Having difficulty determining my next step

InquisitiveAPN · Sep 9, 2018

Just become the NP. If you don't like the clinical stuff you can ways quit that and go support bedside nurses somehow. It doesnt - and shouldn't - take a special credential for that. Plus you can go teach at the University on the side for meager but rather casually earned funds. I love being on the graduate faculty without making a full-time go of it.

nbtw · Sep 9, 2018

I am an FNP. I won't recommend or bash the profession but I will tell you about my experience. I have only worked outpatient as an FNP.

If you're outpatient you are scheduled anywhere from an 8-10 hour day. You are provided with an hour for lunch. You are scheduled acute visits every 15 minutes or 45 minute physicals. In the 15 minute visits you are expected to get history, do some type of physical, come up with a treatment plan which may include doing an in office procedure, prescribing medications, explaining medications, educating the patient and documenting everything that you did. This never happens of course, not if you're a thorough provider. So you end up working through lunch (just like your bedside days), documenting at home and missing out on what's going on with your family. In between your appointments, you're expected to call patients back about results, return patient calls, call other providers back that needed to get in touch with you, read and sign off on patient information. Of course you never have time in between appointments because 15 minutes is unrealistic so your appointments typically run into each other. You will likely be on call. So even when you're not physically in the office you still have to field calls from patients, hospitals, pharmacies, critical lab values.

You are ultimately liable if you don't get back to a patient in a timely fashion (there's no guideline for what timely fashion means), if you don't explain every single side effect and the patient experiences one, if you don't give your drug addict patient more oxycontin but they stay in pain, if your diabetic patient has an A1C of 11 and eats a dozen donuts a day even though you've educated them multiple times, if you go through a depression screen with your patient, they deny being depressed but 2 days later try to kill themselves. Well you won't be liable but people will try to make you liable. The only thing that will save you is if you properly documented but many providers don't. So that they don't take so much work home, many providers use templates which they lack the time to modify and typically don't give the documentation that an insurance company or department of health would deem appropriate for the patients presentation. So I spend a lot of time documenting because I know other APRNs who have ended up with fines or probation from the department of health because their documentation couldn't back up their claims that they met the standards of care.

Oh and there's the patients that want to see a "real" doctor, think that an NP is different from an APRN or that the PA is at a higher level than you just because you have nurse in your title. You'll work with physicians that are grateful to have you as a colleague because healthcare sucks and you need all the hands you can get. But you'll also work with physicians who are resentful towards you because you're stealing their piece of the pie (even though your not because no graduating residents want to do your job anyway, that's why they had to hire you in the first place). And lets not forget that you are likely not being paid 75% of what the physicians are making even though you're both doing the exact same job.

All in all, I still get disrespected as an FNP, I work a lot of extra hours that I don't get paid for, my risk of malpractice and being sued is way higher than a bedside nurse, and you pay more for malpractice insurance, licenses, CEUs.

InquisitiveAPN · Sep 9, 2018

I am an FNP. I won't recommend or bash the profession but I will tell you about my experience. I have only worked outpatient as an FNP.
If you're outpatient you are scheduled anywhere from an 8-10 hour day. You are provided with an hour for lunch. You are scheduled acute visits every 15 minutes or 45 minute physicals. In the 15 minute visits you are expected to get history, do some type of physical, come up with a treatment plan which may include doing an in office procedure, prescribing medications, explaining medications, educating the patient and documenting everything that you did. This never happens of course, not if you're a thorough provider. So you end up working through lunch (just like your bedside days), documenting at home and missing out on what's going on with your family. In between your appointments, you're expected to call patients back about results, return patient calls, call other providers back that needed to get in touch with you, read and sign off on patient information. Of course you never have time in between appointments because 15 minutes is unrealistic so your appointments typically run into each other. You will likely be on call. So even when you're not physically in the office you still have to field calls from patients, hospitals, pharmacies, critical lab values.
You are ultimately liable if you don't get back to a patient in a timely fashion (there's no guideline for what timely fashion means), if you don't explain every single side effect and the patient experiences one, if you don't give your drug addict patient more oxycontin but they stay in pain, if your diabetic patient has an A1C of 11 and eats a dozen donuts a day even though you've educated them multiple times, if you go through a depression screen with your patient, they deny being depressed but 2 days later try to kill themselves. Well you won't be liable but people will try to make you liable. The only thing that will save you is if you properly documented but many providers don't. So that they don't take so much work home, many providers use templates which they lack the time to modify and typically don't give the documentation that an insurance company or department of health would deem appropriate for the patients presentation. So I spend a lot of time documenting because I know other APRNs who have ended up with fines or probation from the department of health because their documentation couldn't back up their claims that they met the standards of care.
Oh and there's the patients that want to see a "real" doctor, think that an NP is different from an APRN or that the PA is at a higher level than you just because you have nurse in your title. You'll work with physicians that are grateful to have you as a colleague because healthcare sucks and you need all the hands you can get. But you'll also work with physicians who are resentful towards you because you're stealing their piece of the pie (even though your not because no graduating residents want to do your job anyway, that's why they had to hire you in the first place). And lets not forget that you are likely not being paid 75% of what the physicians are making even though you're both doing the exact same job.
All in all, I still get disrespected as an FNP, I work a lot of extra hours that I don't get paid for, my risk of malpractice and being sued is way higher than a bedside nurse, and you pay more for malpractice insurance, licenses, CEUs.

