I think my most rewarding work has been with the families of the terminally ill. Talking with them, listening to them, helping them make the difficult decisions is so powerful. Helping the family take the focus off of themselves and put it back onto their loved one usually gives them the perspective to decide whether to place a PEG tube or not, whether to treat a newly discovered breast cancer or not, whether to choose palliative care vs. curative care, whether to choose hospice or curative care.
About Mary Thiel, MSN, ACNP-BC: Mary Thiel is an Adult Nurse Practitioner at Premier Health Partners, where she provides primary care services to patients ages 14 and older, including preventative care, disease management, and prescriptions. Prior to her role at Premier Health, Ms. Thiel was a Geriatric Nurse Practitioner for Geriatric Providers, Inc., where she managed the primary care and psychiatric care of adult and geriatric patients in long-term care and assisted living settings, coordinated end of life care services both in collaboration with and independently of a hospice, and addressed patients’ acute conditions. Before working for Geriatric Providers, Inc., Ms. Thiel served patients in long term and assisted living settings as a Nurse Practitioner for UnitedHealth Group, providing chronic disease management, care coordination, and psychiatric care.
Prior to her career as a nurse practitioner, Ms. Thiel worked as an Operating Room Nurse for the United States Air Force for over 21 years, between 1986 and 2007; during this time, she served in Active Duty and in the Reserves as an Orthopedic surgery team leader and Operating Room Staff Nurse. During her tenure in the United States Air Force, Ms. Thiel was also the Department Supervisor for Group Health Associates, where she managed 25 physicians’ offices, as well as 40 LPNs and medical assistants. She was also an Orthopedic Surgery Team Leader at Trihealth, where she managed the orthopedic surgery team in the primary operating room and supervised 10 RNs and surgical technologists on a daily basis. Ms. Thiel earned her Bachelor of Science in Nursing from the University of Cincinnati in 1986, and her MSN in Adult Acute Care Nursing from the same institution in 2005.
[OnlineFNPPrograms.com] Could you please give us an overview of your academic and professional path in nursing?
[Mary Thiel, MSN, ACNP-BC] I obtained my Bachelor of Science in Nursing from the University of Cincinnati College of Nursing and Health in 1986. I was a National Merit Finalist, and inducted into multiple academic honor societies including Sigma Theta Tau. After graduation I joined the United States Air Force as an operating room nurse, where I worked for the next 5 years doing predominantly orthopedics. I obtained my CNOR, which is the certification for peri-operative nurses. I left active duty and joined the USAF Reserves also as an operating room nurse, and took a civilian job as an operating room nurse in Cincinnati, Ohio. I worked as the orthopedic team leader at a large teaching hospital. I then changed gears completely after 12 years in the OR, and became an office manager for a large multi-specialty practice, still in Cincinnati Ohio, but continued to work part time in the OR to maintain my proficiency for my USAF reserve status. I was responsible for the activities of 25 physicians in 8 specialties and 40 medical assistants who worked in 6 different office locations. It was while I was hiring a nurse practitioner for the group, that I noticed how similar our career paths had been, and she encouraged me to return to school for my Masters of Science in Nursing from the University of Cincinnati College of Nursing.
My field of study was Adult Acute Care, and after graduation I obtained certification in the same. At this time I retired from the USAF at the rank of Lieutenant Colonel after 20 years of combined service. I took a job with Evercare/Optum, which is a division of UnitedHealth Group, working with the elderly in Long Term Care for the next 7 years, and then took a similar job with Geriatric Providers for 18 months before taking a sabbatical. I now work for Premier Health Partners doing out patient adult medicine.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as an Adult Nurse Practitioner for Premier Health Partners? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Mary Thiel, MSN, ACNP-BC] I function as a primary care provider. We see adults 18 and older, and by certification I am restricted to ages 14 and above. The practice only does outpatient, and the physicians have long-term care (LTC) practices. I cover the LTC practice patients when the physicians are on vacation, but do not have any of my own. I joined the practice to help them transition one of the physicians into retirement. We use an electronic medical record. I see the bulk of the new patients coming into the practice, as well as established patients from the physician who will be retiring in July. I see essentially anything that walks through the door, such as the usual hypertension, diabetes, heart failure, and arthritis. I also see hepatitis C, breast cancer, substance abuse, and skin diseases of every sort. I have my own patient panel, and I get calls related to my patients thru the EMR that I answer. I get the results of labs I have ordered through the EMR. The office is arranged with three medical assistants, one office manager, one NP and two MDs.
