Diane E. Judge, APN/CNP, is a family nurse practitioner at Heartland/Health Outreach, a Chicago health center for homeless and community clients. A Chicago native, Diane has devoted 30 years to her nursing career. She has worked as a staff nurse in a medical intensive care unit and as a research nurse in a study looking at emphysema patients using home oxygen. For the past 24 years she has been a certified Family Nurse Practitioner (FNP), where she started out at a community health center and spent 15 years as the director of Womancare at University of Chicago Hospitals, where she provided primary health care for women.
She also currently serves as Adjunct/Complemental Faculty for Rush University and the University of Illinois-Chicago and Loyola University Nurse Practitioner Programs; is an advisor to the Illinois Breast and Cervical Cancer Program through the Illinois Department of Public Health; and is the preceptor for medical, nursing and midwife nurse students.
In addition, Diane is a member of the Editorial Board and is the Patient Education Editor for the Journal Watch Women's Health as well as serving as Patient Education Materials Writer for The Female Patient.
You & Your Career
Tell us about your career. How did you break into the field? How did your career unfold to allow you to advance to where you are today?
I always wanted to be a nurse when I grew up. In my third grade "autobiography" I wrote that I wanted to be a nurse working in countries where people didn't have healthcare. My father really wanted me to be a doctor. When I was in high school and investigated further education after graduation, most of nursing education took place in hospital diploma schools.
At that time, there were very few college-level nursing programs, and unfortunately I didn't know they existed. I wanted a college degree. So I went to college—I spent the first two years doing premedical education, but I really didn't want to take care of very sick people in hospitals. So I changed my major to English, since I also enjoyed writing. When I graduated, I spent some time in Europe and when I came back to the United States I worked as a medical writer.
It was the era when people began talking about healthcare as a right. I covered several conferences on that issue and started thinking, "If I was a nurse, I could do something about that." Then I started writing articles about nurse practitioners—a profession that was new at the time—and knew I had found what I wanted to do.
At the University of Chicago, I provided reproductive health care for well women, virtually all of whom had health insurance and good access to healthcare. I loved working with them but I had set out to work with an underserved population, so I decided that I would fulfill my goal by joining the Peace Corps or a similar organization when I retired.
Then one day I heard on the news that a woman was walking down the street downtown and was killed by a window that fell out of a high rise building. I suddenly woke up to the fact that you never know what will happen tomorrow—and right at that same time I saw an advertisement for the Heartland Health Outreach position. "Opportunity of a lifetime," the headline said, and I knew it was time. Whatever happens now, I have fulfilled my lifetime goal. I feel very fortunate.
What do you enjoy most about your career? Your current position?
There are many things that I love about nursing. It gives you so many different options—hospital, community, direct care, teaching, research, specialty practice, general practice, private practice, advanced practice (nurse practitioner, nurse midwife, nurse anesthetist, clinical nurse specialist)—basically, anything you want.
Nursing and medical science are constantly expanding, so you need to be constantly learning and growing. And it involves working with people. I'm so glad I don't work on an assembly line! In my current position I work in a variety of settings—a primary care clinic, homeless shelters, a school-based clinic, a respite care facility for homeless people—nothing is ever boring. I work with an extremely culturally diverse group of patients and staff, which is very exciting. We use interpreters for languages I had never heard of!
You previously served as director and nurse practitioner for Womancare, a part of the University of Chicago Primary Care Group which provides primary healthcare services for women. Now you are a family nurse practitioner for Heartland Health Outreach, Heartland Alliance for Human Needs and Human Rights, and provide primary healthcare for the homeless and for a culturally diverse community population. How is your current position different from your last? What are the rewards and challenges in your current position?
At the U of C I provided well woman healthcare. It was a great population to work with; the women had many questions and appreciated being listened to, having their concerns addressed, and being treated with respect. If someone needed a medical specialist, it was easy to refer them, because they had health insurance.
Now I am in family practice: men, women and children. Most of my clients have no health insurance and have multiple complicated medical problems such as hypertension, diabetes, asthma, substance abuse, mental illness. If they need tests, such as MRI or cardiac stress tests, or specialty care, such as nephrology or cardiology, I use a computer system to refer them to Cook County Hospital. There is a long wait for specialty tests and services—for example, six months to see a cardiologist. It is also hard to notify some of our homeless clients of their appointments, since they have no mailing address, or may have moved out of a homeless shelter by the time their appointment is available.
When I go to homeless shelters to provide healthcare, I often have to improvise. When I'm doing a Pap smear with a patient slouching on a folding chair in the broom closet of a shelter, I sometimes think "If my University of Chicago patients could see me now!"
