hile I was in college I noted that women not only cared for their own health but for that of the family as well. In fact, sometimes they cared for their family’s health at the expense of their own. Given that big responsibility that so many mothers assumed, I believed that by dedicating my career goals to empowering women in the health care system I could have the biggest impact on the health of the family.
About Nancy Riffle, MS, WHNP: Nancy Riffle is a Nurse Practitioner at Sacred Heart Schools, where she provides nursing and first aid services to the student body, faculty, and staff. Prior to her role at Sacred Heart Schools, Ms. Riffle worked as a Women’s Health Nurse Practitioner for 23 years at an Obstetrics & Gynecology private practice with Dr. Nancy E. Mason, M.D., and for 6 years as a Women’s Health Nurse Practitioner at Stanford University School of Medicine. Ms. Riffle also worked as a Nurse Practitioner for Affiliated Crossover Health, where she provided women’s health services in an on-site corporate health center, and at Sutter VNA, where she provided primary care services such as flu shots and preventive health counseling.
Ms. Riffle earned her BSN from the University of San Francisco in 1974 and her Master’s of Science in Nursing from the University of California, San Francisco in 1978 along with her nurse practitioner certification. She also earned a Certificate in Fiber Art from the University of Washington in 2009.
[OnlineFNPPrograms.com] Could you please give us an overview of your professional path and how you entered the field of women’s health and primary care nursing?
[Nancy Riffle, MS, WHNP] Nursing was my first career right out of college at the University of San Francisco. After working briefly in an Intermediate Intensive Care Unit at Stanford Medical Center, I learned the ropes in Labor & Delivery there in preparation for transitioning to a career in women’s health. While working part-time at Stanford I obtained a federal nurse traineeship, which I used to obtain my Masters degree and proficiency as a Women’s Health Nurse Practitioner at the University of California, San Francisco. Thereafter, Stanford University School of Medicine hired me as their first nurse practitioner, a job partially funded by the March of Dimes. There in the Department of Obstetrics & Gynecology I did research on the effects of intrauterine exposure to diethylstilbestrol on young women. I also had a clinical practice in gynecology, saw obstetrical patients in the resident’s clinic, set up a prenatal education program and wrote a soft cover booklet on prenatal care for our low-income patients. There were few nursing leaders in the School of Medicine. I learned many of my skills from the late Eugene Sandberg, a generous and visionary physician.
After several years I left the academic medical center for the flexibility of private practice, where I worked for many years establishing a private practice in Obstetrics & Gynecology with one physician. I covered the office, seeing patients in the physician’s absence and independently seeing patients for both prenatal and gynecology visits, eventually developing my own panel of patients. After over 23 years in this role, I took a sabbatical to earn a certificate in Fiber Art at the University of Washington.
For a while I did both art and contract work giving flu shots on location at companies like Genentech and Apple, while also working as a Health & Wellness nurse for Sutter Care at Home and doing women’s health exams in a corporate setting for Crossover Health. When I wanted to return to full time work as a Women’s Health Nurse Practitioner the field had changed and many of the jobs were in primary care, rather than in women’s health. So I took a job as a nurse practitioner at a private high school, some of whose female teenagers I’d seen in my former practice.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as a Nurse Practitioner at Sacred Heart Schools? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Nancy Riffle, MS, WHNP] At Sacred Heart I am the only health professional at the high school. I function much as a public health nurse would in a community. I make decisions about communicable diseases for adults and students, deciding who can attend school and who needs to remain at home. I liaison with the county health services department and send out Notices of Exposure to communicable disease where indicated. In addition to providing first aid for cuts, concussions, syncope, panic attacks, and rashes, I also establish individual health plans for students with chronic illnesses like asthma and life threatening allergies. Of students with chronic illnesses, I am most involved with the students with Type I diabetes. Generally, these high school students manage their diabetes largely independently. I am familiar with their care plans, keep in touch with them and do crisis intervention when their usual care routines go awry.
I also communicate with the students, parents and primary care providers of students diagnosed with concussions to assure that they are given appropriate supports to heal their brains from trauma. I medicate students with minor illnesses like upper respiratory infections and headaches. Each one of those encounters with students becomes an opportunity to assist them with self-care in preparation for their transition to college.
