NP's answering to Nursing Management?

[ohiosam2]

I am wondering if anyone has any experience with this. I have been an NP in my area for a few years now and I am very familiar with practice at other hospitals. I currently work in an ER. There are both NP's and PA's in the ER. We work under physician management. As far as I know, the other hospitals in the area also work under the physician management teams. Recently there was a very big discussion going on in the hospital. It seems that the nursing management felt that they should be in charge of both PA's and NP's. Fortunately, the hospital physicians absolutely refused to allow this. I was shocked. I do not feel a nurse manager should be dictating practice to those who are advanced providers. During the discussion, nursing stated that many hospitals around the United States are putting their NP's and PA's under nursing management instead of the physicians. Is anyone out there under nursing right now? If so, are you having difficulties with this arrangement?

[PG2018]

Can you do me a favor and reference those laws.

The issue is going to be different in each facility and it's important to be comparing apples to apples. As a CNO i had direct oversite of the ED. This meant I handle administrative functions. I also ensured that everyone was meeting the standards the hospital had set up through the Medcial Staff and the Board. There were certain things that all clinicians had to do, MD, DO, NP, PA. I handled all the QI and credentialling, etc. When a specific clinical question came up, it was forwarded to both the ED director who was an MD and in general the Chief of Staff for review and I took action based on their recomendations. This was the same for any clinician.

In every state I"ve worked in I was qualified to manage and supervise clinicians. I wasn't however qualified to dictate medcial practice. But I could enforce standards that had been set.

p.s. the last time I checked most hosptial administrators weren't MD and they have a certain amount of supervisory/management responsibilities, including HR functions.

p.s.s. It also depends on who's hiring and that is a completly seperate issue. In once facility NP (including CRNA's) were hired by the nuring department. In another facility they were hired by the medcial staff or in some cases either the hospitlaist or the ED group.

I think we all understand administrators having no awareness or insight into niche fields under their purview. Look at who's sitting in the White House as an example.

Despite validating Susie, I do not perceive she had the perspicacity to view a "nurse manager" as anything other than a supreme authority to a NP given her repeat BON citations. As you corroborate, you needed the counsel of qualified persons to enact policy.

All here know the foolishness that would transpire if a lay COO were compelled to dictate the actions of employed clinicians and understand a reasonable administrator would defer clinical judgment to a clinician or panel of supervisory of advisory clinicians none of which a unit manager will typically have access to.

I also believe the NPs here understand the difference between employed clinicians and credentialed clinicians as well gaining corresponding privileges.

On a side note, I'd love to bend your ear about administration sometime.

[Susie2310]

Despite validating Susie, I do not perceive she had the perspicacity to view a "nurse manager" as anything other than a supreme authority to a NP given her repeat BON citations.

I'm sorry you are descending to the level of insulting comments. Doing so does nothing to enhance your credibility as an advanced practice nurse.

[allennp]

Good comments here, and to answer the OP.

I worked in a large academic center ED and the NP/PA's were managed by the RN director of the ED. Medical control by the EM director. The manager had a remarkable control including excluding NP's from having NP students, yet of course their were medical students in the ED.

Also input over hiring and schedules.

So it does happen.

I never felt comfortable with it. I am still in the same system and have my administrator being a NP with my Medical director a MD which for me is comfortable.

[cjcsoon2bnp, MSN, RN, NP]

I was once a nurse manager of an inpatient psychiatric/mental health unit and when I took over the job I was told that in addition to the nursing staff I was the manager for the single NP. I asked the HR department why I was considered her manager because she was a clinician/provider and I considered her in the same group as the psychiatrists and the psychologist of the unit. I was told by HR that it was because "she falls under the nursing department". I spoke with the NP when I first came on board and said that I didn't feel like it was appropriate for me to be her manager because she was being separated from the other clinicians/providers and she should be managed by the Unit Chief/Medical Director. She seemed quite happy with my thoughts on this and so I spoke with the Unit Chief/Medical Director, CMO, and CNO about the issue and we came to an agreement. The NP and I worked very well for the rest of the time that I was in the position and she regularly sought out my advice on various matters because she knew I wasn't trying to be her boss or insert myself into matters that were none of my business.

I will agree with the poster who said that NPs are still nurses, but they are advanced practice nurses (an important distinction). However, NPs usually function in the role of a clinician/provider along with physicians and physician assistants (PA). With that being said, I think that clinicians/providers should be managed by someone who is in that role and not have NPs managed by nurse managers and have physicians and PAs managed by a medical director. I don't think that it makes sense and causes an unnecessary separation between the advanced provider roles, in my opinion.

