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Joined Apr 4, '11 - from 'Northshore, MA'. BostonFNP is a Primary Care NP. Posts: 4,565 (61% Liked) Likes: 10,930

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  • Jan 16

    I had a few days orientation, mostly to learn the EMR and organizational policies. I was started with 1 patient every 30 minutes, but was expected to ramp up to a full patient load within a few months. There were always providers around to consult with, but I was expected to handle the routine cases independently. OP-I am a little concerned that you're taking so long to handle a simple case. Did you not work up cases from start to finish in your clinicals? Is this a knowledge issue or is this a confidence issue?

    A new grad should not be an expert by any means, but should know how to handle common issues like basic prescribing for HTN, 1st line treatments for diabetes, diagnosing and treating a simple URI. Review these and other common issues. I would go home from work when I was a newbie and study every single night. I still study on my own to stay abreast of current and new practices in my area.

    I think your physician is giving you a decent orientation. The basic training should have happened in your clinicals.

  • Jan 7

    RockyMay seems to strongly dislike NPs and I have to wonder if she joined this site just to argue that NPs are incompetent. I can't find a way to quote her past posts and put them here with the quote function, but here are some of the things she has said (I copy/pasted):

    She frequently makes very strong statements against NPs/nurses...
    - "Sounds like you want to throw every test in the book at the PT. That's both unnecessary and also inappropriate, but it's common in NPs." (March 11, 2016)
    - "NPs utilize more resources than PAs or MDs as a result of their inferior training and lack of preparation for the autonomous practice of medicine" (March 11, 2016)
    - "Welcome to nursing, Michelle. You will never meet a nastier group of people" (June 8, 2016)
    - "Most clinical training sites loath taking NP students due to their extreme lack of preparation and knowledge." (June 8, 2016)
    - "MD/DO>PA>>>>>>>>>>>>>NP" (August 3, 2016)
    ... and then of course, everything she has said on this thread

    It is also very unclear what type of clinical degree/license she has.
    - "I am about to graduate from PA school." (March 9, 2016)
    - "I am *NOT* a PA. I am more nursing experience then most people here!" (June 22, 2016)
    - "Nope, I am *definitely not* a PA. You misread my post." (June 22, 2016)

    I don't disagree with everything she says and if people have strong opinions regarding the relative competency of PAs and NPs it's perfectly fine to express that in a respectful way. However, RockyMay's statements are very inflammatory and inconsistent and I believe she is trying to get us riled up (and speaking for myself, I hate to say it's working). I honestly forgot what the initial question in this thread was because I've gotten so distracted/off topic by RockyMays statements. I guess I "took the bait", so to speak

    RockyMay: I am sorry for whatever experience you went through that made you hate NPs so much. I would really like to know where this hate stems from, because it seems quite personal to me. I understand if you don't want to share, and you probably don't, but is there any chance you could clarify the following:
    - Under what license are you practicing? Did you go to/complete NP school? Nursing school?
    - What do you hope to achieve by expressing such hostility towards NPs on this website?

  • Jan 6

    Quote from BostonFNP
    I give all my students my "worst" patients. It's good for them. And me
    Because they are doing all your work for you for free, right? lol

  • Jan 2

    Quote from casias12
    I feel the same way. I was a nurse for 15 years, and worked closely with physicians to gain trust and write "verbal" orders for things that made sense. As time went on, I think autonomy and involvement dwindled. Making the jump to nurse practitioner was, for me, a necessity.

    When I walk into hospitals today, never see the same nurse twice, and see them all sitting at the desk doodling on their i-things, I get a little annoyed. Ask a question of a nurse, the common answer is, "I don't know if he went to surgery yesterday, I've only had him for 4 hours".

    But any nurse who is planning to move up to NP should already be at a point in their career where they are thinking "I know what I would order/do for this patient. Man I wish I could just write the orders". That is someone who has enough experience to make the transition and be successful.
    Then why go to NP school? Just sit for the exam and be done with it if you already know what to do? I'm being facetious of course, but that just seems a bit over the top. Anyone who thinks they already know what to do before going into a NP school is setting themselves up to be a dangerous provider.