By choice I am self-sufficient. I am more computer literate, and I like to do my own work. Therefore I enter my own orders, tests, and schedule my own follow up appointments. Occasionally if I cannot find something, the medical assistant will do it for me, and send it for a signature. By contrast, the physicians have them enter most of the meds, orders, and schedule all appointments. If I have a medical question, I will approach one of the physicians for advice. We have a standard care agreement as is required by Ohio. But for the most part, I work independently alongside the physicians. However, Ohio does not allow nurse practitioners to have their own independent practices. Nurse practitioners can open their own business, but they still must have a collaborative agreement with a physician.
[OnlineFNPPrograms.com] You also worked as a Geriatric Nurse Practitioner for Geriatric Providers, Inc. and as a Nurse Practitioner for UnitedHealth Group. Could you please elaborate on your responsibilities in these roles, and how your team and patient population differed from those of your current position?
[Mary Thiel, MSN, AGNP-BC] The nearly 9 years that I worked for Geriatric Providers and Evercare/Optum were all spent in long-term care. Evercare/Optum had what was essentially a PPO for nursing home patients. The NPs functioned as the primary care provider in the nursing home. We interfaced with the actual PCP, but we took over the day to day work, labs, PT/INR, ordering UA/C&S, etc. In practice, the medicine is not different, other than sometimes in its application. Medicine in LTC is more nuanced. Does a 90 year old need to take a statin for hyperlipidemia? Does she need Aricept any longer? There was more risk/benefit analysis to what meds were prescribed, and which should be stopped. There was a lot of end of life planning, especially with Evercare/Optum. Some patients were enrolled into hospice, some families chose not to enroll, but wanted the same comfort care. We would then function as the hospice team for that resident. We had a high psychiatric population, and there was a psychiatrist who came to the facility monthly. Our relationship evolved over time, with my initially calling for med adjustments, then my calling for advice, then my just documenting the med adjustment after we had ascertained that our thought processes were the same. We worked together for 7 years, but we did not have any formal relationship. We established a basic algorithm for the usual psychiatric problems such as depression, anxiety, dementia with behaviors. I would institute the usual acceptable treatments, and consult him only if they had failed. No reason to waste his time with a referral for depression if a trial of a simple antidepressant had not been attempted. The medicine is the same between the settings. The circumstances are different, and the special situations are more variable in LTC. I still treat basic depression and anxiety in adult medicine, but refer out people who need more extensive help or those whom I feel would benefit from counseling.
[OnlineFNPPrograms.com] What motivated you to work in advanced adult and geriatric nursing care, and what professional and academic experiences helped you determine that this area of advanced practice nursing was the right one for you?
[Mary Thiel, MSN, ACNP-BC] I spent 12 years as an operating room nurse doing orthopedic surgery. I then spent 7 more years as an office manager for a musculoskeletal medicine practice, so I wanted to become an NP to see orthopedic patients in the office and assist in the operating room during surgery. I had that job lined up with my current employer at the time, and it fell apart 3 months before graduation. They only had one orthopedic physician at the time, and he was not busy enough to handle adding an NP. So I had no job, no prospects, and had tailored my education to fit this job. I ended up doing geriatrics because it was the first job offered to me after 15 months of unemployment. And I loved it. I love the elderly, and have a passion for end of life care. I truly believe that we as a society do horrible things to our elders, and instead of living their final days or months in comfort surrounded by love, they are in ERs or ICUs which only causes more misery. Very little of what happens at the end of life for our elders is fixable in an ER or ICU. But I can tell you that hugs, kisses, and laughing make all the difference in the world. So I believe that somehow this was where I was meant to work.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as an adult and geriatric nurse practitioner? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these difficulties?
[Mary Thiel, MSN, ACNP-BC ] I think my most rewarding work has been with the families of the terminally ill. Talking with them, listening to them, helping them make the difficult decisions is so powerful. Helping the family take the focus off of themselves and put it back onto their loved one usually gives them the perspective to decide whether to place a PEG tube or not, whether to treat a newly discovered breast cancer or not, whether to choose palliative care vs. curative care, whether to choose hospice or curative care. I find working with the families of the terminally ill to be very rewarding as they try to determine what is best for their family member. And sometimes their decision is contrary to the one I would choose, but my role is to guide them to their own conclusions. Many of my patients’ families are stuck because they wish to avoid the pain of a tough choice–for example, the decision to let mom go. But if you reword the question to ask what the patient, their family member, would really want, the light bulbs go off, and now the decisions come much more easily.
The challenges have revolved around controlled substances. At first as an NP, we could not write for any. I watched a woman who wanted no resuscitation, and no transportation to any hospital die of a massive heart attack in pain because I could not get any morphine to give to her. A lot of our older residents choose to have “do not resuscitate,” “do not hospitalize,” and/or “do not transport” orders, because they do not want to get sent to the ED during their last hours. This instance was one of only two in my 8 years in LTC where I actually watched someone die, because they did not want any intervention outside of the building. By the time we got the order from the PCP it was over, but it wasn’t a good way to die. The whole event was very traumatic for the staff. Now I have prescriptive privileges for all controlled substances except for a few schedule IIs like methadone, but my group will not let me send those prescriptions electronically. The MDs can, but the nurse practitioner and physician assistant cannot. I am told that it will be fixed this year, so here is hoping.
