From medical staff to nursing

[Jules A, MSN]

I work at a hospital in a decent size city. The powers that be have discovered the ineptitude of many new graduate nurse practitioners. We can of course argue whether it is the university's responsibility to turn out a competent product or not but regardless that ship has sailed. The fact is actually as with undergraduate education the schools seem to have minimal interest in ensuring their students are ready to function upon graduation. No surprise and this will not change. I'm heading toward acceptance, grudgingly, lol. They want to hire us because we are so plentiful and often so inexpensive which of course is a rant for another day.

Gone are the days of hiding behind my NP friendly physician colleagues as I nonchalantly meander into the physician's lounge and attempt to avoid other physicians realizing I'm a NP. I have seen casual conversation fall flat the minute an unfamiliar physician finds out I'm a NP. It was an excellent set up where for the most part I could forget I was a NP and function as a peer with psychiatrists. However as they say all good things come to an end. We are a dime a dozen now, even in psych and I am being changed from medical staff to nursing staff. My privileges are being restricted as the hospital recognized the new NP hospitalists are incapable in many cases of managing patients independently. I will have a doc who co-signs my charts. I am mortified but thankful they aren't touching my salary for now.

We will have a senior DNP who manages the NPs. We will report to our department chairs but will have a NP administrator to run interference. He will set up standardized and then specialized new grad orientation programs with clinical and didactic training as well as an assigned peer mentor. Another necessary evil that will solidify the terrible salaries new grads are accepting.

I am thankful for our patients and also hopeful our reputations can be repaired however disgusted and sad that this has taken us back decades. Our responsibilities are now more limited than the PA hospitalists who have gained physician's trust based on their similar education and competence. So ladies, and by ladies I mean all NPs, get it together so we can start to regain the ground recently lost.

[traumaRUs, MSN, APRN]

Sorry Jules. This is what was present in the hospital system I just left.

[spudbunny]

Time to start your own practice.

[Spadeforce]

How does the hospital think this will help? Not a rhetorical question, legitimately wondering...

I think if I was a doc in practice, I would want direct monitoring of the NPs IF i was worried about their ability to provide care. What do they deem beneficial from putting NPs under the nursing staff? Do they have to report back to just the DNP leader person, or to the CNO and other nursing admin also? I feel if they had to report to the CNO it would make things messy since you know CNO= I have never prescribed in my life or diagnosed.

Also, are the department chairs docs or nurse pracs?

[Corey Narry, MSN, RN, NP]

I've seen in both ways and worked in hospitals that use both models: NP's under the medical group vs NP's as a division of advanced practice nurses who fall under the larger nursing umbrella. I have no preference either way as I'm in California where many NP's who work in hospital settings are unionized anyway so the pay doesn't really make a huge difference.

Many larger institutions with a cadre of NP's (and CRNA's) have started designating an Advanced Practice manager who is typically an APN himself/herself. We have this very set-up and I think it is beneficial in making sure someone familiar with the NP (or other APN) role is overseeing the on-boarding, education, training needs, etc of newly hired NP's and can represent our voice with physicians in the round table discussions of medical staff credentialing.

[Jules A, MSN]

How does the hospital think this will help? Not a rhetorical question, legitimately wondering...

I think if I was a doc in practice, I would want direct monitoring of the NPs IF i was worried about their ability to provide care. What do they deem beneficial from putting NPs under the nursing staff? Do they have to report back to just the DNP leader person, or to the CNO and other nursing admin also? I feel if they had to report to the CNO it would make things messy since you know CNO= I have never prescribed in my life or diagnosed.

Also, are the department chairs docs or nurse pracs?

It is messy although a plus is the NP leader is a practicing NP and while he answers to the CNO they have a long term working relationship so hopefully no major issues there. The chairs are physicians so NPs are now being managed both by physician and NP oversight while the nursing department is scrambling to train the new grads who they finally openly admit are not fit to practice upon graduation. Some have quit and some have been let go due to inability to get up to speed.

In addition there have been scope issues that the NP leader will be overseeing . Apparently schools aren't educating on scope? There has been improper use of NPs often at the urging of physicians who have no clue what we are able to do and included a FNP being boarded in the ICU which had all camps in a tizzy.

Department chairs are physicians so depending on the department one could have a supportive chair or an unsupportive chair in which case the NP leader will attempt to mediate? Anyone know how this is going to work? The rates have been declining so I suspect this will ignite that fire.

[Jules A, MSN]

Many larger institutions with a cadre of NP's (and CRNA's) have started designating an Advanced Practice manager who is typically an APN himself/herself. We have this very set-up and I think it is beneficial in making sure someone familiar with the NP (or other APN) role is overseeing the on-boarding, education, training needs, etc of newly hired NP's and can represent our voice with physicians in the round table discussions of medical staff credentialing.

Thanks Juan we must have been posting simultaneously. I wish we were unionized here. Do you think it minimizes our value? I'm unable to be objective due to embarrassment that medical staff realized we need remediation and oversight which we didn't have in the past. When there were only a handful of us it was easy to blend in and see our patients without someone signing off on our charts. The physicians we worked with knew we would seek assistance when needed but other than that trusted us to take care of business.

[Corey Narry, MSN, RN, NP]

How does the hospital think this will help? Not a rhetorical question, legitimately wondering...

I think if I was a doc in practice, I would want direct monitoring of the NPs IF i was worried about their ability to provide care. What do they deem beneficial from putting NPs under the nursing staff? Do they have to report back to just the DNP leader person, or to the CNO and other nursing admin also? I feel if they had to report to the CNO it would make things messy since you know CNO= I have never prescribed in my life or diagnosed.

