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!
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:
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?
lack of independence is a good thing but I cannot write your paper for you.
For profit education is a joke and Walden students are generally bottom of the barrel. You're right that school takes anyone with a pulse which means they admit a lot of people who have no business being providers, and people who definitely have no critical thinking skills. I worry for their patients.
That doesn't change the fact that there ARE good nurse practitioners who go to good programs and have great mentorships or residency periods after school. I work with top notch NPs who function as colleagues equal and indistinguishable from the MDs in the practice.
It also doesn't change the fact that in general the supervision requirement is mostly in place in the remaining states because MDs lobby against it as they do not want to compete against other independent practitioners for business. The same physicians who lobby against independent practice because of "patient safety" often hire NPs at their own practices and allow them to work mostly autonomously to improve their bottom line.
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:
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?
lack of independence is a good thing but I cannot write your paper for you.
Thanks for the response. NP certification toward independent practice definitely needs a lot of work. But we’re headed that way whether AMA likes it or not. ? I would never ask anyone to write my paper neither will I be using any of your ideas since they are not congruent with my topic question.
For profit education is a joke and Walden students are generally bottom of the barrel. You're right that school takes anyone with a pulse which means they admit a lot of people who have no business being providers, and people who definitely have no critical thinking skills. I worry for their patients.
That doesn't change the fact that there ARE good nurse practitioners who go to good programs and have great mentorships or residency periods after school. I work with top notch NPs who function as colleagues equal and indistinguishable from the MDs in the practice.
It also doesn't change the fact that in general the supervision requirement is mostly in place in the remaining states because MDs lobby against it as they do not want to compete against other independent practitioners for business. The same physicians who lobby against independent practice because of "patient safety" often hire NPs at their own practices and allow them to work mostly autonomously to improve their bottom line.
I appreciate your input. And totally agree with you. NPs have a more holistic approach to patient care (from what I am starting to see). It doesn’t have to be a competition. Sadly, AMA makes it seem that way. It’s about patient safety and access to equal care. There has been some MD associations that support NP independence because they see the work and quality care they can give.
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:
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?
lack of independence is a good thing but I cannot write your paper for you.
There’s a lot to unpack here and I don’t have a ton if time this morning. But you do raise good points of a few areas.
Finding our own preceptor imo isn’t the worst thing in the world so long as there is a rigorous evaluation in place. My school actually did this. We had regional facilitators who’s job was to do a preclinical site visit and visits during the clinical process to make sure goals were being met. I knew about this process before enrolling, but verifying this ahead and getting s clear understanding Scott what a school does for their scholastic integrity is important.
Frontier also pays their preceptors. Something they call an honorarium. There is a lump sum that is divided among anyone who precepted. Whether that student passes or not, it’s is still eventually sent out. I had witnessed one student not do well with a preceptor and they were forced to find a new one. While that was a personality conflict in my opinion, that student eventually did move on to pass. The school came and evaluated that student in person multiple times after that to make sure they were safe clinically and at an appropriate level of progression (I picked up the student after they had their previous issue). That preceptor still received a small portion for the 80 some odd hours spent. I didn’t bite that incident as the student “failing” or just being passed as I was able to objectively assess the students abilities myself.
I don’t begrudge NPs who feel like we are money makers for uninterested “collaborators” or “supervisors”. Many doctors have made a healthy side salary of the backs of NPs for just being a glorified auditor. And many don’t even do that job with integrity. My last boss co-owned the practice and was collaborator for at least 10/12 NPs because he was the only family medicine doc at the practice. You can’t tell me with a straight face he looked at any of our charts while maintaining his own full patient load. Sure he was a source of consult, but we often used other MDs in the building well before going to our collaborator. If the theory is to pay someone for the expertise they bring then give. But when we are seeing the same patients and making similar educated medical evaluations, perhaps that MD and the rate they charge isn’t as necessary as many profess.
I am an ACNP (in PA, not CA). I work in critical care. I have collaborating docs in my practice and we work hand in hand daily. It’s a different world in ICU but in my case, we split the 24 bed unit in half and they round one half, I round one half, then we run the list. I tell them what procedures etc my patients need and whether I will do them, or if their residents can do under my supervision. We split the notes. I bill my own procedures and critical care time. If someone decompensates, we often go together to the bedside. If someone needs to be intubated etc, 80% of the time I do it and they watch. We split the new postop cases. They co-sign my epic notes per hospital bylaws which consists of clicking in epic and signing. They don’t read them. Granted, I have worked >5yrs with this team and built a high level of collaboration and clinical trust.