You can find jobs that fund malpractice, licensing, and CEUs. I don't see any of that as a problem. I don't let patients leave my presence until I'm finished documenting. Why? Because by 10:00, I wouldn't have a clue what the 8:30 said or did. If you're making a lot of call, etc you need to block out admin time for your own wellbeing. You might lose $120-150 a day, but you could take a shorter lunch or just be present with your family. Sounds like more than anything you need a better job, sister!

Dodongo, APRN, NP · Sep 9, 2018

Outpatient work sounds like a literal nightmare.

nbtw · Sep 9, 2018

Quote from InquisitiveAPN:

You can find jobs that fund malpractice, licensing, and CEUs. I don't see any of that as a problem. I don't let patients leave my presence until I'm finished documenting. Why? Because by 10:00, I wouldn't have a clue what the 8:30 said or did. If you're making a lot of call, etc you need to block out admin time for your own wellbeing. You might lose $120-150 a day, but you could take a shorter lunch or just be present with your family. Sounds like more than anything you need a better job, sister!

I've shared my personal experience as an FNP across 3 different employers. Thanks for sharing yours.

InquisitiveAPN · Sep 10, 2018

Outpatient work sounds like a literal nightmare.

Inpatient work is a dungeon. Much worse, IMO.

InquisitiveAPN · Sep 10, 2018

Quote from InquisitiveAPN:
You can find jobs that fund malpractice, licensing, and CEUs. I don't see any of that as a problem. I don't let patients leave my presence until I'm finished documenting. Why? Because by 10:00, I wouldn't have a clue what the 8:30 said or did. If you're making a lot of call, etc you need to block out admin time for your own wellbeing. You might lose $120-150 a day, but you could take a shorter lunch or just be present with your family. Sounds like more than anything you need a better job, sister!
I've shared my personal experience as an FNP across 3 different employers. Thanks for sharing yours.

You come off as snarky.

djmatte, ADN, MSN, RN, NP · Sep 10, 2018

I am an FNP. I won't recommend or bash the profession but I will tell you about my experience. I have only worked outpatient as an FNP.
If you're outpatient you are scheduled anywhere from an 8-10 hour day. You are provided with an hour for lunch. You are scheduled acute visits every 15 minutes or 45 minute physicals. In the 15 minute visits you are expected to get history, do some type of physical, come up with a treatment plan which may include doing an in office procedure, prescribing medications, explaining medications, educating the patient and documenting everything that you did. This never happens of course, not if you're a thorough provider. So you end up working through lunch (just like your bedside days), documenting at home and missing out on what's going on with your family. In between your appointments, you're expected to call patients back about results, return patient calls, call other providers back that needed to get in touch with you, read and sign off on patient information. Of course you never have time in between appointments because 15 minutes is unrealistic so your appointments typically run into each other. You will likely be on call. So even when you're not physically in the office you still have to field calls from patients, hospitals, pharmacies, critical lab values.
You are ultimately liable if you don't get back to a patient in a timely fashion (there's no guideline for what timely fashion means), if you don't explain every single side effect and the patient experiences one, if you don't give your drug addict patient more oxycontin but they stay in pain, if your diabetic patient has an A1C of 11 and eats a dozen donuts a day even though you've educated them multiple times, if you go through a depression screen with your patient, they deny being depressed but 2 days later try to kill themselves. Well you won't be liable but people will try to make you liable. The only thing that will save you is if you properly documented but many providers don't. So that they don't take so much work home, many providers use templates which they lack the time to modify and typically don't give the documentation that an insurance company or department of health would deem appropriate for the patients presentation. So I spend a lot of time documenting because I know other APRNs who have ended up with fines or probation from the department of health because their documentation couldn't back up their claims that they met the standards of care.
Oh and there's the patients that want to see a "real" doctor, think that an NP is different from an APRN or that the PA is at a higher level than you just because you have nurse in your title. You'll work with physicians that are grateful to have you as a colleague because healthcare sucks and you need all the hands you can get. But you'll also work with physicians who are resentful towards you because you're stealing their piece of the pie (even though your not because no graduating residents want to do your job anyway, that's why they had to hire you in the first place). And lets not forget that you are likely not being paid 75% of what the physicians are making even though you're both doing the exact same job.
All in all, I still get disrespected as an FNP, I work a lot of extra hours that I don't get paid for, my risk of malpractice and being sued is way higher than a bedside nurse, and you pay more for malpractice insurance, licenses, CEUs.