[OnlineFNPrograms.com] For current and prospective MSN students who are interested in becoming adult nurse practitioners, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Mary Thiel, MSN, ACNP-BC] I don’t remember there being much flexibility about classes when I went to school, but you should try for as much variety as possible in your clinical experiences. I tailored my clinical experiences to match my expected job, and when it failed to materialize, I found myself with limited skills. Do clinicals that are as varied as you can find. If they really like you, you may find a job through this rotation. But it helps round out your skills and level of comfort. Think about what you like to do and what you do not like to do. I wanted to work with orthopedic surgeons, so I went for an adult acute care certification, which I believe is now obsolete. But that means that any jobs that need an FNP, I cannot apply for because I cannot treat anyone under the age of 14. Family nurse practitioners generally have the most flexibility, but if you know you want to work in an adult hospital then don’t waste your precious clinical hours getting that FNP, because you will have to have hours in pediatrics and women’s health.
At present, the acute care nurse practitioner certification has been retired from ANCC. So has the geriatric nurse practitioner (GNP). You can continue to recertify, but new graduates cannot get certified in this. The replacement certification is Adult-Gerontology Acute Care Nurse Practitioner (AGACNP). I believe the thought process was to combine geriatrics into the curriculum, so that everyone has geriatric training with the greying of America. So I cannot speak to what educational preparation might still exist, but I know that you cannot get certified any longer from ANCC as an ACNP or a GNP. You can maintain it if you had it prior to 2016. I don’t feel that the certification itself is obsolete, but it is being packaged differently.
In terms of finding one’s optimal niche in advanced nursing practice, some specialization comes by certification: family, pediatric, neonatal, women’s health, midwife, adult/gero, etc., but the rest of it is on the job training. You need a good solid base, and then you can join a cardiology practice, become a neurosurgical NP that first assists in the OR and sees new neurosurgery patients in the office. It just takes time, willingness and an openness to learn, and the ability to check the attitude at the door. I don’t know as much as my physician colleagues do about medicine, but I am much more computer literate. They help me and I help them.
[OnlineFNPPrograms.com] What is the difference between adult-gerontology acute care and adult-gerontology primary care, in terms of the work settings, the types of patient conditions treated, and the certifications necessary to work in either field? In your opinion, how much does one’s APRN certification dictate one’s work setting both immediately after graduation and in subsequent years?
[Mary Thiel, MSN, ACNP-BC] Technically, the training for the adult-gerontology acute care NP and the adult-gerontology primary care NP was different. The initial classwork was the same. The primary care NP group veered off into outpatient management of common medical conditions, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and immunization schedules, while the acute care group learned arterial blood gases, how to place central lines (in theory), management of acute life threatening medical problems such as acute coronary syndrome, pneumonia, sepsis, and renal failure. However, after graduation, the degree you have is less important that the skills you possess. For an example an ICU nurse who became an adult gerontology primary care NP would likely be easily hired in the hospital. You can be taught the missing knowledge, but very little replaces real world experience. On the flip side, very few people notice my acute care certification, but they look at my work experience. I think for liability’s sake, the hospital would prefer the adult gerontology acute care certification, but qualifications outside of formal certification, such as superior clinical skills or the ability to place central lines, are also important factors when hospitals are deciding among applicants.
Your choice of major and certification will determine where you can work, as well as the patient population with which you work. A pediatric NP can work in a pediatric hospital and in a pediatric office practice, but not in a practice with adult patients. Adults NPs can move around a bit, but cannot take care of children. Geriatric NP cannot see anyone younger than 55. Women’s health can only do women’s health. The most versatile degree is probably the family nurse practitioner (FNP) certification. It does not seem to matter a lot whether you are an FNP an ACNP (acute care) or an ANP (adult) if you work in a hospital that sees adults or a nursing home. But if you are a GNP (geriatric) you cannot see anyone under the age of 55, and to be able to see patients in an adult medicine practice, you have to go back to school and get a post-master’s certificate. Which is to say, all of the course work for the degree that you didn’t take, and complete the clinical hours as well, then take the appropriate certification exam. So for me to get an FNP certificate, I would need to go back and take pediatric classes and women’s health classes, then do clinicals in pediatrics and women’s health, then sit for the certification exam. Otherwise you are practicing out of your area of certification, and the State has huge issues with that. Insurance companies will not insure you for malpractice, and no one will hire you with on the job training.
Thank you Ms. Thiel for participating in our APRN career guide interview series!