The main difference between my role as a Women’s Health Nurse Practitioner in a private practice and providing care in a high school is that at school my scope of practice is broader and less deep. When I practiced in the field of Obstetrics & Gynecology I knew that one field very deeply whereas I did not have to know other areas of medicine as well. My work at the school requires broad knowledge of public health, pediatrics, and chronic illnesses, for example. In private practice, I worked directly with my women patients and they generally disclosed relevant medical information. In a school, parents can be reluctant to disclose medical information about their children, which can sometimes compromise care. Moreover, I can often have less impact on student health than I could on the individual women I saw in private practice.
I had more professional colleagues before I joined a school. Fortunately, the nurse at a neighboring school is helpful and accessible. I am also grateful to have a responsive, knowledgeable colleague who works at the lower middle school on our nearby campus. The school has an informal agreement with a physician parent who volunteers his expertise when I need consultation. The school nurse liaison at the county health service is an invaluable source of information and referral. I believe that my colleagues in the California School Nurses Association have been instrumental in my ability to practice safely and grow as a professional in this role.
[OnlineFNPPrograms.com] You were also a Nurse Practitioner at Crossover Health and are a Health and Wellness Nurse at Sutter VNA. Could you explain your responsibilities, patient population, and work environment in each of these roles, and how they differ from your primary role at Sacred Heart Schools?
[Nancy Riffle, MS, WHNP] I did contract work for both Sutter Health at Home and Crossover Health between working in private practice and taking the school nurse job because contract work allowed me to schedule work hours around my program in Fiber Art, my chosen avocation. Both jobs involved delivering health care in corporate settings, a concept that I’ve advocated for years because of the convenience and accessibility it offers for employee patients. At Crossover, I joined a team that screened corporate employees for cardiac disease risk factors. After the screenings we contacted the employees deemed high risk, counseled them and set up the next step in follow up whether it was seeing a nutritionist, health coach, or physician. Later I did annual gynecological exams for women employees in a Crossover Health Center at the workplace. It was a successful model that Crossover Health is implementing at a variety of corporations including Facebook and Apple.
[OnlineFNPPrograms.com] Can you please describe what your typical workday was like in your past roles at an Ob/Gyn private practice, and at Stanford University School of Medicine?
[Nancy Riffle, MS, WHNP] At both Stanford and in private practice I saw prenatal and gynecologic patients on an outpatient basis. At Stanford I participated in the High Risk Obstetrical weekly conference and co-managed some of these patients with the residents. When I was not in the clinic I did research on women exposed to diethlstibestrol in utero. We examined these women semiannually and recorded, then categorized the genitourinary changes we observed. Our team was among the first to delineate and later publish the cervicovaginal changes apparent in young women exposed to diethylstilbestrol. Later, we gave talks around California about the research. Knowing as much as a handful of experts in the world about in utero diethylstilbestrol remains one of my career highlights.
I found it much easier to do research in an academic medical center than I did in private practice. There we were able to do the work without relying on grants. In addition, the in house institutional review board and Human Subjects Committee were readily accessible. In private practice it is probably cost prohibitive to do research without getting grant funding. The only research I did in private practice was for a drug manufacturer who was developing a new intravaginal antifungal product. The work was lucrative but I did not design or publish the research as I had at Stanford.
During my time at Stanford, I also set up prenatal classes for low income patients who came to the clinic and hired a nurse midwife to offer the classes while patients were waiting to see a health care provider in the clinic. Initially, my position was partially funded by the March of Dimes and it was a condition of their grant that I write a soft cover prenatal self care manual for our patients.
In private practice I mainly saw patients and billed for my services. The physician and I covered the office from Monday to Friday with neither one of us there everyday. The initial patient visits were the most time consuming so those usually fell to me. After that visit and depending upon the acuity of the patient’s problem she could see the physician or myself. I usually did the second prenatal visit and sufficient other prenatal visits so that I was familiar with the patient. Once we did ultrasound confirmation of pregnancy I frequently did those visits at about seven or eight weeks of pregnancy. Overall, most of the patient visits I did were for gynecology. Visits for contraception, including intrauterine system insertions, annual exams, menopausal issues, amenorrhea, dysmenorrhea, dysfunctional uterine bleeding, sexually transmitted disease checks and abnormal Pap smears made up my practice. I also saw most of the teenagers who sought care. The most challenging times occurred when my physician supervisor left town. I assumed responsibility then for all of the patients in the practice. I triaged which patients I could see and which I needed to send to a physician who took call with our practice. At Stanford I had resident physicians to call on but I did not have that kind of support in private practice.
