FNP in Hospital Setting

NewBostonFNP · Oct 17, 2019

On 10/17/2019 at 2:20 PM, adventure_rn said:
The scary thing to me is that for every well-intentioned post like this, there are hundreds of other new grad FNPs out there starting jobs just like this one, blissfully unaware of how far outside of their scope that they may be practicing.
Lately on AN I feel like I've seen a concerning number of FNP students and hopefuls claiming, "I'm going to be an FNP, therefore my scope is all patients," including acute care specialties, emergency medicine, mental health, etc. (that's not necessarily what this OP is saying, but just a general observation).
We talk all of the time on this site about the proliferation of FNP programs flooding the market. Maybe in an effort to sell their program, recruit students and increase revenue, those programs are telling their participants "You can be whatever you want to be" instead of being realistic about their scope of practice regulations and limitations.
I'm a little disappointed (but not necessarily surprised) that hospitals still offer jobs to new grads that are outside of their scope under the Consensus Model. It seems like something the hospitals would do to try to get cheaper labor based on the glut of new graduate FNPs. Meanwhile, it puts people like the OP at risk of practicing outside of their scope without even realizing it (because 'why would a hospital hire them if they weren't qualified?') I'm guessing that at some point, CMS is going to stop reimbursing for inpatient care provided by 'primary care providers;' billing issues might be the only thing that stops hospitals from this sketchy practice.

I think you have a very valid argument. I have hesitated to respond because I don’t feel comfortable saying what I’ll be hired to do given that my username states my location. I truly feel as if I’ll be within scope given what the job is, but I’m failing to provide details because I’m paranoid about internet stuff.

That being said, the responses have been great and I will certainly be reviewing my state guidelines and comparing them to practice guidelines. I will keep these guidelines in my mind during the orientation process to ensure that I am right with regard to my thought that the specific thing I’ll be doing is truly within scope. But again, it’s specific enough that combined with my location makes me feel uncomfortable divulging.

As an aside (and not specific to me), I have been looking at all jobs offered for NPs in my job search (which encompasses a majority of Massachusetts and Rhode Island) and every single inpatient role offered is looking for an FNP, PNP or PA. Very few of them include acute care NPs (although I have seen that sometimes). Some of the more acute jobs are requiring either acute care NP experience or RN experience in the ICU.

Obviously the onus is on the NP to protect their own license, but it also seems to me that if every single hospital is hiring this type of practitioner for this type of role, it must have some level of acceptability and pass some state litmus test where guidelines and scope are concerned? It is every single hospital. Every single one.

I put the above thought out there to evoke a thoughtful dialogue on the subject.

Wuzzie · Oct 17, 2019

40 minutes ago, NewBostonFNP said:
Obviously the onus is on the NP to protect their own license, but it also seems to me that if every single hospital is hiring this type of practitioner for this type of role, it must have some level of acceptability and pass some state litmus test where guidelines and scope are concerned? It is every single hospital. Every single one.

Don't be so sure. With the glut of FNPs so many large cities are experiencing jobs are becoming harder to find and people are taking what they can get...often for less money than they deserve. Hospitals are benefiting from that.

NewBostonFNP · Oct 17, 2019

On 10/17/2019 at 3:22 PM, Wuzzie said:
Don't be so sure. With the glut of FNPs so many large cities are experiencing jobs are becoming harder to find and people are taking what they can get...often for less money than they deserve. Hospitals are benefiting from that.

OK so all I can add is my recent experience: new grad NP with 8yrs of RN experience.

I was offered a job with no benefits at a weight loss clinic south of Boston for $89k. I basically laughed in their face.

Was one of two final candidates at a large pediatric hospital to be a care coordinator in an outpatient specialty clinic. Full and excellent benefit package and starting at $100k

Turned down a sleep/pulmonary NP position interview because it was a bit further than I wanted to commute - it was offering an excellent benefit package and starting at $110k

Accepted a job in a hospital-based specialty at a large hospital in Boston with an excellent benefit package starting at $112k full time.