New Mexico NPs have had independent practice for about 30 years. It’s a rural state. There are many NPs that own their practices. As an NP student in Texas one NP clinic owner paid the collaborating doc to audit 10% of her charts. According to her that was the “supervising”. Locally, Most NPs have collegial relationships with local MDs that are readily available for consultants. I work at a FQHC that has 6 clinics. Our chief medical officer is a FNP. Each clinic has a physician and are the medical directors for their clinic. They are not supervisors to the NPs. The 2 docs I have worked with have aways been available for quick consultations and the atmosphere is of mutual respect. The doc I have now is very casual and actually pops in to ask for feedback on treatment plans & often we collaborate on patients that we have both seen. I love when he says “ so hey I was going to do x,y but wanted to ask what you think”.
Independent practice does not mean we practice in a vacuum. You can refer to specialist and most specialists are available by phone for consultation.
I work in a specialty practice where physicians co-sign my notes. This is related to payment, but underlying I have no patient of my own but rather see the physician's patients (there are 7) and then send the note to that patient's physician. I find peace of mind with this, as why not have their input. Every now and then I'll get a message from a MD to ask if we can chat about a patient, and we discuss the plan or the like. Sometimes I'll be given a heads up about a patient before seeing them, often related to an immunosuppressant plan which is an art all itself, ...no algorithm to follow if you know what I mean...I appreciate the collaboration, as the culture on my team involves physicians often openly chatting with each other about difficult cases. I can go through a week of not interacting much, just busy seeing patients, whereas in one day I might have a few patients who deserve discussion, often which I initiate. I have no shame in asking if there is something the MD can add if I am at all with question, and the patients I see seem to be comfortable with seeing me because I am clear about my NP role. I stay up to date and am always learning, so I strongly basically know what I am doing in my specialty and feel strong and empowered. Patients know if I order or advise something it is something I am very sure about, if not, they will know I will be chatting to their doc and the MA or I will give them a call later. Outcomes are good and I am given a lot of respect and kudos from my team, and I sleep well at night.
I work in a specialty practice where physicians co-sign my notes. This is related to payment, but underlying I have no patient of my own but rather see the physician's patients (there are 7) and then send the note to that patient's physician. I find peace of mind with this, as why not have their input. Every now and then I'll get a message from a MD to ask if we can chat about a patient, and we discuss the plan or the like. Sometimes I'll be given a heads up about a patient before seeing them, often related to an immunosuppressant plan which is an art all itself, ...no algorithm to follow if you know what I mean...I appreciate the collaboration, as the culture on my team involves physicians often openly chatting with each other about difficult cases. I can go through a week of not interacting much, just busy seeing patients, whereas in one day I might have a few patients who deserve discussion, often which I initiate. I have no shame in asking if there is something the MD can add if I am at all with question, and the patients I see seem to be comfortable with seeing me because I am clear about my NP role. I stay up to date and am always learning, so I strongly basically know what I am doing in my specialty and feel strong and empowered. Patients know if I order or advise something it is something I am very sure about, if not, they will know I will be chatting to their doc and the MA or I will give them a call later. Outcomes are good and I am given a lot of respect and kudos from my team, and I sleep well at night.
My state does allow independent practice.
Thank you for the thorough response! I’m starting to think that collaboration is something we can do without being forced to supervision and collaboration. Physicians very often collaborate with each other. Being independent doesn’t mean that we’ll never mean help, it means that we can freely treat patients within our scope of practice and full extent of our education and training. I can see how such complicated patients may benefit from such collaboration. Thank you for all you do!
I'm an NP in California. I have no idea what the supervising physician does.
This. Mine brings Dr. Seuss books on the days he's physically here with me and reads it our loud!! But honestly he is awesome- he does not look over my shoulder, has taught me a lot and has never once been unprofessional. He treats me like an equal colleague but I do know that everyone does not have this same experience.
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MentalKlarity, BSN, NP
360 Posts
For profit education is a joke and Walden students are generally bottom of the barrel. You're right that school takes anyone with a pulse which means they admit a lot of people who have no business being providers, and people who definitely have no critical thinking skills. I worry for their patients.
That doesn't change the fact that there ARE good nurse practitioners who go to good programs and have great mentorships or residency periods after school. I work with top notch NPs who function as colleagues equal and indistinguishable from the MDs in the practice.
It also doesn't change the fact that in general the supervision requirement is mostly in place in the remaining states because MDs lobby against it as they do not want to compete against other independent practitioners for business. The same physicians who lobby against independent practice because of "patient safety" often hire NPs at their own practices and allow them to work mostly autonomously to improve their bottom line.