The satisfaction comes in doing what I originally set out to do. Not all my patients now are appreciative of the services we provide. Most of them have difficult lives and do what they have to do to survive. But sometimes patients express their appreciation, or bring little gifts. One patient sometimes brings me a pair of socks or a banana; one of my Vietnamese patients made me spring rolls. It always brings tears to my eyes, because these are people who have so little, and they make this special effort to say thank you. And when I see someone who has been cured of an illness, or who is recovering from substance abuse, goes to school, gets a job—with the support of services I have been able to provide—it feels wonderful. I have always been aware of what a great life I have had, largely through accident of birth. It is such a privilege to be able to "give back."
What ranks among the favorite projects that you've completed in your career and why?
I love teaching medical students and medical residents to do pelvic exams on women, which I've been doing since 1985. The medical students are usually nervous about doing the exams. Whether they're male or female, they are apprehensive about getting embarrassed, hurting someone, not doing the exam properly, etc. By teaching the exam in a comfortable atmosphere and providing support for them, I can both help them and help the women that they will be examining in the future.
Do you feel that is important for someone to be passionate about the healthcare field in order to be successful? Do you think that it's important to truly enjoy the field in order to be happy in life?
Although I am passionate about healthcare, I don't think you have to be in order to be successful. I frequently think that I am lucky to have a career in a field that I care so much about. But as long as you are realistic about what is needed and are committed to doing a good job, you can be successful.
I do believe that you have to have something in life that you truly enjoy. If it's not the work your doing, that let it be something else—your family, or a hobby. Of course if you hate your work, it's going to show, and you need to move on to something else. One advantage in nursing is that if you're working with people, such as a hospital staff nurse, clinic nurse, nurse practitioner, and don't find it satisfying at this point in your life, you can move to a desk position, like utilization review. You do, however, have to be conscientious and committed to your job. In the healthcare professions, including nursing, mistakes can result in a patient's death.
When I switched careers from writing into nursing, some of my friends, including some nurses, were incredulous. "Why do you want to do that?" they asked me. "Being a writer sounds much more interesting!" To them I said, and still say: If that's how you feel about nursing, you should change careers. Nursing gives me the privilege of being part of people's lives, of listening to them, and of empowering them and giving them the information they need to make changes in their lives.
The Actual Work
You work in a unique area, catering to the healthcare needs of homeless as well as a culturally diverse community. Describe a typical day of work for you. What unique challenges and rewards come from working with your patients?
Here's a typical day in the clinic:
8 a.m. Check and return phone and e-mail messages, check any new lab results that have come in and start following up on them. My homeless clients can be hard to reach; it sometimes takes days to weeks.
8:20 a.m. Start seeing scheduled patients. Perhaps the first one is a homeless man staying on the street who has diabetes and high blood pressure and is depressed. I take a health history to determine what is going on with him: Does he have his medications, or have they been lost or stolen? Is he taking them regularly, as prescribed? If not, why not? How is he feeling? Is he checking his blood sugars with the glucose meter he carries with him? How high or low have they been? Then I'll do a physical exam, guided by his symptoms; ordinarily I'll check his blood pressure, heart and lungs and feet. We'll talk about his health conditions and his problems. I may give him a prescription for medications, which he can fill at a local pharmacy with which we have an arrangement, or I may have to give him a prescription to take to Cook County Hospital, where he will have to wait in line for hours to drop off the prescription, and then return in 3-7 days to pick up the medication. If he's interested in help finding housing or a drug rehabilitation program, I'll have him talk to one of our social workers, and I may ask one of our community health nurses to educate him on some ways to take care of his diabetes.
Another patient may be brand new to our clinic. I'll take a complete health history, do a complete physical exam, including Pap smear, explain to her how we'll go about figuring out what is causing the health problem that brought her in and have her go to our lab to have blood drawn. I may also refer her for a mammogram. If there is no way to contact her, I'll ask her to make a return appointment to get the lab results… and hope that she keeps the appointment.
In the afternoon I may have Vietnamese clinic. A Vietnamese case manager brings in uninsured clients from the Vietnamese community. She interprets for them and is sometimes able to help them find resources. Many of my Vietnamese clients are depressed and there are few Vietnamese-speaking mental health therapists in the community.
A shelter day is a little different: I'll pack up the things I need for the shelter, such as paperwork to document the patients I am seeing, equipment to do a physical exam and sometimes basic medications. At the shelter, my "office" might be in the basement or a large storage closet. I'll walk around announcing that the "health team"—sometimes myself and a community health nurse, or sometimes just me—has arrived and ask if anyone wants to be seen. Depending on the site and the amount of privacy, I may or may not be able to do complete exams on patients. At some sites, I will mostly talk with people who want to be seen, maybe take a blood pressure, offer throat lozenges for their colds and try to "engage" them so they will come back to see me the following week, or make an appointment at our primary care clinic.
Education efforts have become an integral part of your career; you are a student precept, serve as an adjunct faculty member to several universities, act as an advisor to a state health department and are active in medical publishing. What drives you to be so active in this area?
