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First NP Job With Little Autonomy


Specializes in Med-Surg, Transplant. Has 4 years experience.

Sooo, I'm having a dilemma. I started my first NP job about a month ago and for multiple reasons it is just NOT turning out to be what I envisioned, both in a work-life balance and even more importantly, a professional way. I was initially so excited about this job. I'm working at a world class institution (if nothing else comes of this career phase, at least the name will look good on a resume) and thought it would be awesome/advantageous to further my RN specialty by taking a first NP job working with a similar patient population. I also suspected that being in an academic environment with multiple resources and the support of a fellow midlevel/a few experienced attendings would be a solid way to start as an NP. I'd heard from a few former RN coworkers turned NPs that some settings who'd never used NPs before or just expected COMPLETE autonomy instantly were pretty terrible work environments that they had quickly left.

However, fast forward a month and there are some serious issues. First, and perhaps least important (LOL) is the fact that the other midlevel and I work 10-12 hour days 5 days a week. Truthfully, I would say 85-90% of the time it is 11-12 hours. Apparently for months before I came there was talk of constructively addressing this with increased staffing but it seems that nothing has changed. Our division used to have an experienced nurse working with us but stupidly enough she has been transferred elsewhere within this larger outpatient setting, leaving us again with a crazy amount of work. Because really, as I'll discuss more later, the reason for staying so late is NOT because we are doing mostly advanced practice level work, it is because the two us are doing EVERYTHING for this patient population between the two of use-refills, prior auths, disability paperwork, returning allllll patient phone calls, doing charting and notes that are apparently "supposed" to be done even though they mimic that of the MDs, seeing patients in clinic, tracking certain testing requirements/procedures for the patients, etc., etc., etc.

When I interviewed for this job, it was reiterated constantly throughout the entire process that although this specialty/division had previously utilized RNs/LPNs alongside the MDs, they had realized for multiple reasons that it would be advantageous to transition to having APNs/PAs in the mix. Even during one of my interviews with one of the attendings, we discussed midlevel autonomy quite frankly and I was again led to believe that at some point I would achieve a reasonable level of it.

Truthfully, now, my biggest gripe, even more so than my schedule (and my relatively pathetic salary given my area's insane cost of living/taxes...one of the highest in the country), is that the other midlevel and I are treated like glorified RNs. And really, this DOES NOT appear to be changing at alll. After every patient's appointment, one the the MDs has to see them before they leave, we discuss the patients with the MDs every day prior to our phone calls to them with updates/lab results and without fail the conversation pretty much becomes them telling us what to do, and although they have all been cordial to me, any "teaching" I get is pretty much from asking questions and pushing for a reason as to WHY they are choosing something. I'm not a whiner and certainly don't expect full freedom at this point, but it's abundantly apparent that we WILL be treated like non-provider staff indefinitely. I just feel like this is very sad because I have enough experience in the specialty that I'm far from clueless, despite of course still needing to learn a lot.

I guess my question is whether I should stick this out for a least a year just so my resume continues to look solid. Of course even if a "better" job presented itself in the meantime I would not quit this job until I had secured another offer. I suppose I'm just worried that I will lose provider skills, thinking ability, and just that whole mindset/persona if I continue in this job. It is just very silly to get shot down about putting a patient with insomnia on 25mg of trazodone qHS and instead being told to put them on Ambien - no rationale, just, "No, give her some Ambien" (stupid example, but just what came to mind). Of course I try to research things, continue to learn, etc., but at the risk of sounding whiny I'm so bogged down but all of the above clerical junk that I mentioned...as well as "confirming" everything.I.do with an MD that this is tough to do. So, basically, hope that all of the above magically changes and try to hang on, or look for something more advanced-practice oriented to give myself a good foundation?

I'm soooo sorry this is so long...apparently this is the result of holding your frustrations in at work.

I doubt that short of a miracle, things will change anytime soon. I would probably start a relaxed search at about the six to nine months mark.

