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.
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.
I suppose this is a good point. One reason why you should always, always, always know how much revenue you generate. As an NP you need to be aware of every dollar you make. And, if it comes down to it, as much as it sucks, you can always voice your opinion by seeking employment elsewhere.
to jules- how did they restrict their practice? did they knock them down to H and P and discharge summary mules? or can they still see patients and provide management? or somewhere in between (as in low acuity post ortho surg courtesy consults)?
"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."
The NPs community has shot itself in the foot, in my opinion. I have seen many NPs and DNPs come before the BON for some really scary practice issues. It is good that docs have to sign your charts. Attendings have to sign resident's charts and NPs are in no way as educated as medical residents.
Honestly, how would you possibly consider yourself a peer with psychiatrists when they have gone to 4 years of med school and a residency.
"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."
The NPs community has shot itself in the foot, in my opinion. I have seen many NPs and DNPs come before the BON for some really scary practice issues. It is good that docs have to sign your charts. Attendings have to sign resident's charts and NPs are in no way as educated as medical residents.
Honestly, how would you possibly consider yourself a peer with psychiatrists when they have gone to 4 years of med school and a residency.
I was afraid that if I made a similar comment I would be accused of hatred towards NP's, even though I am just stating facts, but you said what I think. I was reluctant to comment because obviously Jules has a lot invested in his/her career and is venting here, but when he/she has even commented on this forum that the physicians/psychiatrists he/she works with know far more than he/she does, I can't help but wonder why he/she is so outraged that some physicians have recognized the lack of education/training that NP's have versus their own education/training, and are taking very reasonable steps to try to ensure patients receive safe, quality, care.
NP's are NURSES. They are NURSES. It is good for patients and NP's that physicians have to sign NP charts. As far as forgetting one is an NP and functioning as a peer with psychiatrists; when one has a fraction of a psychiatrist's education/training how can one argue that one is entitled to forget one is an NP and function as a psychiatrist's peer? We are adult nurses and this is not a game of make believe. Why do some NP's believe that their education and training, which is a small fraction of a physician's, entitles them to be recognized as equals to physicians and to be accorded the same respect by a physician that a physician would give to a physician colleague? Egotism/delusions of grandeur are a big problem in the NP/Advanced Practice field.
The point that I think Jules is making (correct me if I'm wrong Jules please) is that now APPs are going to be under the nursing umbrella at her facility, not the medical team.
This is what occurred in the hospital system I just left also. It resulted in lower wages, less PTO, less benefits. Staff nurses can't bill, APPs can so therefore their worth is more - healthcare is a business and APPs are revenue-producing.
I was afraid that if I made a similar comment I would be accused of hatred towards NP's, even though I am just stating facts, but you said what I think. I was reluctant to comment because obviously Jules has a lot invested in his/her career and is venting here, but when he/she has even commented on this forum that the physicians/psychiatrists he/she works with know far more than he/she does, I can't help but wonder why he/she is so outraged that some physicians have recognized the lack of education/training that NP's have versus their own education/training, and are taking very reasonable steps to try to ensure patients receive safe, quality, care.
NP's are NURSES. They are NURSES. It is good for patients and NP's that physicians have to sign NP charts. As far as forgetting one is an NP and functioning as a peer with psychiatrists; when one has a fraction of a psychiatrist's education/training how can one argue that one is entitled to forget one is an NP and function as a psychiatrist's peer? We are adult nurses and this is not a game of make believe. Why do some NP's believe that their education and training, which is a small fraction of a physician's, entitles them to be recognized as equals to physicians and to be accorded the same respect by a physician that a physician would give to a physician colleague? Egotism/delusions of grandeur are a big problem in the NP/Advanced Practice field.
Maybe we should focus our frustrations and accusations of "delusions of grandeur" toward governing bodies that are moving towards "independent practice" rather than towards individuals who by all instances have shown themselves on this board at least to show pretty sound thoughts and arguments regarding a range of issues?. Many nurse practitioners are expected to perform the same tasks as physicians. Regardless of how well trained we are. There are many states that let us work without a collaborator and own our own clinics. Either a lot of faith in our progression was misplaced or maybe it's evidence of the impact of newer low grade schooling choices. But the point remains that multiple levels of systems put their faith and expectations in us to work at the pace and competence of a doctor. And for those who have been, it's an understandable slap in the face when they try to take that independence away.
Devil's advocate question: Would new NPs be "more in tune" with what they didn't know (and maybe the fact that they were paying for a crap education) if they had a decent amount of clinical experience as an RN? (Instead of all these direct entry "advanced practice" programs)
I realize this might only be part of the problem, but is it a part?
It must be the case at Jules' hospital that many experienced NPs are respected, and have proven themselves. So it is very, very sad to think that totally unprepared new graduates have entered into the mix and ruined it for everyone. But we have allowed it. We allowed the low standards. Medical school and PA school are both really hard to get into. NP school should be hard to get into, but the last I knew, it was not.
I see things people write here, that they work full time and take NP classes full time online. Disgusting. There is zero academic rigor. And the pay reflects it.
I am just holding on for dear life, only a few more years to go, thank God.
The DNP actually makes things worse, because it only takes about 5 minutes of online research to see it is a complete farce.
I agree that pound for pound physicians have more experience and education, that's just objective data. But that doesn't automatically equivocate what makes a good clinician. Because a good clinician is not based solely on experience and education- it's also judgment and using the best evidence available at hand, something that not all providers do.