Well, for one thing I don't have small children at home, so I don't have a lot of demands on my time! It's been a wonderful thing for me to be able to combine my writing skills with my nursing skills.
I also became a nurse practitioner fairly early in the development of the profession, when there was lots of work to be done legislatively to authorize NP practice. There were many political battles that needed to be fought. I still consider it important to be active in the profession to be an advocate for patients. Providing healthcare to underserved patients benefits a few people; enacting legislation to fund healthcare for uninsured people—or even better, enacting legislation for Universal Healthcare—protects a whole population.
I think education and mentoring are extremely important in nursing. Nurses need good role models.
What are the greatest rewards in your profession?
Definitely nurses have the ability to touch, change and even save people's lives. There is no greater satisfaction than knowing you have truly helped someone, unless it's hearing them thank you for something no one else could have done for them.
It's also wonderful to be the person who knows what to do in an emergency. Many years ago I was walking into a bathroom in a hotel. I was met at the door by some anxious-looking people who said, "We have an emergency here, please go away." "I'm a nurse," I said. "Maybe I can help." And all of a sudden instead of trying to shoo me away they were pulling me in!
I save every note, letter and crayon drawing I have received from patients. When I've had a bad day or week, or question my choice of career or job, I read them over and know I've done the right thing.
How can the reality of nursing as a career differ from typical expectations?
One of the problems with hospital staff nursing is that it can involve off shifts, like 11 a.m. to 7 p.m. or midnight to 8 a.m., or rotating shifts, and can require working weekends and holidays. When I was working the midnight shift as an intensive care nurse, I had a really hard time sleeping during the day. Because of the nursing shortage, many hospital staff nurses are asked, or even required, to work overtime.
In most clinical settings, the constraints of "productivity"—being required to see a minimum number of patients per hour or per day, necessary to make your position cost-effective—can interfere with the "ideal" job you'd like to do. It's hard to provide what you think of as the perfect care when you need to see a patient every 15 minutes.
Do nursing professionals typically use any specialized computer programs? If so, how important is it for graduating students to be well-versed with these programs?
Nurses know how to use computers. Many practices, both inpatient and outpatient, use electronic health records. Most lab results are posted electronically. I don't know too much about hospital practice, since I haven't practiced in hospitals since 1978 or so, but I do know there are lots of electronic monitoring systems. We also can obtain multilingual health education information for our patients online, and can individualize it. I use a computerized database of drug manufacturer patient assistance programs to help my patients obtain necessary prescription medications free or at low cost if they cannot pay.
What are the best ways to land a nursing job?
In the current climate of nursing shortage, the best way is just to get your license and apply! However, if there is a specific position or location you want, the same principles apply to landing a nursing job as apply to any other job.
Find out as much as you can about your potential employer and think about how your skills can fulfill what he or she is looking for. Do some research beforehand, and in your cover letter and interview, point out your specific strengths that will benefit the employer.
For nurse practitioners specifically, the best way to find a position is to network. Many nurse practitioner positions are not advertised. Another approach for nurse practitioners is to find an area or a practice they would like to work in, contact the physicians or health care providers, and talk with them about how a nurse practitioner can contribute to their practice.
Education Information and Advice
You have earned a bachelor's degree in English, a nursing diploma and a community nursing master's degree. In retrospect, what do you know now that you wish you knew before you pursued your education in the field?
I went the route I needed to. When I decided to go into nursing, I already had a bachelor's degree in English, and I didn't want to get another college degree. I knew that if I became an RN and could pass the placement tests at Rush University College of Nursing, I could go on for my master's degree. So I went the fastest route to get my RN. It would have been good if I had known in high school that there was such a thing as a college-level nursing education program, as there were a few back then. However, since my writing skills have come in very handy, I'm not sure I would change anything.
When is it a good time to go after a graduate degree?
This is an interesting debate. Some nursing professionals believe that you should practice as a registered nurse before going on to obtain an advanced degree as an advanced practice nurse, teacher, or researcher. Others believe that if you have a goal—becoming a nurse practitioner, for instance—you should go right on after your basic nursing program.
What is right and wrong with nursing education in America?
The problem with nursing education is that we have never been able to come to a consensus about what basic level of education should be considered "entry level." At the present time, you are eligible to take the exam to become an RN if you have graduated with an associate degree from a community college, or if you have obtained a baccalaureate degree. Many of us believe that it takes a four-year college degree to obtain the knowledge you need to become an RN in this day and age.
Some advanced practice nursing specialties such as nurse midwifery, do not require a master's degree, while a master's is required in other areas, such as clinical nurse specialist. There are several different certifying bodies for nurse practitioners—for example, the American Nurses Credentialing Center and the American Academy of Nurse Practitioners. It's very confusing.
Editor's Note: Do you have further questions about the nursing profession or other points touched on in this interview? Click here to contact Diane Judge directly.