The other differences between private practice and working for the medical center was that I was admitted to the Professional Staff at Stanford and able to make rounds on our postpartum hospitalized patients. Also, as mentioned previously, I do not have nearly as many opportunities to do research in private practice as I did at Stanford. Now that I am working at a high school I would love to look at the social and psychological impact of major athletic injuries in teenagers. With several doctorally prepared teacher colleagues, I may find a way to do this at the high school level.
[OnlineFNPPrograms.com] Why did you decide to work specifically in women’s health and obstetrics/gynecology, and what academic and professional experiences helped you determine that this area of advanced practice nursing was the right one for you?
[Nancy Riffle, MS, WHNP] While I was in college I noted that women not only cared for their own health but for that of the family as well. In fact, sometimes they cared for their family’s health at the expense of their own. Given that big responsibility that so many mothers assumed, I believed that by dedicating my career goals to empowering women in the health care system I could have the biggest impact on the health of the family. In my first job I worked on a post cardiac surgery unit where the majority of patients were men. At that time many of the men deferred their own post op care to their wives. When I saw that much of my post op teaching had to be geared to wives or girlfriends that further reinforced my desire to teach women about their bodies and to teach them skills to navigate the health care system.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working in women’s health nursing? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these challenges?
[Nancy Riffle, MS, WHNP] Some of the most satisfying parts of my career have come about from relationships forged. I met a young, single, pregnant junior in high school in the clinic at Stanford. I followed her through to her successful delivery of a healthy son. When I left the clinic she had a long way to go in finishing her education and obtaining employment. Several years later, she had joined the Postal Service as a mail carrier and greeted me as she delivered the mail to our office! More recently, the first student I met when I started work at the high school was a young man whose mother I’d assisted through three pregnancies in the private practice.
Aside from the satisfying relationships, I derive deep satisfaction from working autonomously. For example, in private practice I managed a caseload of patients with occasional physician consultation. At high school I possess the only medical eyes so I make those decisions with occasional consultation from a physician or public health authorities. That said, I do prefer a health care setting to a school; in academic settings, my colleagues are teachers for whom medical issues are outside their scope of practice. And not only are teachers my colleagues in a school but my superiors are administrators, not nurses. As such they are educators who lack a firsthand understanding of nursing or the Nurse Practice Act. In health care settings members of a team generally understand one another’s roles.
I’ve had a great career so far. And I’ve appreciated the opportunity to reflect back on it. Even as students, nurses have the opportunity to have an incredible impact on the lives of the patients they encounter. One example of this fact was an experience I had while enrolled in my graduate nursing program at the University of California, San Francisco. I recall how deeply satisfying it was at the time.
When I was enrolled in the clinical practicum part of my graduate nursing program at UCSF, I worked with my mentor, Eugene Sandberg M.D. in the Diethylstilbestrol Clinic at Stanford. He ran the clinic with another nurse practitioner named Jo Hebard, who was trained initially by Planned Parenthood as a Family Planning Nurse Practitioner. On the day in question Jo and I ran the clinic together in Dr. Sandberg’s absence. I saw a young woman, around age 16 who had a 20 cm. pelvic mass. By this time I’d seen a number of pregnant women and felt confident that the midline mass was approximately the size of a 20 week pregnancy and likely uterine. Jo had not seen any pregnant women so suddenly the preceptee took the lead with the preceptor. Since the young woman denied being sexually active, we had a nonpregnant woman with a pelvic mass on our hands. Ours was a referral clinic so the young patient opted to go back to her Chicago home to have the mass worked up. Several weeks later her physician wrote to us describing her successful myomectomy. I felt really proud and satisfied of how we helped this woman while I was still a student.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in working in women’s health nursing and obstetrics, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Nancy Riffle, MS, WHNP] The biggest challenge to working in the Women’s Health field now is a disappearance of training programs that do in depth training of nurse practitioners in women’s health. Most programs now appear to be training nurses in “Family Practice” as an FNP. It is often difficult to get the depth of training necessary for specializing in Women’s Health or to work in Obstetrics and Gynecology at a medical center or a private office. My advice for nurses who want to work as Women’s Health Nurse Practitioners is to work or volunteer as a nurse in both labor and delivery and outpatient prenatal and gynecology clinics or practices. That would give them a good background upon which to build their nurse practitioner skills.
Aside from that, this is a great time to become a nurse practitioner. For nurses who possess good skills there are more opportunities than ever.
Thank you Ms. Riffle for participating in our APRN career guide interview series!