!Chris

[casias12]

I will elaborate on my real-world example posted in #26, and why I don't think many nurse managers are capable of managing NP practice.

I was employed as part of a complex case management team for home-bound patients in a Medicare managed-care plan. The goal, when I was hired by the medical department, was to decrease hospitalizations and specialist care in patients nearing end-of-life. So basically, I was taking the medical clinic to their home.

I was placed under the supervision of a supervisor of case management, who was a registered nurse.

I had a patient, 73-year-old, who was essentially bed-bound from Parkinson's disease. I arranged home health for nurse visits and HHA visits, PT, and referred to our social worker who helped his wife connect with a couple of local groups for support. She absolutely wanted to keep him home as long as possible, and wanted to keep him out of the hospital. Even going to a clinic appointment was a challenge.

He developed a skin abscess like this one, but probably about half this size. The HH nurse called me about it, so I went by one of our clinics, grabbed an I&D kit, and went to the house to lance it. No big deal, right? I lanced it, grabbed a culture, put him on doxycycline plus cephalexin, and left wound orders for the HH nurse.

A few days later, this was brought up in a meeting by one of our nurses. The nurse looked right past me, told the nurse manager what had transpired, and asked if she should call the PCP about it. The manager started flipping out. I mean, losing her mind. She asked why I didn't call the PCP (because he hadn't seen him in the office in 6 months), why I didn't refer to dermatology (Wha? A bed-bound guy nearing end-of-life?), and told me this was not in my scope of practice.

Then she directed the nurse to call the PCP and request a dermatology consult ("Just to make sure we cover this up for you").

This was the beginning of the end for me in this position.

Slippery slope.

[PG2018]

I'm sorry you are descending to the level of insulting comments. Doing so does nothing to enhance your credibility as an advanced practice nurse.

My observations are valid.

[PG2018]

Good comments here, and to answer the OP.

I worked in a large academic center ED and the NP/PA's were managed by the RN director of the ED. Medical control by the EM director. The manager had a remarkable control including excluding NP's from having NP students, yet of course their were medical students in the ED.

Also input over hiring and schedules.

So it does happen.

I never felt comfortable with it. I am still in the same system and have my administrator being a NP with my Medical director a MD which for me is comfortable.

Sadly we know it happens and shouldn't. It's likely going to happen at the local ED is well.

[llg, PhD, RN]

I've worked in a couple of NICU's where the NNP's were "co-managed" by the physicians and nursing departments. Since the NNP's are practicing advanced-practice nursing (not medicine) when they work, they are part of the nursing division. Administrative matters (annual education, parking, scheduling, etc. is managed by the nursing division). However, their direct patient care is supervised by the physicians.

I guess it comes down to what you consider an NP to be:

1. An advanced nurse?

2. A junior physician?

Those who consider them to be advanced nurses want them to be a part of the nursing profession and organizational department. The aspects of their care that require physician supervision can always be "added on" as needed. Those who truly feel that NP's have left the nursing profession when they acquire those "advanced nursing practice skills" may not see themselves as nurses anymore. If you don't see yourself as a nurse any more, you should call yourself and advanced practice nurse.

You can't have it both ways. If you see yourself as still a nurse, then being a part of the nursing division should not be a problem unless and unqualified nurse manager is trying to tell you how to manage the patients (which should not be happening.) But there are many ways to stay a nurse and be a part of the nursing department while still having the clinical portion of your practice supervised by a physician. However, if you feel you are no longer a nurse anymore, you should not call yourself an "advanced practice nurse" or "Nurse Practitioner" to begin with.

[Jules A, MSN]

I was once a nurse manager of an inpatient psychiatric/mental health unit and when I took over the job I was told that in addition to the nursing staff I was the manager for the single NP. I asked the HR department why I was considered her manager because she was a clinician/provider and I considered her in the same group as the psychiatrists and the psychologist of the unit. I was told by HR that it was because "she falls under the nursing department". I spoke with the NP when I first came on board and said that I didn't feel like it was appropriate for me to be her manager because she was being separated from the other clinicians/providers and she should be managed by the Unit Chief/Medical Director. She seemed quite happy with my thoughts on this and so I spoke with the Unit Chief/Medical Director, CMO, and CNO about the issue and we came to an agreement. The NP and I worked very well for the rest of the time that I was in the position and she regularly sought out my advice on various matters because she knew I wasn't trying to be her boss or insert myself into matters that were none of my business.

