Latest Comments by juan de la cruz

juan de la cruz, MSN, RN, NP Guide 51,366 Views

Joined: Nov 14, '06; Posts: 3,573 (47% Liked) ; Likes: 4,386

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  • 1
    ICUman likes this.

    I work at an academic medical center as an ICU NP on the West Coast. By academic, I am referring to a university hospital with affiliated medical, nursing, pharmacy, rehabilitation sciences, and dental schools. One thing about academic medical centers is that you will always have a hierarchical structure in everything and that applies to MD-NP collaboration models. The attending physician (who is also a faculty member) will be the ultimate person responsible for a specific patient. As academic medical centers go, there's always a physician faculty expert for every condition that the hospital treats and in many cases multiple teams of providers care for a single patient.

    I happen to work at an institution that welcomes interdisciplinary collaboration especially between nursing and medicine. The institution is NP-friendly and the affiliated nursing school has a number of highly ranked NP programs (per US News for what that is worth). We have enough autonomy to do procedures (lines, intubations) but the overall care of each patient is dealt with in a team approach model. That's not to say that an NP is unable to manage an admission in the middle of the night because for sure, that is what happens when the entire "team" is no longer present at the bedside.

    The other aspect of this environment is the requirement that the NP should be able to work with fellows and residents as well as NP students and medical students. The NP's have their own patients of course and does the procedures, notes, and orders on their own patients. But we must be able to also work alongside providers and providers-in-training in a teaching environment.

    I won't discuss pay and location here but you are welcome to PM me.

  • 0

    A former ICU NP who worked with us in San Francisco moved to Oregon a few years ago and works as an ICU NP at OHSU.

  • 1
    ICUman likes this.

    Quote from Ruby Vee
    Or you are trying very hard to accept all LGBT people because you know it's the right thing to do, but you still have a few blind spots you haven't yet eliminated. Or you haven't yet spent enough time with a LGBT individual to realize that they're just people too. Give us all a chance to change before you discount us as allies.
    Really? I prefer to keep all my personal life separate from allnurses but I am VERY familiar with the LGBT community. I am not here to change people's opinions, I'm just stating my own but everyone has their own prejudice and I accept that.

  • 0

    Even though CA does not require national certification for initial NP license application (for in-state NP program grads) and renewal (for everyone else), some employers do ask for current national certification at least in my field of practice (Acute Care). National certification is required for billing with CMS if you became an NP after Jan 1, 2003 (you're grandfathered if you were an NP and already have a billing number prior to that date). If you think you'll work for more than 5 years more, it might be worth it to update your credentials.

  • 6

    The usual answer is there is room for both types of provider and I tend to agree with that based on my personal experience with the caveat that role bias toward one provider versus the other will always exist in some specialties and geographic locations. NP's claim that the existence of states with Full Practice Autonomy works to our advantage especially in securing primary care roles but some data actually show that the percentage of PA's in primary care are higher than NPs.

    I think that what can work to our disadvantage overall is our larger number compared to PA's and the even larger number of routes to an NP career with some being perceived as too easy (i.e., for profit programs, distance learning routes). However, there are specific NP specialties with lower numbers overall such as NNP's and PMHNP's who fill a niche role where the market isn't saturated.

    The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States | Agency for Healthcare Research & Quality

  • 1
    marienm, RN, CCRN likes this.

    Actually, low molecular weight heparins such as Lovenox does not typically affect PTT and INR and both are not used to assess the efficacy of therapy. These drugs have more stable absorption than heparin and don't necessarily require lab monitoring except for cases of those with extreme weights (the drug is dosed based on weight) or those with renal disease (usually contraindicated). You would measure anti-factor Xa level and specify to the lab that you are checking for Lovenox if you want to make sure that the Lovenox is working adequately.

    Some places also use anti-factor Xa level for measuring heparin efficacy (with level specifically targeted for heparin).

    Aside from monitoring Coumadin therapy, the INR is also used in liver disease as a measure of degree of coagulopathy/synthetic liver function and in determining MELD score (severity of liver failure). It is elevated in patients with malnutrition (such as those who are Vitamin K deficient).

    Argatroban therapy, an anticoagulant that is not heparin-related, hence used in heparin induced thrombocytopenia, is monitored by checking PTT, it artifcially elevates INR (not used as a monitoring test due to this fact).

    The NOAC's or Novel Oral Anticoagulants (i.e., rivaroxaban, apixaban) do not affect PTT, PT, INR and have no established monitoring tests.

  • 1
    FullGlass likes this.

    An ACNP colleague at work is enrolled at UNM Albuquerque. It is an online format for the PhD in Nursing with multiple campus visits.

  • 2
    ToFNPandBeyond and Rocknurse like this.

    1. What Department/Care Area do you work in?

    Adult Critical Care

    2. What is the average length of orientation for a newly graduated NP/PA provider? Is there a minimum amount of time (shifts/hours)? Or is there a set amount of time for everyone?

    6 months working 3 12-hr shifts a week.

    3. How is it structured? What portion of time is one-on-one with a dedicated preceptor? When does the new provider come off of orientation and become formally "on the schedule" or as "a part of the complement"?

    New NP is always paired with an experienced NP for the entire 6 months. There is no dedicated preceptor as many senior NP's in the group can fill that role. The new NP is not counted in staffing as a regular NP and must work with the experienced NP while on orientation. Learing goals are discussed between new NP and preceptor and may include increasing patient load as the new NP is ready. All procedures are done with experienced NP supervising.