  • Dec 29 '16

    I am sorry it makes you feel like a criminal David40836, but when I was doing primary care, I had pain med contracts with ALL my chronic pain patients. I explained to them at the start that this is the way it has to be, and if they want/need the meds, they need to comply with the contract. The ones NOT selling their meds had no issue with it, the others (and I heard all the stories, "my child dumped my pills in the toilet," "I had company and someone stole all my pills," "I had them in the glove box of my car and my car was stolen," etc.) left. I was already nearly 100% certain who would be okay with the contract and who wouldn't. I always tried to work with the patients as to need, but I often required physical therapy as part of the contract. I understand chronic and acute pain (I worked in oncology for 23 years) but I also am not a fool and have no desire to have my compassion taken advantage of. And I totally agree we need non-addictive pain meds.

  • Dec 29 '16

    As a novice (in any field) it is acceptable and advisable to seek answers from those more experienced. I came into a specialty with which I had little experience as a novice APRN. I rec'd five full months of didactic plus clinical preceptorship = 800 hours. I was also expected to put in additional time studying which I did. At the end of the five months, I was seeing pts on my own but still had backup for issues with which I was unfamiliar.

    Even now, 10+ years later, the MD and I talk about issues occasionally though the occasions are now more a teaching point then me asking for advice regarding a certain pt/care situation. I am now the lead APN and the others come to me for advice. However, I still do not have all the answers. I still look things up.

    As nephrology moves into the primary care arena once again, I will look up more because for the past 10 years I have not taken care of all primary care issues where I will now.

    Providers that think they know it all, be they APRNs, PAs or physicians are the ones that we need to be afraid of...

  • Dec 29 '16

    I think it's a bit of an exaggeration and somewhat dramatic to say all NP programs suck. Many do, but some do have stringent admission criteria and give adequate preparation for a novice. I would like to see more science based education and less "fluff". I also think clinical hours should be increased and schools should have relationships with preceptors that have been vetted carefully. I was fortunate in that I had a few very reputable brick and mortar programs to choose from in my area. I researched them, visited the schools, and felt informed to make the best decision for me. The program I chose accepted less than 10% of applicants. I did not even consider applying to any for profit schools. I knew that a lot of my learning would be up to me, and would not take place in the classroom, and i was prepared to work hard so I wouldn't suck.

    It's also my opinion that many NP students (and probably many professionals in other fields) expect to graduate knowing more than they do. Maybe some of that is due to inadequate training, but much of it is due to the fact that we are all beginners or novices when we graduate, regardless of how smart we are or how much experience we've had in nursing or other fields. I'd love to see paid residencies for all NP graduates. It would be so beneficial to have a year with a mentor and would go a long way in increasing the competence and confidence of a new grad.

    So NPman, I'm glad you are asking how not to suck. It's encouraging that you have a realistic view of your training and that you know you still have a lot to learn once you graduate.

  • Dec 29 '16

    Gee thanks because there aren't already enough new grads with no nursing experience let alone any psych experience just dying to diagnose someone's poor child with Bipolar disorder and start Lithium.

    I disagree that there are a shortage of programs or they are difficult to get into. In fact I know of two online programs with rolling admissions and virtually no admissions criteria. Rumor is one even said if you can't meet the gpa requirement they will admit on a a provisionary basis. It appears there are approximately 100 programs listed here and if each only accepts 25 students a year that is 2,500 new providers a year so not so rare and in a few years the market will likely be saturated with wages tanking.

    Psychiatric-Mental Health Nursing Graduate Programs by State - American Psychiatric Nurses Association

  • Dec 29 '16

    I've actually considered adding another post-MSN cert as a PMHNP to my credentials as more and more of my "medical" pts need psych help and the wait list is one YEAR!!!

  • Dec 27 '16

    Quote from jelnurse
    I think that sort of situation calls for direct frank discussion with the patient with two clinicians present, preferably with everyone seated so no one looks extra intimidating. Of course be sure the test is correct. If it was just a "dipstick" test, get a real one using gas chromatography, then start the conversation with virtually certain confidence the test results are correct.

    Talk with her with a strong bias toward discovering a mental health problem that she is treating with the benzodiazepines. She might be using the benzodiazepines to relieve anxiety, and she might have been using the hydrocodone for the same reason. Maybe the benzodiazepines are just to fill in after she runs out of hydrocodone each month.

