Primary Care/IM: Ask me anything.

wanna_be · Mar 22, 2017

Hello, thank you for the offer to help! I was just accepted to a DNP/FNP program and although this has been a career goal for many years, I am already getting nervous about job prospects after graduation as a new APRN.

Background: I have about eight years' experience working in FQCHCs and look-alike clinics, first as case manager and later a medical assistant. I hold an undergraduate degree in public health and graduated in July 2016 with a BSN. My current (and first) job as a nurse is in a FQCHC; I work as a floor nurse, take triage calls, and participate in leadership activities at the clinic. I am a HRSA NURSE Corps scholar.

The DNP is approximately three years and does not confer a MSN as part of the program. I will continue to work at my current position and the clinic is very supportive of furthering my education while working.

My question is, what are the job prospects for a DNP/FNP upon graduation? Would my previous experience appeal to employers in primary care, or would being a relatively new nurse prior to starting my APRN degree negate that? Since many of the clinics where I've worked have employed APRNs I assumed the job market was good, but in doing more research I see that there are few openings for mid-level providers and many requires 3-5 years experience.

Thank you so much for your insight!

allnurses Guide · Mar 22, 2017

My question is, what are the job prospects for a DNP/FNP upon graduation? Would my previous experience appeal to employers in primary care, or would being a relatively new nurse prior to starting my APRN degree negate that? Since many of the clinics where I've worked have employed APRNs I assumed the job market was good, but in doing more research I see that there are few openings for mid-level providers and many requires 3-5 years experience.

It sounds like you will have an excellent background for the transition into primary care. The experience you bring from having been both an MA and an RN in a primary setting will make things easier for you when it comes to your job search.

Nationwide, NPs are still in demand, especially in the primary care setting. That being said it varies a tremendous amount locally, with your personal and professional network, and with your school/alum network. Job postings will often "require" 3-5 years of experience: it is more of a wish list and a potential bargaining chip than it is a true requirement. From your perspective, you have a significant amount of primary care experience, and while not in a provider role, you know the workflow and the pitfalls of clinic work.

The best jobs are often never posted: they come from your networking and from your clinical rotations. You likely have a lot of contacts through your work history, make sure everyone knows that you are in a program. Often times clinic will know about an opening months or even a year in advance and they may be more than willing to hold a job for you if they think you are the right candidate. Additionally, many positions in small independent clinics are filled via provider networks (I have offices call me a few times a year asking if any of my good students are looking for work or if any colleagues are).

Hope that helps, if you have follow-ups fire away. Best of luck.

SopranoKris, MSN, RN, NP · Mar 22, 2017

Have you had students with acute care/critical care backgrounds who feel "bored" by family practice or clinical work? Would an urgent care setting be better than family practice? I'm an ICU nurse and I just love the ICU. However, I see how the night shift NPs get treated and it doesn't seem appealing to me to fill their shoes. (7 days on/7 days off, nights only, on-call during day, etc.) I'm just worried that transitioning to family practice might not seem as interesting as ICU. Do you feel it gets routine to see the same patients all the time?

allnurses Guide · Mar 22, 2017

Have you had students with acute care/critical care backgrounds who feel "bored" by family practice or clinical work? Would an urgent care setting be better than family practice? I'm an ICU nurse and I just love the ICU. However, I see how the night shift NPs get treated and it doesn't seem appealing to me to fill their shoes. (7 days on/7 days off, nights only, on-call during day, etc.) I'm just worried that transitioning to family practice might not seem as interesting as ICU. Do you feel it gets routine to see the same patients all the time?

In the past several years I have had three seasoned nurses from high-acuity care MICU/SICU/Trauma and well as dozen+ more from telemetry/medical/surgical tertiary care.

All of them had a new-found respect for primary care; granted I work with a complex adult medical patient panel. One of the three, a MICU nurse at a major tertiary academic hospital for more than 15 years, really struggled in the primary care and the provider role; her difficulty was that she could not step back and see the larger picture of the patient instead she was focused on trying to micro-manage each individual problem and she was not familiar with many primary care meds. The other two students did well, were able to take control of a patient and direct their care. One ended up in cardiology and does a mix of inpatient and outpatient. The other stayed in primary care and has done quite well.

There is very little that is "routine" about my days in clinic. Having longevity with patients is something that I really love about my job. I don't find it boring at all; keep an open mind because you may find it is a lot of "fun and excitement" trying to manage complex patients outside of the hospital! The primary setting is no less challenging that the acute setting, it is just a different set of challenges.