    We have a minimum number for each type of supervised procedure prior to being allowed independence. New NP must attend all critical care didactics (daily conference, M&M, etc). As the new NP progresses, the preceptor may want to pull back on close supervision and see how the new NP handles it. We have a 6 month probationary period (per union contract) and have let go of poorly performing new NP's during this period.

    4. Do new providers have to report off any/some/all of their cases to the preceptor or attending physician? If so, for how long?

    The new NP presents their patients on rounds to the team (attendings, fellows, residents, students, other NP's). Early in orientation, the new NP may want to have a dry run with the preceptor as far as honing presentation skills and articulating plan of care. Experienced NP can critique new NP's notes but they are not cosigned (new NP is already fully credentialed). We've not had a new grad in a while as most of our recent hires are experienced or grads of the in-house fellowship program.

  • 1
    FSZ Student Nurse likes this.

    It's an interesting study. I've worked in various types of hospitals as a nurse and ACNP and there's certainly a degree of variation in the care hospitalist's bring in terms of knoweldge base and skills. I never saw the length of years as a hospitalist as a factor. In my unscientific/anecdotal assessment, I find those who did residencies in less selective programs and some IMG's being less competent. This is a distinction that wasn't illuminated in the study and is probably hard to to research in the first place.

    The article was right to point out that the transition phase from resident to new hospitalist needs to be investigated further to see what factors contributed to the results. It's hard to analyze the study as it relates to NP's who work as hospitalists as we practice in a range of models from close collaboration to supervision to full independence. Mentorship is always a good thing no matter what, but the quality of the mentorship experience will make a big difference.

  • 0

    Even if they haven't worked with an NP before, the practice should be familiar with the process because it is very similar to a new physician who is applying for NPI number and DEA license. You can do these on your own, however.

    To apply for NPI, go to: 400 Bad Request. You basically create a new account. This process is a free so just follow the steps on that website. While you may not be required to list an employer, you should associate your NPI number with the practice you're working under.

    To apply for a DEA, go to: DEA New Registration Applications - Welcome Screen. This is not free ($750), so you should check if the employer will pay for it. Also check with your state if you need additional documents before applying.

    Best to speak to the practice manager or whoever is in charge of physician on-boarding where you will be working. You will also need to be enrolled into Medicare. The practice should be fairly familiar with these requirements.

  • 3

    Acute Care NP programs are either Adult-Gerontology or Pediatric. There are no combined programs but one could certainly go through Adult-Gerontology Acute Care then Pediatric Acute Care later or vice versa.

    As far as online programs go, you can look into University of Alabama Birmingham, University of South Alabama, St Louis University, George Washington University, and a few more. I am not familiar with those programs but have worked with NP's in the past who went to those schools.

  • 0

    I don't see that as a negative if you can articulate your reasons for withdrawing your interest in pursuing the program to the director. It may also depend on the school. As you know, NP programs come in many different forms from the selective to those that are open to anyone who can write a check. Selective programs may say no later if you happen to reapply at a time when there are many applicants much more qualified than you are.

  • 1
    wondern likes this.

    As a bedside RN, I've only worked in non-union hospitals. I've been an NP since 2004 and have worked in both union and non-union NP positions in two states. I prefer union overall. I like the collective bargaining aspect where salaries are pre-determined based on seniority and that working conditions are monitored by a "watch dog" entity such as the union.

    However, this system can only work best in an institution that also has a commitment to nursing excellence and higher standards of nursing practice. Take for example rewarding seniority which can be its own downfall. Nurses with lots of seniority yet put little effort to their work, don't update their skills, are "lazy", or provide poor nursing care can be at an advantage and in some instances, never get fired.

    Fortunately, I don't see that in the hospital I work for where there is a balance of having a union and at the same time nursing management's commitment to high standards of nursing practice. We are a magnet facility and I know that's sometimes an overrated claim of excellence but I see our magnet badge as an affirmation of how well we live the ideals of that designation in our nursing culture.

  • 6

    OP, this is the reason why the bulk of my NP career has been spent working 3 12-hr shifts a week in an hourly position. I started out working Mon-Fri in a supposedly 40-hr work week that ended up being 60 hrs with staying over for late admissions. The job wasn't hard but I felt like with the salaried classification, I was either working extra for free or making less per hour than when I was an RN at the bedside if I divide the hours I put in with how much I was getting paid.

    In my current job, we do stay over for sign out which takes around 30 mins. If I have to be called in to work an extra shift, that's time and a half. There are busy days or stretches of days that wipe me out but I have enough days off after to recharge and take my mind off of being annoyed with the kind of days I just had. I can even take a short trip somewhere. I have picked up moonlighting gigs here and there outside of the hospital I work for and that has helped with having extra disposable income and getting a perspective of how things are done in other places.

  • 0

    I'm familiar with the UC system just not UCD. The pay grades are in the public domain under the nursing union umbrella that represents all the UC owned hospitals. The union contract is currently still under negotiation as the current one is expired. I'm not active in the union and can't speak to why the delay but UC has been a good employer with lots of talented and highly skilled people across all disciplines.

    Current Contract | UCnet (look for appendix section for the salary schedule for each hospital)


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