Also, are the department chairs docs or nurse pracs?

The CNO does not oversee the clinical activities of the NP's. As the chair of the entire nursing department, they tend to focus more on finances and budget. In our case, the Advanced Practice Manager for the institution is overseeing the hundreds of NP's, CRNA's, and even PA's who work in the institution. This person reports to the CNO directly. Some of the larger APN groups within the system (Critical Care NP's, NNP's, NP's in the surgical subsepcialties) have a designated manager who is also an NP.

Clinical activities still fall under the specific department (such as Critical Care, General Surgery, Neurosurgery, etc) and they have a physician chief as you're probably familiar with. The physicians have a say on NP annual performance evaluations, new hire feedback, criteria and protocols for collaboration, criteria for which roles are independently performed by NP's, everything that has to do with NP practice. This is why it is important to have someone who is also a Nurse Practitioner serve as a manager to speak for the issues and needs of the NP's and other APN's and not have physicians have free reign on what they would like the relationship to be.

[Corey Narry, MSN, RN, NP]

Thanks Juan we must have been posting simultaneously. I wish we were unionized here. Do you think it minimizes our value? I'm unable to be objective due to embarrassment that medical staff realized we need remediation and oversight which we didn't have in the past. When there were only a handful of us it was easy to blend in and see our patients without someone signing off on our charts. The physicians we worked with knew we would seek assistance when needed but other than that trusted us to take care of business.

I think that it is an unfortunate consequence of our increasing numbers in hospitals. It is no longer a matter of an MD working with a specific NP side by side which used to be the case. We have a situation where we have a pool of MD's and a pool of NP's in a specific department or specialty. It is of course not a bad thing but someone has to be the spokesperson for each group.

The union situation is both a plus and a minus. On one hand, it helps us bargain for our pay collectively with a standardized pay schedule and not get screwed over when a new NP gets offered a higher salary yet some older NP's have not even gotten a raise and I've seen that in other places before.

On the other hand, nursing unions like to talk about making sure nurses get their breaks, patient ratios are observed, ceiling lifts are installed, stuff that are of no consequence to NP's but are important to bedside RN's. When a strike is being proposed for those issues, we as NP's have to join in support.

Unions are of course, not typical for NP's anywhere else. I found it odd that we have it here at first myself but academics in universities have unions so I think professionals like us can benefit from having them. The ANA of course would disagree.

[core0]

The CNO does not oversee the clinical activities of the NP's. As the chair of the entire nursing department, they tend to focus more on finances and budget. In our case, the Advanced Practice Manager for the institution is overseeing the hundreds of NP's, CRNA's, and even PA's who work in the institution. This person reports to the CNO directly. Some of the larger APN groups within the system (Critical Care NP's, NNP's, NP's in the surgical subsepcialties) have a designated manager who is also an NP.

Clinical activities still fall under the specific department (such as Critical Care, General Surgery, Neurosurgery, etc) and they have a physician chief as you're probably familiar with. The physicians have a say on NP annual performance evaluations, new hire feedback, criteria and protocols for collaboration, criteria for which roles are independently performed by NP's, everything that has to do with NP practice. This is why it is important to have someone who is also a Nurse Practitioner serve as a manager to speak for the issues and needs of the NP's and other APN's and not have physicians have free reign on what they would like the relationship to be.

We have a different system. Within each division there is a lead APP. The lead APP and the medical director are responsible for performance evaluations. The lead APP is responsible for the schedule. Hiring is a joint decision. Moving up the chain each division has a lead APP along with a medical director. Where it falls down currently is above division. For example there is not a clear path between APPs in the division and higher up. We have hired a director of APP services that reports directly to the CEO of the healthcare organization. Currently they are also in charge of managing the student placement.

So for example in our critical care center each ICU has a lead APP who is in charge of scheduling and managing evaluations. They report to the medical director. They also report to the Lead APP of the critical care center. Basically clinical report goes to the medical director administrative oversight goes to the lead APP. Overall we have around 14 ICUs and 140 or so APPs in four hospitals. Our cancer center works in a similar manner. Wherever they have more than 3 APPs one is lead and reports up the chain. They have similar numbers and cover a similar number of hospitals. What is missing is a direct line to the director of APP services. We also have an APP council which is elected and liasons directly with the director of APP services.

We are still building out our structure but in my mind it should paralell the medical staff model and have a report as close to the top as possible. I can't see how reporting in the nursing structure is going to help. Nursing (at least in the hospital) is an expense and managed as such. APPs are revenue producers in a manner similar to physicians and should be managed as such.

[Dodongo, APRN, NP]

We have a chief APP (currently an NP) that is more involved with overseeing system wide reimbursement and salary issues. Each department's staff APPs still report to the department's chief medical director. I've heard of NPs falling under the purview of "nursing staff", however, I was under the impression that this equated to higher salaries for these NPs (i.e. unionized). It wasn't so much an issue of the NPs answering to RNs, just that their salaries were on a different scale. But they were still managed by the medical staff.

Regardless, I agree that we need to drastically restrict the numbers of graduating NPs. CLOSE FOR PROFIT "SCHOOLS".

[Jules A, MSN]

I've heard of NPs falling under the purview of "nursing staff", however, I was under the impression that this equated to higher salaries for these NPs (i.e. unionized). It wasn't so much an issue of the NPs answering to RNs, just that their salaries were on a different scale.

I can't imagine being under nursing will do anything for my rates as instead of being considered a bargain compared to physicians now they will be looking at my salary which is 2-3xs higher than the average RN and wanting to trim my fat.