but most situations are not emergencies.
The last thing is being seduced by money rather than experience. The case study for this is retail clinics – it’s not a good first experience for nurse practitioners because there’s very little mentorship, but they pay well. I would recommend you take the job that gives you the quality experience.
5. Where do you see the future of APN’s? Will we all be DNP’s? What are our greatest obstacles as a profession?
The writing’s already on the wall for DNP’s, that’s definitely not going away. But I cannot see anything in the foreseeable future, at least the next ten to fifteen years, that will put masters’ prepared nurse practitioners at any disadvantage in the job market. The scope of practice laws are also going to change, and it’s getting there little by little. I think we have about seventeen states that have full practice authority. As the evidence that supports NP practice continues to grow, one of the most insightful questions I was asked by my state representative was if there was a state that gave full practice authority to NP’s and then had to reverse it because it was not working well? And I realized, there definitely isn’t. Rather the scope has grown and grown after each state became a full practice authority state. The Illinois state senator that oversees the licensed activities committee would not speak to me directly, but her staff nicely told me that she would not change her opinion on this topic, and a good portion of it was because nurse practitioners do not have a doctoral degree. I told her we actually do. As yet there’s no evidence that a DNP provides safer care than an MSN, but for a lay person it is harder to see that. Thus if we are seeking legitimacy, and we are constantly needing to defend our legitimacy unfortunately, we need to have a terminal degree in our profession.
Also we need to fix the system where students are sometimes finding their own clinical practicums. When we go to a legislative office and they ask us how we teach our students clinically, it’s hard to say “well we give them a telephone and tell them to start calling!” I was at a national conference recently where I stood up in response to a question about what we, as educators, would tell university administrators, and I said that we should limit the number of spots in our NP programs to how many we can take responsibility for placing clinically. I thought that was such a no-brainer, but a woman in the crowd defended the practice and told the group that her students were learning job seeking skills from the process. So, even among NP educators, there is a disagreement about this practice. Though, I continue to believe that our role as NP educators must be to train future NPs in clinical and leadership skills, rather than clinical placement finding skills.
6. But what about all of us who already are practicing as MSN’s? Do you recommend practicing NP’s to go back for their DNP?
If you have more than fifteen years of practice left in you, then definitely yes it’s worth it. However there’s a lot variability between programs, so you should shop around for programs that fit your needs and interests. I can’t speak for the for-profit programs, but there are a vast number of distance learning options in the not-for-profit programs that make it worth the energy and worth the time. Speaking for myself, completing my DNP has broadened my view of how the healthcare system works. Just like an Associate’s prepared nurse is perfectly capable of performing the skills to take care of a patient, but the Bachelor’s prepared nurse is trained better to take care of the patient and think about what happens after they get discharged into the community. I saw this evolution in my practice from when I went from an MSN into a DNP. As a MSN you think “Wow, our healthcare systems sucks” and you just get by as well as you can, but as a DNP I was able to see why the system is the way it is and what we can do to change that system. It’s a systems education, and NP’s can lead the change to fix our broken system. So, the short answer is, I would definitely encourage people to do it.
7. If you had the chance to completely restructure the way nurse practitioners are trained, would you make any changes? Why?
First, we would not admit students to a program that didn’t have the ability to arrange and supervise their clinical placements. Clinical learning should be held to the same rigorous standards as classroom learning. We need to provide resources to support the continuity of those clinical experiences. Also, we need to start compensating preceptors for their generosity. If preceptor generosity dried up tomorrow, NP education would effectively cease entirely.
Also we need to adopt a lifespan-management curriculum that gets more complex over time but addresses the entire lifespan in each course. Many programs teach management in discrete topic areas during a given term (e.g. women’s health, adult health, pediatrics). Unfortunately this makes it difficult to apply classroom learning in a family practice setting where every day includes care of people across the lifespan. We need to structure our management courses to more accurately reflect the clinical experiences in which we place our students.
Like I was saying before, we also need standardization to the DNP. It makes it easier to communicate with legislators, consumers, stakeholders and other clinicians about our profession if we are all educated to the same level. This is necessary if we want equity in our pay and we want full practice authority. It gives us a leg to stand on when we have a very well developed educational model that’s consistent across programs.
Rapid Fire Questions (Answer with only one sentence!)
1. You have just wrapped up your fifteen minute visit where you addressed all your patient’s needs (or so you thought), and then he asks, “So you’re the nurse practitioner, right? When will I be seeing the doctor?” How do you respond?
I would be happy to schedule an appointment with a physician at a time that’s convenient for you, but your appointment today is with me, the nurse practitioner.
2. Favorite conference you’ve ever attended?
AANP every year.
3. What is the best part of teaching?
Having the opportunity to see the impact that former students have on their patients and the healthcare system.
4. The worst?
The worst part of teaching is salary inequity between practice and teaching.
5. Why work at a FQHC?
Community health centers, aka FQHC’s, embody the nursing philosophy of accessible, affordable, patient-centered care.
6. Affordable Care Act, good or no good?
Good in theory, bad in practice. Single payer healthcare (i.e. Medicare for all of us) is the only solution.
7. White coat, yay or nay?
8. Should DNP’s refer to themselves as Dr. ___ to patients?
I see no reason why they shouldn’t, though I do not.
9. Snack of choice when charting through your lunch break?
A mangoñada from La Michoacana in Cicero – a mango smoothie with a ribbon of chamoy sauce, a healthy dose of lime, and a sprinkle of tajin!
10. Final thought or last piece of wisdom?
Call your legislature and demand full practice authority.