I would say in pediatric nursing, those who chose pediatrics want to be there. The nurses are a little nicer, there is a sense of hope, one which is sometimes missing in adult medicine where chronic illnesses and end of life issues are apparent. There are some who will go to all measures to save a child.
About Kelly Ruemmele, MSN, PNP-BC: Kelly Ruemmele is a Pediatric Nurse Practitioner with over 15 years of experience across numerous medical settings. She currently works at two private practices, providing pediatric primary care services to a primarily underserved Medicaid population in Pasadena, Texas. She also serves patients in the Legacy Community Health Care System, at Urgent Care for Kids, and Houston Methodist Sports Medicine.
Ms. Ruemmele also works as an Adjunct Nursing Instructor at Texas Woman’s University’s College of Nursing, where she teaches advanced health assessment courses and the accompanying clinical skills lab. She has also held Clinical Instructor roles at College of the Mainland, San Jacinto College, and the University of Texas Medical Branch (UTMB) School of Nursing.
Prior to her work as a pediatric nurse practitioner, Ms. Ruemmele was a Registered Nurse at Texas Children’s Hospital and a Staff Nurse at UTMB’s Children’s Hospital, within their Medical-Surgical Pediatric Unit. She earned her BSN from UTMB at Galveston in 1994, and her MSN with a specialization in Pediatric Nurse Practitioner in 2000 from the same institution.
[OnlineFNPPrograms.com] Could you please provide us with an overview of your academic and professional path in advanced pediatric nursing?
[Kelly Ruemmele, MSN, PNP-BC] I began my nursing career working as a patient care assistant at UTMB Children’s Hospital while attending the school of nursing at UTMB in Galveston. After graduating in 1994 with a BSN with Honors (Bachelor’s degree in Nursing) I was inducted into Sigma Theta Tau, a national nursing honor society. I was very active in the school’s student nurse’s association, Texas Nursing Student Association.
Concluding graduation, I began working as an RN and charge nurse on a general, inpatient medical-surgical unit at the UTMB Children’s Hospital for a year. In 1995, I had the fortunate opportunity to work at Texas Children’s Hospital (TCH), which is situated in the world-renowned Texas Medical Center and ranked 3rd top children’s hospital in the US. My career at TCH began as a registered nurse (RN) with charge nurse responsibilities on an inpatient pediatric cardiology unit for almost 2 years. Floor nursing gave me solid foundation to grow. Initially, I had applied to the PICU as a new graduate; however, a position was not available. Two weeks after applying to transfer to the PICU, my old unit needed a day nurse manager and I rose to the challenge. I stayed in that position for almost 2 more years, staffing the unit 50% of the time, while managing schedules and giving yearly performance appraisals for 30 employees, including RNs, LVNs, nurses aides, and EKG techs. Nursing management has its challenges–I was often pulled into staffing more often than not and expected to keep up with my management duties.
I’d always wanted to go back to school for an advanced degree and it seemed logical to pursue the Pediatric Nurse Practitioner (PNP) route as my entire nursing experience was in pediatrics. Luckily, a faculty mentor was my course director. At that time, I decided it was best to step down from my management position and transferred to a part time “float” nurse position. Floating gave me the ability to schedule my days around school and the pay was comparable to my management position. Floating is hard work; often the staff reserve the most challenging patients, and jumping into a different unit daily is difficult. The benefits of floating in hindsight outweigh the negatives–I was able to gain experience in the PICU, Level II nursery, every sub-specialty unit in the hospital, and most valuably the ER.
Graduate school included over 600 hours of clinical time in primary care, which was all new to me. My nursing experience up until graduate school was entirely hospital-based acute care. In nursing graduate school, all of the clinical sites were entirely out-patient based, solo practices, school based clinics, and often located in underserved areas. With time, I was able to acclimate to outpatient care. The benefits of working in primary care includes 8 hour days and typically no weekend or holiday shifts, with comparable hospital pay.
In 2000, I graduated with my MSN with a Pediatric Primary Care concentration. At that time, I was expecting my daughter and began working with Dr. Gendi on a part-time basis. Since that time, I have worked in many private pediatric offices, serving a primarily Hispanic Medicaid population. I began raising my children and decided to transition to teaching nursing clinical rotations at various institutions, such as local Associate Degree community colleges and Bachelor’s degree universities.
The Texas Board of Nurse Examiners (BNE) requires all nurse practitioners to obtain 400 clinical hours in pediatric primary care every 2 years in order to maintain licensure. Teaching nursing did not meet these requirements; therefore, I was unable to renew with the necessary hours and returned to my general RN license, but always maintained my national certification as a PNP though the Pediatric National Certification Board (PNCB) since graduation. I do not regret that decision.
Once my children were in school, I contemplated my next career move. Did I want to continue teaching or return to primary care? In order to return to PNP work, I needed to complete 400 hours of unpaid clinical time. I eventually decided to go for it. While working towards my hours, I taught in the Advanced Health Assessment course for NP students at Texas Woman’s University and have continued to do so for the last 5 years. Securing a clinical site was tricky as I wasn’t a student or a licensed PNP. Many offices were swamped with students and others were hesitant. I eventually found private offices, rather than university or larger offices, were more receptive to my situation. Often, I was able to spend only a few days at a time, but eventually, I was able to reinstate my NP license with the BNE. I found a part-time position with Dr. Carlos Melendez’s office, where I currently work with a Physician Assistant serving a primarily Hispanic patient population.
