Are you ACTUALLY supervised???

Specialties NP

Published

Specializes in Critical Care.

Hello! I am currently studying to become a nurse practitioner and I am writing a paper about the lack of independence NPs face in California. I would like to know what it's like to work with a physician in the sense of supervision. My idea is that they don't actually read all your care plans and micromanage but I really have no idea. I know the medical association strongly opposes NPs becoming independent because of a safety issue but is it really that or that they don't want us to take over the field? 

Has there been a time when a physician corrects your care plan? or disagrees with your treatment?

Do you think we should be supervised or not?

Does your state allow independent practice?

I'm just trying to get some real answers from NPs in the field. Thanks!

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I think you are confusing the ideas of supervision with requiring a collaborative agreement. 

While I work in a collaborative agreement state -- I would hope that no APRN would work in an environment where a physician would looking over their shoulder and overtly correcting their practice throughout the day.. and no physician is going to have that kind of time in their day anyway.

Our collaborative agreement requires that our Doc reviews a certain % of our charts monthly and we have a documented personal meeting with him/her at least quarterly.. they must also be available either on site or readily by phone during any clinic hours. If they are going to be unreachable for any reason then we need to have a back up filed with the BON or can't practice until our primary Doc is back available. 

And no I don't live in an independent practice state but I know a great number of APRNs in the state that own and operate their own clinic as a single provider clinic. Their collaborating physician in several cases is 100 of miles away.  

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Specializes in Critical Care.
42 minutes ago, 203bravo said:

I think you are confusing the ideas of supervision with requiring a collaborative agreement. 

While I work in a collaborative agreement state -- I would hope that no APRN would work in an environment where a physician would looking over their shoulder and overtly correcting their practice throughout the day.. and no physician is going to have that kind of time in their day anyway.

Our collaborative agreement requires that our Doc reviews a certain % of our charts monthly and we have a documented personal meeting with him/her at least quarterly.. they must also be available either on site or readily by phone during any clinic hours. If they are going to be unreachable for any reason then we need to have a back up filed with the BON or can't practice until our primary Doc is back available. 

And no I don't live in an independent practice state but I know a great number of APRNs in the state that own and operate their own clinic as a single provider clinic. Their collaborating physician in several cases is 100 of miles away.  

Thank you for the response. Do you feel safer with a physician overlooking your work? Do you feel it is necessary? 

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I can’t specifically qualify what my collaborator did or did not sign off on. Nothing in our agreement stated what was necessary and if memory serves Michigan doesn’t spell out specific needs of supervision. We always signed into our EMR as under supervision. Someone told me once all of our charts “go through” our collaborator and addended to say the patient was personally reviewed by the physician. Something I personally know to be false. At the end of the day, I made the judgement calls for every single patient and my “collaborator” had little to no involvement. Occasionally, other physicians who were located at the same facility were of value to reference and pick their brain. But they were neither by collaborator or clinical supervisor. 

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Specializes in Critical Care.
1 hour ago, djmatte said:

I can’t specifically qualify what my collaborator did or did not sign off on. Nothing in our agreement stated what was necessary and if memory serves Michigan doesn’t spell out specific needs of supervision. We always signed into our EMR as under supervision. Someone told me once all of our charts “go through” our collaborator and addended to say the patient was personally reviewed by the physician. Something I personally know to be false. At the end of the day, I made the judgement calls for every single patient and my “collaborator” had little to no involvement. Occasionally, other physicians who were located at the same facility were of value to reference and pick their brain. But they were neither by collaborator or clinical supervisor. 

Amazing. Thank you for the response. 

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Specializes in Psychiatric and Mental Health NP (PMHNP).

I'm an NP in California.  I have no idea what the supervising physician does.  

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Specializes in FNP.

I'm in Texas and I have a collaborative agreement with a supervision physician, I have no idea what she does.  She gets a lot of money for doing nothing, I know that.  It's just another way physicians can make money.  There is no other reason for the relationship, other than control.  

 

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Specializes in Psych/Mental Health.

My supervising MD doesn't read my chart. She has no time for that. I talk to her once a week to go over complex cases since the clinic pays for all of it. Other practices have fewer supervision, group supervision, or have experienced NPs doing the supervising.

I think it's good to have supervision in the first couple years especially given the lack of standard and depth in NP education. However, I don't think it must be done by physicians. Many experienced NPs are capable of supervising new NPs.

 

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Specializes in mental health / psychiatic nursing.

I work in an independent practice state, my supervisor at work is a physician,  he doesn't "supervise" me in the sense of practice restriction. 

