How to stop last minute calloffs?

[PManager]

Hi everyone,

I am a practice manager for one doctor and 4 nurse practitioners (all NPs part time- most work 1-2 days per week for example. This is their choice because they all like the flexibility and down time. We have accommodated very unusual schedules specifically on their behalf and are happy to do so.) My question is this: what is the ethical standard for an APRN for patient commitment and shift abandonment? I am struggling with one NP who continually makes up a questionable reason to not do her 5 hour shift and sticks the doctor with a double schedule. Her view is that he can just cover for her, which is not always possible (nor is it fair). This is a physician who is extremely kind and supportive of the NPs and gets taken advantage of continually (by people who are takers of course- there are people who understand and nurture the relationship in spite of his being a big bad MD who is of course the enemy in every instance *eyeroll*).

Without making this person feel that I am somehow demeaning her because she is an NP instead of a doctor (this has never come up, EVER, but NP's seem to have an obsession about this) how can I make it clear that sticking the patient schedule to the doctor is not doctor-level-pay acceptable and professional? Our NPs are all 6 figure earners. Or is this considered acceptable (I.e. shift work- oh well, not my shift, if I can't be there I will just let the management worry about it a la Wendy's or McD's)? Is this considered part of the ethical standard for the advanced nursing degree? It is absolutely not considered acceptable for any DO/MD. Thanks so much for any ideas!

[Corey Narry, MSN, RN, NP]

I will say that the expectations for professionalism with physicians apply to NP's as well.  In a setting where NP's and MD's share the patient load, it should not have to come to a point where the NP needs to be reminded of their commitment to patient care as providers. I also find it insensitive that an NP would assume someone is going to pick up the slack with a last minute call off unless it is a true emergency situation and not a pattern of behavior. Unfortunately, AANP does not mention this specifically in their Standards of Practice because let's be honest, this is really just a rule of common decency.

[verene, MSN]

There is definitely a high level of professionalism required from NPs and in my setting we are held to the same expectations of professionalism as the physicians we work with.  

As NPs and Physicians we are expected to find our own coverage for times when we know we will be out (vacation, medical appointments etc) which is usually not a big deal to find.  Most of us will go so far as to find coverage for ourselves if we are calling out sick  or more minor emergency issues (e.g. tree fell on driveway don't know when you can get out, dog is ill and you are headed to emergency vet) and let our supervisor and unit know coverage plan. 

If there is an emergency situation or you can't find coverage yourself expectation is to reach out to supervisor and/or Chief of Department - they may not always be able to cover needs themselves but will find coverage for any critical needs (sometimes farming things out to multiple people). (This shouldn't be something that happens often!). 

Lots of last minute call outs is NOT professional and should NOT be considered acceptable.  I'd probably be having a very frank conversation with this NP about why she is calling out so often and the need for her to either commit to her responsibilities as a APRN in this setting (possibly with probationary period to show she is making changes?), take FMLA or other leave if warranted to address issues that are causing need to call out, or give her the option to resign and seek work elsewhere. 

[JBMmom, MSN, NP]

I think this would absolutely require a meeting to review expectations and the work role. If there's a concern about the tone of the meeting you could try to approach it out of concern- "I'm worried that you have needed more unexpected time off lately, would you like to revisit your current schedule/agreement to make sure we are meeting our needs and yours?" That way you're not asking for specific reasons, which I think can get sticky legally, but she will know that you are concerned that the practice needs aren't being met. I'm sure it's a difficult situation, good luck. 

[PManager]

Thank you all. You really have provided me some excellent ways to look at this and address it with her. I know that the reason she does this is that she knows the doctor won't leave the patients high and dry. But that is not an excuse to just call off when she doesn't feel like coming in. Again, the input is so much appreciated.

Most NP's I have hired would not consider doing this to a fellow NP or doctor unless it's truly an emergency! And even then, they feel awful.

[CommunityRNBSN, BSN, RN]

I also don’t really think their particular roles are all that relevant. She is an NP and she is sticking the MD with her work. That is unacceptable, and it would be unacceptable if an MD was always doing that to an NP, or if an LPN was doing it to another LPN. 

[PManager]

"I also don’t really think their particular roles are all that relevant..." <---- TOTALLY agree. I guess I was trying to make sure that this was not me being overcritical or insensitive. I find that out of all staff (MD, LPN, RN, MA, front desk, lab techs, NPs, PAs etc) certain NPs are the most defensive about being treated with respect by patients and other staff (certainly not all!!) So I try to be as sensitive as possible so as to not insult them. 

[Zyprexa_Ho]

This sounds like something that needs to be covered in a contract. Repeated issues like this need to be grounds for terminating their contract.

[MentalKlarity, BSN, NP]

Very unusual and unprofessional. However, I would caution against "assuming" the reason. There are numerous medical conditions, for example, that can flare-up last minute and make working impossible, such as IBS. I would have a meeting with her, discuss what you've noticed (not in an accusatory way, come across as concerned for her) and let her know that if there is a specific issue with that schedule that you can accommodate her by moving her to a different day. Let her know the consequences of the call outs last minute (the other provider is doing double duty) and let her know that is okay in emergencies but not routinely. See how she responds - she may open up about some medical/psychological issue that you two can work through. She may simply understand it is not acceptable and change her attitude. If not, you can discuss potential termination or reduction of schedule.