I’m fortunate to work part-time in a clinical setting while teaching in the graduate program. Due to my part-time status, I work in many locations on a per diem, or as needed basis. In addition to working at Dr. Carlos Melendez’s office, I work at Dr. Aucinson’s office serving patients from newborn age to 18 years of age. I also contract as a Locum Pediatric Nurse Practitioner, often filling in for providers’ vacation time. Agency companies send me on assignments, such as providing sports physicals and health screenings through Houston Methodist to help underserved high schools during the summer months. I’ve also worked in urgent care clinics such as Urgent Care for Kids, Legacy Community Health Care systems, walk-in clinics, and Dr. Ortega’s Pediatric clinic.
[OnlineFNPPrograms.com] Could you please describe your core responsibilities as a Pediatric Nurse Practitioner?
[Kelly Ruemmele, MSN, PNP-BC] As a pediatric nurse practitioner, I see patients for both well and sick visits, conduct health assessments, and provide primary care services such as immunizations, patient education, and screenings for specific pediatric diseases and disorders. Well visits are scheduled appointments for when patients are not sick, such as routine checkups. Sick visits include appointments to address coughs, colds, skin infections, rashes, and most common childhood illnesses.
Education is the foundation of all primary pediatric care. NPs share information on developmental stages, common illnesses, and chronic conditions such as obesity, asthma, and even constipation with their patients, with the aim of empowering them with knowledge to prevent more serious ailments or conditions down the road.
PNPs screen for autism and speech delays, referring to available resources and coordinating the care with external specialist agencies. It’s imperative to intervene early with suspected delays, as the early intervention increases success in closing gaps. We order labs to determine anemia, lead poisoning, and to evaluate obesity and pre-diabetic conditions and we are able to write necessary prescriptions, such as antibiotics.
The MAs (medical assistants) obtain vital signs, height, weight, and determine necessary vaccines and administer them. Some offices employ LVNs and/or RNs to assist the providers, often in major medical groups or university based practices. The NP reviews the record, performs the physical exam, and orders necessary tests. Follow up for testing and further evaluation is done when results are available and communicated to the parents either by phone, with consultants, and/or scheduled follow up appointments.
Most offices, whether private or large, are more alike than different; the basic care administered is the same. Larger offices tend to have multiple providers available for consultation for difficult cases, and may offer their employees more extensive benefit packages. It’s fair to say that staff turnover is often higher at larger offices as well.
The challenges facing my patients, which has also become a national concern, is the high prevalence of obesity. Our patients often eat a high fat diet, fast foods, starches, sweetened beverages such as sweet tea, juices, and soda. They consume few fruits and vegetables. This diet also causes a great deal of constipation, which translates into stomach pains so severe that it is leading to school absenteeism. Financial resources are scarce; many are on public assistance, such as WIC and food stamps.
We struggle as practitioners to combat circumstances which interfere with our pediatric patients’ health: public schools have cut back on physical education to 2-3 days/week, parents have concerns with allowing their children outside for safety reasons, and increased tablet time all contribute to the problem. School lunches are also high in fat, and parents rely on them due to financial resources.
Another issue, which is unique to Houston’s urban and suburban areas, is asthma. The climate has frequent fluctuations in temperature, high pollen and mold counts, and pollution from nearby chemical plants. Asthma also plays a part in hindering physical activity and school attendance, adding to the obesity crisis. Providers manage these conditions by prescribing allergy medications, preventative inhalers, and referrals to specialists, if necessary. Fortunately, about half or more of all children outgrow the condition or have a drastic decrease in flare ups.
As practitioners, we educate parents on the importance of healthy food choices including high fiber foods, limiting starches, increasing water consumption, and increasing physical activity to 20 minutes per day. Some offices have implemented exercise programs and frequent office visits assessing weights at 3 month intervals. This is an ongoing issue for all ages, as the best outcomes are when the entire family embraces the healthy lifestyle change.
On a positive note, my patient population is extremely compliant with vaccinations and scheduling well visits. While there is considerable vaccination controversy facing many practices, we claim a 100% vaccination rate. Other preventative measures completed during the well check visits include: applying fluoride varnish for children 6 months to 3 years of age. NPs educate parents to transition off the bottle by age 1, brush teeth twice a day, and encourage dental cleanings every 6 months to prevent dental caries. For the most part, my patients are very positive and often have a large, supportive extended family and there are few mothers with postpartum depression.
By far the best part of my job is the privilege of walking with my families as they raise their children from infancy and adolescence. Collaborating with parents, giving advice, and listening to their struggles to meet the common goal of raising happy, healthy children. One challenge is that I am not bilingual and still struggle with the language barrier, but I continue to learn each day and my patients are patient with me!