Nurse midwives vs OBs are a good example of this. Here's a link to a cochrane review that looked at studies of women who were randomly assigned OBs or nurse midwives. Those with CNMs had less episiotomies, less epidurals, and less instrumental birth. While there were no differences in neonatal/fetal death or c-section rates, the other factors make for less complications and certainly much less expensive healthcare.
Why is this? OBs have a 4 year residency in pregnancy after medical school. Shouldn't they have better outcomes no matter what? Theoretically, maybe. But it's not bore out in practice.
I agree that pound for pound physicians have more experience and education, that's just objective data. But that doesn't automatically equivocate what makes a good clinician. Because a good clinician is not based solely on experience and education- it's also judgment and using the best evidence available at hand, something that not all providers do.
Nurse midwives vs OBs are a good example of this. Here's a link to a cochrane review that looked at studies of women who were randomly assigned OBs or nurse midwives. Those with CNMs had less episiotomies, less epidurals, and less instrumental birth. While there were no differences in neonatal/fetal death or c-section rates, the other factors make for less complications and certainly much less expensive healthcare.
Why is this? OBs have a 4 year residency in pregnancy after medical school. Shouldn't they have better outcomes no matter what? Theoretically, maybe. But it's not bore out in practice.
seems as the midwifes had a healthier group of patients with less fetal death prior to 24 weeks and less preterm birth since both of those factors are more related to genetics and how the mother cares for the baby than intervention by a provider. Not discrediting the entire study but even if its random if the odds/rr/etc have higher levels of neonatal death prior to 24 weeks and stuff thats a sign of a sicker population, no failure by the provider
I have hired a lot of medical staff and nursing staff in my administration career. I have hired only 3 NP who I knew would be great without additional training.
When I hire NP I only have to follow the state Nursing Board and what ever my facility credentialing office/Education office determines. I then rely on the NP boss usually me and I follow the regulation requirements. I also place them on probation for 6 months in which they have to have so many hours along side the physician usually it is 800 hours, the physician's signs off on the necessary skills to practice. It is up to the NP to get those signatures for competence, if they do not have it after 6 months they are gone. That was my additional training. Some NP were grateful, the doctors were grateful. Did it cost more monies yes and I do not regret this. It is money well spent. Do I pay less for NP than Physician assistant...no I pay according to experience, training (and the content of that training).
When I hire Physician Assistance they work under the physician. They have to meet so much more criteria to be hired and to maintain their credentials. It was up to the physician to see to it if they had their required hours, required continuing education, and required peer reviews to continue to work at my facilities. Back in the day PA's did not even have to have their Bachelor Degree! They were usually EMT's who have experienced a life time or army medics.
So you really begin to see the difference requirements between a NP and a Physician Assistant (PA). I am not saying NP are not as effective as PA, I am saying in the medical arena we think of these professions with similar and different skills. For me it is much less expensive to hire NP however with the additional training I make NP go through it really evens up as far as costs. After this the PA costs rise more because of the required steps to maintain their license which we usually pay for.
Again and here is my soap box about my nursing profession. Here we have very qualified NP who have been trained and passed a specific exam for NP practice and we are still regulated to "nurse designation". I am feeling one step forward and 5 steps backward.
In Nursing we have at least 3 different pathways to obtain the right to sit for the NCLEX-RN. ADN, Diploma and BSN. Within those there are a number of ways you can enter the RN field i.e. accelerated with Bachelor in another discipline or fast track from ADN to BSN, or Diploma to BSN. In the end we all have the same responsibility of taking care of patients-only the advance degree gives you opportunities to become a supervisor and in many cases that may not be true.
Now we are going through this with NP. Advanced degrees, prescriptive authority, treatment plan development and outcomes, and here we are 5 steps back again. What are we doing about this.....complaining to anyone who will listen about the nursing situation. Do you know any PA or physicians that have a forum such as this, complaining of how they are being managed???
The NP level of responsibility should reflect the same treatment as the PA or doctor for that matter otherwise NP will always be a step child (so to speak and not meant to offend anyone), coming back to this forum for nursing is OK but in my Administrators mind and really I mean with no disrespect....you are acting like a RN not a NP. My expectations for NP on this forum is to lead, encourage, mentor other nurses, not vent like the rest of us. Yes I can see the daggers and eye rolling and all else, this is just my opinion, and I maybe off base so teach, mentor and lead me about NP.
We Need
A single pathway for RN's and the most basic level is BSN. With each new higher education your span of authority is expanded and relied upon. For NP there should be no doubt as to the competence of what skills are taught in the NP education.
There should be a CPT code for nursing services that include basic patient cares of medication administration, of assessment, of ADL assistance, education (must be very specific) for example. We are providing a service the facility should get reimbursed for that service.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Jules,
I'm not clear what the signing of the charts mean in your setting. There is no federal regulatory requirement that states NP's H&P's, consults, and progress notes must be signed by a physician. Presumably, this could be state mandate.
The important point to be made about signatures on someone's notes is that these are tied to reimbursement. I'm not sure how in-pt psych billing is different from our setting but the agreement to have both NP and MD sign on a chart (and add their own important pertinent details) is usually tied to the ability to share the billing instead of an attempt to counter-check what the NP wrote.
Dodongo, APRN, NP
793 Posts
I suppose this is a good point. One reason why you should always, always, always know how much revenue you generate. As an NP you need to be aware of every dollar you make. And, if it comes down to it, as much as it sucks, you can always voice your opinion by seeking employment elsewhere.