    Have a referral ready for a mental health evaluation from either a psychiatrist or psychiatric NP, and offer to continue pain treatment while that referral is being planned, but insist on bi-weekly urinalysis and pill counts - she shows up, or she gets no Rx.

    Drug abusers have a horrible problem, and I think we have a moral and clear ethical duty to help without just throwing them out. If this is her first time "caught" abusing two drugs (using benzo's and NOT using hydrocodone is TWO abuses in my opinion), then be frank but supportive. Include early in the discussion that you intend to keep treating her, and if she has a pain condition, even assure her you intend to keep using the hydrocodone with special arrangements to make sure she uses it correctly.

    Unless you also are a lawyer, do not give her legal advice per se, but DO remind her that selling or sharing hydrocodone is a serious crime, and so is acquiring benzodiazepines without a Rx. Make it clear you intend to help her, and actually plan to do so. In all that you do and say to her, be genuinely biased toward helping her and not just getting rid of her.

    Consider exotic scenarios, but those usually are not what's happening. Of course, be open to the possibility that she is being abused and forced to hand over the hydrocodone to someone. Benzodiazepines sure would make a person more cooperative with an abuser, so maybe the benzo's are being forced on her. That sort of thing certainly does happen. You might even want to start the next assessment with a focus on whether she is safe or being abused by anyone. If she is, that will sure affect how the interview continues.
    Not trying to be insensitive, but this just doesn’t happen in the real world. A $55 office visit just doesn’t cover all of that, and it happens often enough, a clinician just has to have a plan ready.

    This fabricated scenario was presented to see what clinicians would do when faced with this.

    I would continue to decrease her medications and offer non-opioid alternatives, and refer to rheumatology for the osteo, referral to spine clinic for low back pain.

    Depending on her co-pay, a patient like this may or may not go to these, or any other therapy.

  • Dec 27 '16

    So...you’ve decided to advance your education and obtain a masters degree in nursing (MSN) or a terminal doctoral degree. Which route will you travel? What is your ultimate goal? Where do you see your nursing career in 5 years, 10 years, 20 years? AN has a robust Advanced Practice Forum.

    In this article we will explore the four options for advanced practice careers.

    Nurse Practitioner

    According the American Association of Nurse Practitioners, NPs are:

    “...clinicians that blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management, NPs bring a comprehensive perspective to health care.”

    NPs fulfill many roles both in the hospital, in private practices, nursing homes, correctional institutions, home care and in management positions. NPs are sought after for their clinical expertise and ability to provide cost-effective medical care in our ever-changing world of nursing. They perform their duties professionally and compassionately. Outcomes from NP care are economical and have been proven to be on par with professional medical standards. Today, many NPs function as the primary gate keeper to US medical care. Many patients have an NP as a primary care provider.



    ANs NP forum has many threads and articles about NP practice, duties and responsibilities. We also have a student NP forum where students can discuss issues about schools, classes, obtaining preceptors and the new-grad job market.

    Certified Registered Nurse Anesthetist

    Nurse anesthetists have been providing anesthesia care for more than 150 years. The certification CRNA was developed in 1956. From the American Association of Nurse Anesthetists:

    “CRNAs are anesthesia professionals who safely administer approximately 43 million anesthetics to patients each year in the United States, according to the American Association of Nurse Anesthetists (AANA) 2016 Practice Profile Survey.”

    In the CRNA forum, discussions range from new grad job offers to practice pearls to how to develop an independent practice. AN also has a very active student CRNA forum where members discuss shadowing experiences, interviews with schools, and the life of an SRNA. Frequent discussions focus on how to blend the student role with the practicing CRNA role.

    The military has long used CRNAs in field hospitals on battlefields on the front lines. CRNAs first provided care to wounded in the Civil War. Nowadays, the military continues to utilize CRNAs in active duty environments as well as the Veterans Administration facilities.

    Cost-containment is another aspect of nursing care where CRNAs excel. They provide high-quality anesthesia care in an efficient manner with reduced expenses to patients and insurance companies. This makes this career choice very lucrative.