All of these are great jobs that are paying over the average new grad salary for my area. Despite being in an area with many NP programs. I looked for work for 3 weeks - 15 months out from graduation and had enough interviews to fill my plate (more opportunities than listed above).

I had ample opportunity for a high paying job. So it seems that is in contrast to the above for my area. So if the hospitals are still offering this much and have a wide pool to choose from, why hire people outside of their scope?

(again, asking respectfully so we can have an enlightening dialogue)

Wuzzie · Oct 17, 2019

No idea. Did this great hospital job come with a residency or at least an extended orientation so you can learn the critical care medicine you didn't learn in your FNP program? What are your other responsibilities, besides weaning vents (yikes)? In my previous life I worked in ICUs and flight. Critical care isn't cut and dry. Are they paying for your insurance (which I still think you might have trouble finding). What is the FNP scope in Mass. Again just feeling your responsibilities are in scope is not the same as them actually being okay. Where I am FNP's can't work in critical care but so far they can work in acute care with associated RN experience.

Home Health Columnist / Guide · Oct 17, 2019

As a former Clinical Manager working for a multistate health system, HR hiring software open clinical position titles being posted are often not updated -sometimes for years so may not fully reflect type NP they desire to hire.

My background also home home x 25yrs post 10yrs working on Respiratory/telemetry unit -weaned many patients off vents. Initial home care RN was working 1:1 with vent dependent patients 6-8hr shifts along with perdiem home infusion visits. Was your 8 yrs. home health performing intermittent skilled visits or was it private duty shifts with vent dependent patients? You do not present to AN members as having the skill set to manage vent weaning as no hospital experience listed therefore grave concern that you are unprepared to handle this specialty role.

Advanced Practice Columnist / Guide · Oct 17, 2019

In the end, I think you just have to be honest with yourself. You picked a job that offered the best benefits and pay but does it have a cost to your own liability risk? You will be practicing in a field that you never trained in as an FNP and you have not recently stepped foot in a hospital in your RN career yet you would be "consulting" on the sickest patients in the hospital. That does not sound right no matter how you look at it from any angle. Does it happen in real life? oh yes. It's one of the reasons our training as NP's get viewed as disorganized, inconsistent, with a half-baked product unprepared to hit the ground running.

There are specialty practices where the NP's serve more as the liaison between the attending hospital physician or primary provider team and the specialty consultant physician. Is that the kind of role you signed up for? In these scenarios, you assess the patient, report to the physician, and you are told of his or her plan which you then communicate to the primary provider or team. You are basically a messenger. You may have less risk in that situation given that you are working directly under a "supervising" physician who makes the decisions.

However, realize that in a consultant role, billing must be signed off under whoever wrote the consult (NP or MD). Would that be you? then you could be held responsible for recommendation on that consult. If something were to go awry and you are questioned about the recommendations you made because of a poor outcome, would you be able to prove that you are fit for the role based on your training? Would the physician back you up? I would clarify this scenario specifically. I've seen some NP's serve as scribes were physicians do the rest of the consult and bill it under their billing number. I'm not sure about the legality of that practice, however.

NewBostonFNP · Oct 17, 2019

Again, I shifted the conversation away from the role I will be having for Internet/security reasons. I was very vague in my description for privacy reasons. Yes, I’ll have some patients in the ICU but won’t be working with them outside of a consultative capacity with my specialty. Nothing hands on. Nothing that will be solely my discretion. A focus of my role will be on discharging/outpatient patients, hospital policies, etc etc.

I am part of an ambulatory clinic and will only round on inpatient patients in prep for discharge and I am responsible for outpatient follow up! Please, please, please. I am not a child; no more slaps on the proverbial wrist about my choice.

As I’ve stated, I’m not sharing the job for privacy concerns since stupidly made a username with a location.