I can empathize and probably relate to much of what you speak to in primary care. But it does sound like you personalize much about what you do. It's important and commendable to own your work and put in the effort that gets outcomes met. I can't say I don't take work home with me. Occasional charts closing or lab reviews at home aren't outside the realm of possibility. Sometimes I have enough time at work during the patient visit to chart a diagnosis, throw in some orders, and document patient education before I jump onto the next patient. I write notes through my interview so I never lack something to refresh my memory later on. Also I'm huge on education, so that can occasionally slow me up.

But even the work from home doesn't bother me as I have a firm belief that primary care physicians of old were working far more hours than the 9 to 5 to care for their patient panels. I think it's the nature of the business to some degree. But I also love this role and live working to find options to improve patient outcomes... Even when it appears the patient will never change.

I've met other NPs who have that palpable level of urgency of their jobs who similarly appear to be burning out or getting exceptionally frustrated in the realities of primary care. One I work with always expresses her frustration about how she had 40 some odd charts open at any given time and is struggling to keep up. Now granted she's seeing more patients than me by maybe 3-4 a day, but she's also been employed here 8 months longer. It certainly isn't an easy job and requires a certain outlook to do it.

pro-student · Sep 10, 2018

Back to the OPs question, I noticed that in all the descriptions of what you would like to do you never once described the NP role. Never mentioned wanting to assess, diagnose, write orders for your own patients. Everything you described is firmly in the CNS/educator role. I totally understand that the CNS role is under siege and poorly understood but if I ever heard someone who embodies it, you certainly do. So I think you have to ask ourself if you're willing to take the risk and pursue the role that matches your desired career goals or take the more secure route that will leaving trying to squeeze in what you actually want to do in between your actual job requirements.

I'd also like to point out that you specifically mentioned wanting to be a change agent. This is a laudable goal and certainly necessary in nursing and healthcare. I would like to suggest that maybe a major way you could make a meaningful change is my contributing to a reinvigoration of the CNS role. Part of the reason the role is dying is that students are passing it up for the more trendy NP. Yes it might be an uphill battle to land a position but when you do, it will be in the career you seem to truly desire. And worst comes to worst, a post masters NP is always an option if your interest or the job market change (and are much more prevent that post masters CNS). Best of luck!

Xlorgguss · Sep 10, 2018

Back to the OPs question, I noticed that in all the descriptions of what you would like to do you never once described the NP role. Never mentioned wanting to assess, diagnose, write orders for your own patients. Everything you described is firmly in the CNS/educator role. I totally understand that the CNS role is under siege and poorly understood but if I ever heard someone who embodies it, you certainly do. So I think you have to ask ourself if you're willing to take the risk and pursue the role that matches your desired career goals or take the more secure route that will leaving trying to squeeze in what you actually want to do in between your actual job requirements.
I'd also like to point out that you specifically mentioned wanting to be a change agent. This is a laudable goal and certainly necessary in nursing and healthcare. I would like to suggest that maybe a major way you could make a meaningful change is my contributing to a reinvigoration of the CNS role. Part of the reason the role is dying is that students are passing it up for the more trendy NP. Yes it might be an uphill battle to land a position but when you do, it will be in the career you seem to truly desire. And worst comes to worst, a post masters NP is always an option if your interest or the job market change (and are much more prevent that post masters CNS). Best of luck!

I appreciate such a thoughtful response. While there is part of me that thinks I could enjoy the role of a provider, as you pointed out- thats not where my passions really are. I personally feel that the role of CNS's are more important now more than ever. I have to admit that the uncertainty of the future for CNS's is my major cause for concern with going with that specific degree.

WestCoastSunRN, MSN, CNS · Sep 14, 2018

Just become the NP. If you don't like the clinical stuff you can ways quit that and go support bedside nurses somehow. It doesnt - and shouldn't - take a special credential for that. Plus you can go teach at the University on the side for meager but rather casually earned funds. I love being on the graduate faculty without making a full-time go of it.

Ugh. Supporting bedside nurses doesn't take a special credential? Do you even understand what is happening at the bedside? And what's at stake?

Don't become an NP unless you want to be a provider. Don't become a CNS unless you want to support and develop nurses, bring research to the bedside, shape policy and be able to provide direct patient care as well.