    Clinical Nurse Specialist

    The National Association of Clinical Nurse Specialists state that CNS’s are expert clinicians who care for a specific population. In most states they are recognized as APRNs and able to examine, diagnose, and treat patients as well as to bill for this care. They function in a wide variety of settings including hospital, clinics, nursing homes, home care, and hospices. There are a myriad of roles for the CNS and depending on the facility, the CNS might be a change agent or educator, or manager or provide bedside APRN care. AN’s CNS forum can be found here.



    Certified Nurse Midwives

    The American College of Nurse Midwives is the organization devoted to supporting and providing cutting edge information to CNMs. For many women in the US, CNM care is the routine for their pregnancy. These nurses care for the pregnant woman and child during pregnancy and labor. They have a much lower rate of operative births. And the rate of labor interventions is often less also with CNM care. The CNM forum on AN also provides much information to the CNM community.

  • Dec 27 '16

    Quote from taivin
    I did say it has a long half life. Small does for a few days isn't going to hook the person and for those who need 24/7 pain management it's a God send. I think the government (who are the ones making all these ridiculous laws governing people with chronic pain) would look at it a little differently when approached with the methadone idea.

    Weaning off of methadone is like weaning off of any narcotic; easy does it...with methadone it takes a little bit longer.

    I would rather the short term tooth pulls, sprains, etc... be treated short term with small doses of methadone then be given Vicodin/Percocet that would put them in the sky if they are opioid naïve. That's where a majority of addiction with young people starts IMO. If there was no high, I believe not only would it save the person from knowing the so called ecstasy of escape (I've heard comments like, makes my tummy all warm, I love that feeling it gives me; from young and old), but the healing process could be more focused on.

    Also, couldn't agree more with increasing doses of methadone to find the right dose. Most careful...in long term, chronic pain patients.

    Either way, if you get hooked/dependent (from your own fault or having to stay on the meds for a long time) you have to give something to pay the piper. I believe the average half life of methadone is 26 to 32 hours depending on the person. Can also be shorter or longer for same reason. All weaning off of any controlled substance II should be monitored and controlled with other meds for comfort measures and safety.

    As with anything, education is key.

    I agree with ladySolo. Methadone can be very dangerous and should not be prescribed as a first or even second line pain treatment. Too little and the pain isn't controlled. Too much and you can die. Some patients do feel a rush from methadone,and can start taking higher and higher doses to find that rush. It can be very helpful for pain, but I feel it should only be prescribed by a knowledgeable pain specialist,and only after other treatments have failed.

  • Dec 19 '16

    Actually, if this goes on unchecked, this could come back to bite the OP regardless of whether he/she utilizes quizlet or not. If the classes ahead of the OP are using quizlet and a large portion of those classes are failing their NCLEX, that could call the school's accreditation into question. And if the school losing their accreditation before the OP graduates, that could create significant problems for him/her when trying to obtain licensure and a job.

  • Dec 18 '16

    How does abuse happen? 15-year-old went to ER for a sore throat (not strep, brought me the ER papers.) Came to me as a provider for a refill of his Vicodin the ER gave him a Rx for to manage a SORE THROAT!! What happened to warm salt water gargles and acetaminophen? Needless to say he did NOT get more Vicodin from me!

  • Dec 18 '16

    Quote from BostonFNP
    The benzo positive is concerning but not my "problem"; sure it is something to talk about.
    .
    You are a seasoned provider and I have no doubt you would wrap this up appropriately however for those who aren't well versed in this arena I'd be careful about blowing this off as someone else's problem because it will quickly become your problem if she dies from respiratory depression or stops the benzos abruptly, seizes and it wasn't documented thoroughly that you had a full IRBA discussion. Trust me "the only reason" she started abusing benzos will later be reported as because she was in such agony after you cut her off the percs sans taper, mourning children and grandchildren making these claims won't help you case. Also consider the off chance that she was getting the benzo from another provider and you either didn't know or knew and didn't attempt to contact the other prescriber to decide who was going to stop prescribing one of this combination. I'm getting letters constantly from the CDC, DEA and pharmacies indicating the dangers when patients are taking benzos with opiates so I have zero interest in attempting to explain why this was happening either in court or to the board of nursing.


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