Advanced Practice Columnist / Guide · Oct 17, 2019

Then I'm not sure why you started a thread. If your question is whether you can get liability coverage, you have to start by applying and honestly answering the application questions about your training, certification, and the specialty you will be working for. It's up to the underwriters to decide after that. I personally think you will get coverage.

adventure_rn, MSN, NP · Oct 17, 2019

I apologize, I know my response came across as kind of harsh. I didn't mean to imply that you personally haven't done your due diligence. Rather, I think the system is broken, and it has the potential to put both NPs (for liability reasons) and patients (for safety reasons) at risk.

3 hours ago, NewBostonFNP said:
As an aside (and not specific to me), I have been looking at all jobs offered for NPs in my Job Search (which encompasses a majority of Massachusetts and Rhode Island) and every single inpatient role offered is looking for an FNP, PNP or PA. Very few of them include acute care NPs (although I have seen that sometimes). Some of the more acute jobs are requiring either acute care NP experience or RN experience in the ICU.
Obviously the onus is on the NP to protect their own license, but it also seems to me that if every single hospital is hiring this type of practitioner for this type of role, it must have some level of acceptability and pass some state litmus test where guidelines and scope are concerned? It is every single hospital. Every single one.

As I said in my first post, just because hospitals are doing this doesn't mean that it's correct, or that these NPs are practicing within their scope.

Another major complication is that a lot of MDs don't fully understand the scope of practice limitations that NPs face under the Consensus Model. I wouldn't be surprised if there are physicians out there who believe that "FNPs can care for all populations, so if I teach them a skill, then it is within their scope," which isn't necessarily true depending on your BON; this topic comes up a lot in the AN forums about Pain Mangement NPs and injection therapy. The NP model of education is pretty different from the medical model. Even though physicians are hiring, training and supervising NPs doesn't mean that they understand the limitations of their scope of practice.

It sounds like you're being cautious and thoughtful, which is important. I just wouldn't assume that what you're being asked to do is within your scope just because 'all of the local hospitals are doing it.' Part of the scary thing about being new is that you don't know what you don't know; if you're in over your head, you may find yourself in a dangerous situation and not even realize it.

Oldmahubbard · Oct 17, 2019

I have never understood these NP jobs where the MD has his or her head in the door for a minute or less, and you somehow bill as though the pt was really seen.

I would not be comfortable with this scenario.

Wuzzie · Oct 18, 2019

13 hours ago, NewBostonFNP said:
Please, please, please. I am not a child; no more slaps on the proverbial wrist about my choice.

Nobody is treating you like you are a child. You are hearing from people with the experience in the acute care setting that you do not have. We are trying to give you a clearer picture of what you are about to walk into so that you are adequately prepared to deal with situations that could impact you professionally with this job. It's not our fault you are not being open about your job responsibilities and it makes it difficult for us to answer your question. We are doing the best we can with the information we are being given. You are free to stop following this thread if you don't like what you're hearing although I think that would be overkill. In addition, you might ask the mods if you can change your username since you chose one that was too revealing. They sometimes will.

Susie2310 · Oct 18, 2019

On 10/17/2019 at 4:02 PM, NRSKarenRN said:
As a former Clinical Manager working for a multistate health system, HR hiring software open clinical position titles being posted are often not updated -sometimes for years so may not fully reflect type NP they desire to hire.
My background also home home x 25yrs post 10yrs working on Respiratory/telemetry unit -weaned many patients off vents. Initial home care RN was working 1:1 with vent dependent patients 6-8hr shifts along with perdiem home infusion visits. Was your 8 yrs. home health performing intermittent skilled visits or was it private duty shifts with vent dependent patients? You do not present to AN members as having the skill set to manage vent weaning as no hospital experience listed therefore grave concern that you are unprepared to handle this specialty role.

Thank you for making this very important point.

I continue to be incredulous at the number of RNs who either never learn how to practice in acute care and/or who have no recent experience in acute care who think that "getting their FNP" will automatically render them competent to provide care to patients of all acuities. It seems the last person they think of is the patient.

Also, acutely ill complicated patients present to primary care offices too!