From medical staff to nursing

Specialties NP

Published

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.

Specializes in ACNP-BC, Adult Critical Care, Cardiology.

Midwifery is also different from the NP world, though, in an important way---all of our educational programs are overseen and accredited by the same organizations---AMCB and ACME---because we're a much smaller group. There are many online midwifery programs out there, but literally no midwifery programs in the U.S. I know about have sub-par standards, because the overseeing bodies are truly rigorous. Sure, some are ranked higher than others, but there just aren't really any midwifery "diploma mills." The standardization of this is really important and keeps our reputations intact (to those really willing to look at the data and appreciate the benefits of midwifery care).

This is exactly why PA's, CRNA's, and CNM's have the better reputation in terms of program rigor.

I agree that the main issue is inferior NP diploma mills churning out grads and grossly harming the profession. I have no idea what the solution to that problem is, honestly, but I wish you well in your endeavor to maintain a professional and skilled reputation for NPs at your institution.

My solution is to split up the NP regulatory and certification bodies. The monopoly imposed by ANCC and AANP in terms of certification and the CCNE in terms of accreditation must end. There aren't many PNP-AC and NNP programs because those certifications are not under the purview of AANP nor ANCC. However, their program accreditation is still under CCNE which oversees a huge number of graduate nursing programs.

There was a time when Adult ACNP programs were rare - now that the demand is there, programs are springing out of nowhere with a seemingly instant blessing of CCNE accreditation. I propose FNP's have their own certification and program accreditation board, Adult ACNP's have their own boards, Psych NP's have their own..., you get the idea. Problem is, I'm not sure how this can undo the damage that has been done.

Specializes in Occ. Hlth, Education, ICU, Med-Surg.
All my patients also have be seen by and have a physician assigned to them which adds liability to my psychiatrist colleagues and reduces my value. They have to sign off on my discharge prior to the patient being discharged which is always a hassle. It used to be just a co-signing the need for admission for CMS.

Interesting...so everyone is assigned a physician. Is the physician required to see the pt first and then the NP "takes over" until discharge? Looks like all the charts are to reviewed and signed off on by a physician for d/c.

Just makes me think that there is a revenue component to this change...namely being able to co-bill with the physician for increased reimbursement rates.

My 2 cents...

I'm sure this new change is rooted in money somehow. I'm inpatient and every inpatient APP note is cosigned by the physician for no other reason than billing. There is just a little addendum at the bottom of my note that says they agree with my assessment and plan, and viola, 100% reimbursement.

Is this billing scheme legal though?

Is this billing scheme legal though?

Is this question for me? If so, yes, it is. They are required to go see the patient at some point within 24 hours of my examination. Some do more than others at this point. Some literally say "Hi, I'm Dr. So and so, if you have any questions ask the nurse." Others will at least listen to heart and lung sounds and ask a few pertinent questions. Depends on the relationship between the physician and APP. Unfortunately, we just hired a new grad PA and NP (from Walden) and they're both clueless.

Specializes in Family Nurse Practitioner.
Additionally frustrating is that insurers are still slow to get on board to cover midwifery care at equal rates, or even at all, when we could be SAVING them tons of money.

Great post, thank you for joining in. One of the big pluses for CNMs is that CMS does allow your patients to be seen by only you as opposed to NPs. Is that correct? My understanding is CMS allows us to have admitting privileges deferring to hospital bylaws but patients must still be under a physician's care. Not that it is appropriate in all areas to lose physician oversight but certainly in psychiatry and possibly other inpatient areas it would be.

Midwifery is also different from the NP world, though, in an important way---all of our educational programs are overseen and accredited by the same organizations---AMCB and ACME---because we're a much smaller group. There are many online midwifery programs out there, but literally no midwifery programs in the U.S. I know about have sub-par standards, because the overseeing bodies are truly rigorous. Sure, some are ranked higher than others, but there just aren't really any midwifery "diploma mills." The standardization of this is really important and keeps our reputations intact (to those really willing to look at the data and appreciate the benefits of midwifery care)..