[OnlineFNPPrograms.com] Could you please explain how the responsibilities of a pediatric nurse practitioner differ from those of a pediatrician? Also, what is the difference between pediatric acute care nursing and pediatric primary care nursing?
[Kelly Ruemmele, MSN, PNP-BC] My role as a Pediatric NP is similar to that of a pediatrician. I am able to work independently, with a delegating physician providing the prescriptive authority. States have the legislative power to control NPs’ ability to practice independently. The only requirement in the state of Texas for PNPs to practice independently is to meet face to face with the supervising physician on a monthly basis to review charts. I see approximately 30 patients a day for a mixture of well and ill visits.
There is an ongoing trend to hire NPs to meet the demands of the Affordable Care Act, and many private physicians’ offices hire nurse practitioners in order to accommodate increasing numbers of patients. Most offices need to see at least 25 patients to stay afloat, and well checks are not only fiscally important, but also the foundation of pediatric primary care.
Advanced pediatric acute care and primary care do not generally overlap when it comes to practice sites. Acute care NPs are typically only able to work in a hospital setting and Primary care NPs only in outpatient settings; however, there is a cross-over with some urgent care/EC settings where the two may practice. A pediatric primary care NP can receive acute care certification, and vice versa, if he or she obtains more education, returns to graduate school for a post-Master’s certification which may take up to a year and includes some didactic and clinical hours in a hospital setting. Clinical hours would typically be completed in the PICU, managing patients, acting as a “medical resident.” Clinical hours are “hands-on” or with simulation experiences. Didactic instruction can be completed by attending lectures, online modules, or by examinations.
Occasionally, acute care NPs act as the liaison between the attending physician and the residents who switch out monthly. They are the constant in the equation, keeping the staff informed of policies and procedures unique to the area of expertise or specialization. Almost all pediatricians rely on hospitalists, like an acute care NP, to manage their patients if/when they are admitted into a hospital setting for serious conditions, and to then transfer care back to them in outpatient.
[OnlineFNPPrograms.com] What are the challenges and rewards of advanced pediatric nursing?
[Kelly Ruemmele, MSN, PNP-BC] The most challenging facet of pediatric nursing is family centered care. The patient includes the family, the parents, and even the extended family. The views on pediatric versus adult medicine are sometimes polarizing. There are some nurses who refuse to work with children for various reasons–some hate to see sick children, others have difficulty working with parents or other family members, some simply don’t like children.
Working with children can be stressful–meeting each one at their developmental stage takes time, and is not always straightforward as some are not verbal, and in those cases we must rely on parental reports, which can be conflicting or incomplete.
I would say in pediatric nursing, those who chose pediatrics want to be there. The nurses are a little nicer, there is a sense of hope, one which is sometimes missing in adult medicine where chronic illnesses and end of life issues are apparent. There are some who will go to all measures to save a child. Losing a pediatric patient is by far the hardest part of the job. With adult patients, it’s an accepted and expected part of life (for the most part). Zipping up a body bag on an infant with an inoperable heart condition was unnatural and haunts me to this day. Twelve hour shifts are brutal for all hospital nursing staff, which is unlikely to change. Holidays, weekends, and ongoing staffing remain challenges to the nursing as a whole. Facing these challenges is not unique to pediatric nursing, but rather is present across all fields of nursing.
Graduate school for NPs has become incredibly competitive. Securing clinical placements is also a challenge; our Houston area has been saturated with both on-line and university students seeking clinical placement sites and preceptors. Some programs are offering incentives for NP preceptors. Graduate Nurse Education (GNE) is a federal grant which provides financial incentives for providers willing to train students. Networking at local and state NP Continuing Education Unit programs is one way to find preceptors and mentors. I also recommend searching on the Texas Medical Board for those physicians delegating to NPs and PAs, as these offices are more open to having students and/or are familiar with the nurse practitioner role. Preceptorships are crucial for skill building and solidification of knowledge and can even transition into a post-graduation NP position.
For graduate nursing students interested in specializing in pediatrics, I would recommend working in a pediatric clinic, ER, or primary care office to determine if this is your calling. The ER is rich in valuable and informative experiences.
Most graduate programs have a good passing rate for national certification, which is required for state licensure. I would recommend a review course–pay the money to attend a well-respected 2-3 day course reviewing all the major content of the exam.
Beyond graduation, keeping up with CEUs is not only a certification requirement, but also necessary to remain clinically competent with evidence-based treatment plans.
It’s important to stay active locally and on a state level to advocate for the advancement of nurse practitioners, especially for independent practice. Local NP groups are helpful for collaborating, networking for employment, and knowledge.
For nursing students contemplating a pediatric nursing career, volunteering at a children’s hospital, a clinic, daycares, schools, or as a nanny can provide useful information about whether working with children suits them. Spend in-depth and quality time with children. Child development courses are available in high schools and college.
For high school students, participating in HOSA (Health Occupations Students of America) is a great avenue to determine if nursing is the right fit. Through HOSA’s program, the high school student rotates through several departments in the hospital, such as physical therapy, pharmacy, and surgery. Personally, I found the experience extremely helpful in solidifying nursing as my career.
Thank you Ms. Ruemmele for participating in our APRN career guide interview series!