I will agree with the poster who said that NPs are still nurses, but they are advanced practice nurses (an important distinction). However, NPs usually function in the role of a clinician/provider along with physicians and physician assistants (PA). With that being said, I think that clinicians/providers should be managed by someone who is in that role and not have NPs managed by nurse managers and have physicians and PAs managed by a medical director. I don't think that it makes sense and causes an unnecessary separation between the advanced provider roles, in my opinion.

!Chris

Although I find it unfortunate the NP wasn't savvy enough to have insisted on being medical staff from the beginning I applaud your insight and willingness to make this happen. Kudos, you sound like the type of NM I'd love to work with also.

[Aromatic]

nursing departments, i am sure at least many, would love to be over everybody.

some of them are like huge macrophages extending out their processes trying to engulf any and all into their clutches to make themselves feel better about themselves.

I am glad those days are over for me

[allennp]

I've worked in a couple of NICU's where the NNP's were "co-managed" by the physicians and nursing departments. Since the NNP's are practicing advanced-practice nursing (not medicine) when they work, they are part of the nursing division. Administrative matters (annual education, parking, scheduling, etc. is managed by the nursing division). However, their direct patient care is supervised by the physicians.

I guess it comes down to what you consider an NP to be:

1. An advanced nurse?

2. A junior physician?

Those who consider them to be advanced nurses want them to be a part of the nursing profession and organizational department. The aspects of their care that require physician supervision can always be "added on" as needed. Those who truly feel that NP's have left the nursing profession when they acquire those "advanced nursing practice skills" may not see themselves as nurses anymore. If you don't see yourself as a nurse any more, you should call yourself and advanced practice nurse.

You can't have it both ways. If you see yourself as still a nurse, then being a part of the nursing division should not be a problem unless and unqualified nurse manager is trying to tell you how to manage the patients (which should not be happening.) But there are many ways to stay a nurse and be a part of the nursing department while still having the clinical portion of your practice supervised by a physician. However, if you feel you are no longer a nurse anymore, you should not call yourself an "advanced practice nurse" or "Nurse Practitioner" to begin with.

This has a great point I have not reflected on much, I am a advanced practice nurse hence I suppose?? I practice nursing.... yet in reality we are in the same healthcare role as our colleagues DO's, MD's and PA's. We are share expertise and consult our expert colleagues when appropriate, and they us depending on specialty. It is a curious twist to consider who manages me, and I do not much care as long as they are professional and provide me the ability to provide the best care at the most efficient cost to my/our patients. I have seen some horrid physician/ARNP managers and superb RN managers. I do not want to get to caught up in the letters behind a name, just as my patients do not get caught up with the letters behind our name, but rather consider the product and outcome perhaps?

[Corey Narry, MSN, RN, NP]

I've seen both models (NP's hired under nursing services and under physician services). I see pros and cons in both models.

Large academic medical centers sometimes hire NP's under nursing either directly under the CNO or under an advanced practice nurse manager (typically someone belonging to one of 4 APN professions: NP, CNS, CNM, or CRNA). I've not seen an NP hired under nursing be managed by a non-APN but I'm sure it exists. This model helps "beef up" the actual number of advanced practice nurses in the total roster of nursing employees (which looks good on paper for institutions who are trying to maintain Magnet certification).

In facilities where nurses are represented by a union, NP's sometimes become automatically represented and can have the benefit of collective bargaining (higher wages than non-advanced practice nurses, protection from long work hours). The downside is that the NP would have to make certain the source of where their salary is taken from - if your cost center is nursing, that can make billing under your name impossible because your salary is not under the physician part of Medicare billing.

On the other hand, working under physician services also has its perks. For one, you could be eligible for a host of physician only accommodations such as physician parking, "physician dining" areas in hospitals. Sometimes benefits for physicians are different than regular staff so you also may be eligible for this higher level of benefits. The downside would be that salary can vary to being low-balled (as physicians would do if they can get away with it). You would need to be good at negotiating a fair wage and proving your ability to ramp up revenue with your RVU's.

Personally, being under either model is not a deal breaker for me as I would look at the total compensation, the opportunity for growth, the overall culture of support and ongoing learning, etc. Nasty politics can exist in both.