Say a prayer that your specialty doesn't sell out like NPs did. I think CNMs and CRNAs are the only APRN subset that hasn't accepted this awful state of educational affairs possibly because many of the NP big dogs are university employees?

Specializes in Family Nurse Practitioner.
This is exactly why PA's, CRNA's, and CNM's have the better reputation in terms of program rigor.

My solution is to split up the NP regulatory and certification bodies. The monopoly imposed by ANCC and AANP in terms of certification and the CCNE in terms of accreditation must end. There aren't many PNP-AC and NNP programs because those certifications are not under the purview of AANP nor ANCC. However, their program accreditation is still under CCNE which oversees a huge number of graduate nursing programs.

There was a time when Adult ACNP programs were rare - now that the demand is there, programs are springing out of nowhere with a seemingly instant blessing of CCNE accreditation. I propose FNP's have their own certification and program accreditation board, Adult ACNP's have their own boards, Psych NP's have their own..., you get the idea. Problem is, I'm not sure how this can undo the damage that has been done.

I think these ideas are excellent but the universities, who the the highest gross to gain, have a foot hold in our profession which I think is even stronger than the accrediting bodies.

What freaks me out, if I'm remembering correctly is that you and Boston used to blow me off when I was ruminating about what a sham our profession was starting to become. Despite me disagreeing it was in an odd way comforting that you both who I hold in high esteem indicated things weren't as bad as I thought. In recent times it seems as if you both have started criticizing our education which now really worries me.

Specializes in Family Nurse Practitioner.
Interesting...so everyone is assigned a physician. Is the physician required to see the pt first and then the NP "takes over" until discharge? Looks like all the charts are to reviewed and signed off on by a physician for d/c.

Just makes me think that there is a revenue component to this change...namely being able to co-bill with the physician for increased reimbursement rates.

My 2 cents...

They aren't required to be seen by physician first just at some point be seen and our dc summary signed off on. It is coming from medical staff being touted as standard of care not admin so I don't think it is about reimbursement and at least in my department the docs aren't submitting billing on these patients.

Specializes in Family Nurse Practitioner.
I'm sure this new change is rooted in money somehow. I'm inpatient and every inpatient APP note is cosigned by the physician for no other reason than billing. There is just a little addendum at the bottom of my note that says they agree with my assessment and plan, and viola, 100% reimbursement.

You guys might be right and if this is the case I'd have no problem with it. I'm all about making the most money possible whether for my family or my facility. Why wouldn't they just say that instead of focusing on the disappointing abilities of recent hires?

Specializes in OB.
Great post, thank you for joining in. One of the big pluses for CNMs is that CMS does allow your patients to be seen by only you as opposed to NPs. Is that correct? My understanding is CMS allows us to have admitting privileges deferring to hospital bylaws but patients must still be under a physician's care. Not that it is appropriate in all areas to lose physician oversight but certainly in psychiatry and possibly other inpatient areas it would be.

Say a prayer that your specialty doesn't sell out like NPs did. I think CNMs and CRNAs are the only APRN subset that hasn't accepted this awful state of educational affairs possibly because many of the NP big dogs are university employees?

I believe you're correct that CMS allows patients to see only us but we still get about 80% of what MD reimbursement is for the same care given (better than the 65% we got before the ACA). Oversight laws vary greatly state to state as well. We have independent practice now in 23 states plus Washington D.C., written collaboration requirements in 7 states, and collaborative practice agreement requirements in 20 states.

While the profession has grown tremendously even in the 5 years since I graduated as a CNM, I don't think we'd ever be able to "sell out" in the same way NPs did, because of the nature of the job. People don't become midwives as an easy way to get out of floor nursing and make a ton of money, because it's just too damn hard of a job. You don't do it unless you're really passionate about it, for the most part, because otherwise why would you? The hours can be brutal, the pay isn't even comparable to NP pay a lot of the time, and the liability is high.

I think higher education in general has just fundamentally changed since online universities have taken off. Diploma mills are incredibly profitable, and so degree inflation is through the roof everywhere. I feel like online MBAs and BSNs are similarly worthless these days. While I believe more equitable access to education is always a good thing, I do think the quality and rigor of higher ed is getting laughable.

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