So who requires you to have the patient see the MD each and every time? Clinic "rules" or just that particular MD ? Or is it some weird state practice act ?

anh06005, MSN, APRN, NP

Specializes in Cardiac, Home Health, Primary Care. Has 6 years experience.

I agree with caliotter3. I'd browse through job openings and if something really catches your eye then apply. The worst they can do is not call you. If they call and interview you the worst that can happen is you don't get it. Even if you got an interview and job offer next week if they're willing to hire you (and possibly provide you with a better atmosphere) then why NOT take it?? If your next job is something you love I doubt a little blip of a few-months-long-job will be overshadowed if you're at your next job for years and do great work.

Keep what pays the bills (duh) but find something you enjoy and can live with for a couple of years.


Specializes in Med-Surg, Transplant. Has 4 years experience.

Re: seeing the MD, just tradition on their part and I think just them not embracing us as actual providers. I'm in a state with independent NP practice so it certainly isn't a legal requirement.

Thanks for the encouragement to continue looking at least by the 6-9 month mark. It helps to know I wasn't alone/crazy in thinking this.


Specializes in LTC.

Question - are NPs just generally NEW to this practice setting? Maybe the docs/admin just aren't used to NPs, so it's difficult for them to let go. Like they're just figuring out how to gauge their level of supervision with your autonomy.

Kind of like when I had a newbie with me - I stuck real close wanting to know how proficient/safe the newbie was before I could start cutting some slack.

I don't get the impression that it's YOU. Just would be any NP or PA that would be so closely followed.

Ok, my first few thoughts are....other than the having to present each case to the doc thing, do you like the practice setting ? What efforts have been made by you and the other NP to sit down with the MDs and push towards more independence? If you haven't done that and haven't pushed back, then maybe they just assume this is how it is going to be ? They have to hate it too b/c it sounds time consuming for all involved.

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

Some suggestions (and I assume you are in a transplant setting as that is your experience?):

1. Have a meeting with the other APRN: find out what they would like in a job setting.

2. Come up with goals for your autonomy, a series of checks and balances at set points during your first year of employment. This will give the docs some control of your practice and reassure them that you are practicing to the standards they require.

3. The financial picture is the bottom line - obviously you can bill for your services: is it adding anything to the billing if the MD sees them? Do some homework and find out what you can bill and bring to the practice.

4. By practicing independently (which your state allows), you are freeing up the MD to see other patients thus bringing in even more money.

5. Propose hiring an RN, LPN or MA to assist you in order to be more productive.

If all else fails, move on.

I'm sorry to hear about your sitch! I totally agree with the above about sticking it out for a few more months before job searching again. First, working 50-60 hours/week is not okay...unless your salary accounts for these "unpaid" hours. Others may disagree, but my work is quality and it's not up for charity unless I say it is. However, I do believe that the hours issue is loosely linked to your current "training wheels" situation...being that the more independent you are, the more leverage you simultaneously acquire. A seasoned PA I'm working with suggested that I periodically seek performance evals with my attending physician(s) and specify goals I have reached as well as current areas of weakness. This way my supervising physician(s) can "tangibly" assess my progress. I'm not sure if your institution allows for adjustments in your role, but I truly believe that regardless, routine communication with my supervisors is important. It doesn't have to be long and drawn out or pestering and incessant, just brisk, confident, and routine conversation. I also love the suggestions made by traumasrus. The financial ineffectiveness of not allowing you to see your own patients is real!


Specializes in Med-Surg, Transplant. Has 4 years experience.

Thanks all for the suggestions; I appreciate it. Thankfully the other midlevel is largely on the same page as me re: autonomy. I think the biggest thing that needs to be determined between her, me and the MDs (yes, I'm in a transplant setting, and yes I realize this may be a little identifying but honestly don't think it's the end of the world) is what LEVEL of autonomy we can all agree on. I'm hoping that as I get close to my formal eval in a couple of months that this can possibly be discussed amongst ALL of us. The other midlevel just told me this week that she is NOT a billable provider (which actually doesn't make sense), so I think part of my "homework" needs to be figuring out what other NPs across the institution do before our group meeting. I honestly have a feeling that they are NOT all this hemmed in. Hopefully we can maybe even get some support from the administrators/financial people/other directors in the group in support of billing authority. Just have to tread carefully so I don't burn bridges.