 

Has there been a time when a physician corrects your care plan? or disagrees with your treatment? I often consult with physician colleagues on challenging cases. I haven't ever had one undermine my care or completely change my plan, my supervisor (and even physicians above his level) have always been respectful of me as the primary attending responsible for the patient and changes have been a matter of consultation and collaboration.  There is one internist I've butted heads with a few times, but this is less a matter of clinical decision making and more that the two of us have radically different communications styles. 

Likewise I've sometimes had physician colleagues come to me in turn for a fresh set of eyes on a particular case or ask for my assistance to help trouble shoot a challenging situation.  

I work inpatient so covering for another MD/NP is pretty normal and sometimes meds get tweaked but usually it's pretty darn clear why and if not people tend to leave a good note or report explaining the rationale.  I've tweaked meds on my supervisor's patients when he's been out, and he's done the same for mine, but it's usually pretty little stuff, or directly safety related.  (E.g. adding PRN antipsychotic for a highly agitated patient). 

Do you think we should be supervised or not?

I love having more experienced colleagues to work with. I don't think we *need* physician oversight, but I do think it is good, particularly for new grads, to work in areas where there are more experienced people (physician OR NP) around to bounce ideas off of and to help trouble shoot difficult cases.  In my setting I'd describe my supervisor as more of a administrative supervisor - he signs my time sheets, but is generally more a mentor than a supervisor per se - he's there if I need him, but generally lets me do my own thing.  I don't think he has it in his personality to micromanage. 

For me, personally, I'll probably never be 100% independent because I like inpatient and like working with an interdisciplinary team. However I did some of my clinicals in private practice or other settings where there was not physician oversight of NPs and I think for experienced NPs who want a high level of independence and who have professional networks for consultation if/as needed,  there isn't any reason to have them supervised by physician at all. 

Does your state allow independent practice? 

Yes. My state allows for fully independent practice. 

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Specializes in oncology.
15 hours ago, MikeFNPC said:

I'm in Texas and I have a collaborative agreement with a supervision physician, I have no idea what she does. 

 

15 hours ago, MikeFNPC said:

She gets a lot of money for doing nothing, I know that. 

This kind of inductive reasoning is why I stopped going to NPs instead of MDs

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Specializes in Critical Care.
14 hours ago, londonflo said:

 

This kind of inductive reasoning is why I stopped going to NPs instead of MDs

Please elaborate on your response, how does this applies to ALL nurse practitioners and not to any MDs as your post suggests. Also, is the response meant to be constructive and a response to the original question or something totally off topic. Thank you. 

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Specializes in oncology.

there may be great  NP schools out there but I was a preceptor for a Walden student (not NP) and was told to pass her even though she showed up on time once for 16 weeks.. This student found another preceptor and neither one has a successfully landed a FT  job in their MSN field.  BUT when students can PAY for a preceptor, that truly is a conflict of interest. Years ago (I am retired now) I investigated the NP Program of a top rated school.....I got the usual ...find your own preceptor... I asked:  Who verifies that the preceptor is competent as a clinical teacher? "Crickets"

Developing the knowledge and skill of making a differential diagnosis takes years of practice.

Certification: I have issues with a  quality control that one test given on one day developed from one test plan can actually determine the ability to apply knowledge and critical thinking to solve a patient's problem successfully without harm to the patient. (After the Walden "pass her on" I was clued into this

Medical schools and the subsequent  qualifying exams are not a ONE time occurrence. AND their preceptors get paid whether they pass or fail a student. In medical "clerkship" there is a construct where a preceptor is able to identify a student's weak areas, design further learning activities and re-evaluate with out loss of income. Have you ever been in the nurse's station when an attending questions a student? the student cannot bluff, etc. 

Please don't tell me this is critical thinking:

On 5/19/2021 at 6:40 PM, MikeFNPC said:

I'm in Texas and I have a collaborative agreement with a supervision physician, I have no idea what she does.  She gets a lot of money for doing nothing, I know that. 

 

On 5/19/2021 at 6:40 PM, MikeFNPC said:

She gets a lot of money for doing nothing, I know that. 

 When I read a "thoughtful" comment like the above...my true feelings re. the ability of an NP to critically think about a comment with relation to supervision and deflect it to $$  solidified  what supervision is occurring  with this NP and any acceptance to it. In addition I wonder if there has been any supervision in the clinical setting that did not involve money.

May be this NP is the only one???? who does not request any supervision?? or with the #s of For profit programs (accepting anyone with a pulse) and telling the preceptor..."pass them" or if the preceptor will lose $$ if they fail the student,  is their any wonder that I have lost confidence in the NP educational process?

 

On 5/18/2021 at 6:47 PM, 203bravo said:

I think you are confusing the ideas of supervision with requiring a collaborative agreement. 

lack of independence is a good thing but I cannot write your paper for you.

https://www.clinicalpreceptorrescue.com/students/

https://nphub.com/pricing

 

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