I also intend to continue to solicit feedback re: my performance, areas of improvement, what I can do to further my level of independence, etc. One MD has worked with MDs before and is very comfortable with them and I honestly have a lot more freedom with her; the others will definitely be more resistant and I have to tread carefully. I have a feeling I'll probably end up leaving sooner rather than later (nothing too crazy, but at the year mark) because of the combination of staffing + autonomy. I also think the autonomy thing can't be fully addressed until the staffing is improved, which I understand but I think the commitment to fixing that will become apparent over the next few months. And honestly, if it's not fixed well it will make my decision pretty easy.

Thanks again all!

Jules A, MSN

Specializes in Family Nurse Practitioner.

I'm sure I will get some flack for this but OMG start looking for a real NP job with decent compensation and autonomy! I am appalled especially because this isn't a state NP restriction issue. As much as I enjoyed the large academic facilities as an ADN undergraduate there is no way I'd tolerate this even as a new NP. My guess is that since the cow is out of the barn ie. you have been doing the grunt work without objection it will be very difficult for you to set boundaries now. If you and your colleague are honest with them it will likely make things easier on the next person who comes along unless they are just of the mindset to grab new grads and use them until they wise up. BTW unless there was a compelling reason for trying Ambien before Trazodone I would say it is a poor choice due to dependence concerns so he should have offered you an explanation imo, although then again he shouldn't even be involved in what you prescribe.

FWIW in my area it is well known which facilities with fancy reputations basically treat their NPs like hand maidens for lousy pay with no real development of skills and trust me their fancy name is more of a detriment on a resume than a wow factor. I'd find something better before your judgement comes into question for staying in a cruddy situation. I'm sorry this happened to you but the writing is on the wall so my advice would be move on quickly! Good luck.


Specializes in Med-Surg, Transplant. Has 4 years experience.

Thanks Jules A. I'm a pretty intuitive person and I feel that you are probably right. Even though I'm kind of freaking out that I've basically uprooted my life only to realize that this position is not right AT ALL I appreciate the truth. On a only-half-joking note, if anyone is looking for a NP and willing to treat me like one- primary care, geriatrics, transplant, adult - I am SO interested

Jules A, MSN

Specializes in Family Nurse Practitioner.

Thanks Jules A. I'm a pretty intuitive person and I feel that you are probably right. Even though I'm kind of freaking out that I've basically uprooted my life only to realize that this position is not right AT ALL I appreciate the truth. On a only-half-joking note, if anyone is looking for a NP and willing to treat me like one- primary care, geriatrics, transplant, adult - I am SO interested

Thank you for not being offended by my lack of candy coating. :) I would imagine there are plenty of places who would love you although on the other side of the spectrum most might expect you to truly function independently. In my experience orientation was being handed a prescription pad and shown a desk but it sounds like you are ready!

Best to you.


Specializes in Psychiatric Nursing. Has 30 years experience.

I agree with those who say this is not a good job for you. As a new provider you need to be in a place where you can be mentored to develop your skills. These folks do not have a clue. You should not be doing refills, prior auths etc. unless the culture is that everyone (including the MD's)are helping out . It is not your problem if refills aren't done- it is a problem in how the place is run. (There are agency RN's) They need education in the NP role. It is probably easier to look around and find a job where you can develop your NP skills..In the meantime try to educate them. How did they become so clueless?


Specializes in Psychiatric Nursing. Has 30 years experience.

You might also review your job description to see what you are doing compares to what you were hired to do. Also this place may not want a APRN as a provider.

I saw a job listing once where they wanted an NP as office manager where the NP could do everything and provide patient education.