SopranoKris, MSN, RN, NP · Mar 23, 2017

In the past several years I have had three seasoned nurses from high-acuity care MICU/SICU/Trauma and well as dozen+ more from telemetry/medical/surgical tertiary care.
All of them had a new-found respect for primary care; granted I work with a complex adult medical patient panel. One of the three, a MICU nurse at a major tertiary academic hospital for more than 15 years, really struggled in the primary care and the provider role; her difficulty was that she could not step back and see the larger picture of the patient instead she was focused on trying to micro-manage each individual problem and she was not familiar with many primary care meds. The other two students did well, were able to take control of a patient and direct their care. One ended up in cardiology and does a mix of inpatient and outpatient. The other stayed in primary care and has done quite well.
There is very little that is "routine" about my days in clinic. Having longevity with patients is something that I really love about my job. I don't find it boring at all; keep an open mind because you may find it is a lot of "fun and excitement" trying to manage complex patients outside of the hospital! The primary setting is no less challenging that the acute setting, it is just a different set of challenges.

Thanks so much for the detailed reply!

I am definitely going in to this with an open mind. I think it's the "unknown" that makes me question. I have always loved to figure things out and solve puzzles, so diagnosing is very appealing to me. I think I just wonder if seeing the same patients routinely would take away some of the "mystery", does that make sense? There are definitely some practices in the area that manage higher acuity patients, so I might be lucky enough to get to spend some clinical time in those practices. We'll see what happens :)

Samoyed, MSN, APRN, NP · Mar 28, 2017

Thank you for your willingness to answer questions! I am a nurse with 6 years of experience, just finishing my second year out of three (part time) in an FNP program in Boston. I am interested in working in the primary care setting as you do, but I would be interested in a family practice setting. It seems there is a lack of family practices in the Boston area-- is this true? Also, I'm worried about the Boston market for NPs. The area is completely saturated with both NPs and nurses. Do you have any specific tips for landing a job on graduation? Do you think the market saturation is driving down salaries in this are? Will my ICU & med/surg experience give me a leg up on other applicants? Lastly, in terms of FNPs in Massachusetts-- are there any laws that prohibit FNPs from working outpatient jobs that may require occasional inpatient rounding? I feel as though scope of practice for FNPs is poorly defined in many ways since we can see all populations. Thanks again for your post. I may use this thread in the future if I have more specific questions.

allnurses Guide · Mar 29, 2017

Thank you for your willingness to answer questions! I am a nurse with 6 years of experience, just finishing my second year out of three (part time) in an FNP program in Boston. I am interested in working in the primary care setting as you do, but I would be interested in a family practice setting. It seems there is a lack of family practices in the Boston area-- is this true?

There are still quite a few family practices within a 30 mile radius of Boston but very few within the city. Most urbanites/suburbanites with good access to healthcare seem to gravitate towards adult IM, pediatrics, and OB/GYN for their family healthcare needs. The further you move away from the city the less that seems to be the case.

Also, I'm worried about the Boston market for NPs. The area is completely saturated with both NPs and nurses. Do you have any specific tips for landing a job on graduation? Do you think the market saturation is driving down salaries in this are? Will my ICU & med/surg experience give me a leg up on other applicants?

The Boston market is tighter than the rest of the state there is no doubt about that; most of the "good" NP jobs are never posted to job sites they are filled internally of via network contacts. This is where your program will be the biggest asset to you. Your clinical rotations will get your foot in the door with perspective employers and if you are well-liked preceptors will help you find a job to the best of their ability.

As far as salaries, I don't think so, at least not yet. Boston has a high cost of living, many of the major healthcare systems have unions, and the percentage of specialty practice is higher, so salaries have stayed north of 100k for most new grads finding work in the city as NPs.

As far as your nursing experience, the simple answer is that it won't hurt. How much it helps depends on who is doing the hiring: if it is a large hospital system and you are interviewing with a nurse manager or you use your years of nursing experience to "counter" a "requirement" of 2-5 years experience it may be a big asset, while if you are interviewing with a physician-owner of an independent family practice, it may not have much impact. Your professional network should help you regardless, especially combined with a strong local program network.

Lastly, in terms of FNPs in Massachusetts-- are there any laws that prohibit FNPs from working outpatient jobs that may require occasional inpatient rounding? I feel as though scope of practice for FNPs is poorly defined in many ways since we can see all populations. Thanks again for your post. I may use this thread in the future if I have more specific questions.

Yes and no. If you can make a reasonable argument that in-patient rounding is within the breadth of your training and experience and you can get hospital privileges then you are likely safe. I round on patients and many of my colleagues do.

Hope that helps, good luck.

advsmuch08 · Mar 29, 2017

Generally, do you see a difference in how well NP students are prepared based upon their school, for-profit versus non-profit? In your experience, has their choice of colleges factored into the hiring process?

allnurses Guide · Mar 30, 2017

Generally, do you see a difference in how well NP students are prepared based upon their school, for-profit versus non-profit? In your experience, has their choice of colleges factored into the hiring process?

Absolutely yes.

There is a big difference in the quality of preparation of students from quality programs vs the rest, to such an extent, my office and many other local offices, only take students that are either current employees at the local hospital, known personally to the provider, or from three local schools, for this exact reason. Most providers don't have the time in clinic to teach NP students from scratch; they need to be able to attain a basic history and physical independently. We have local program which does standardized patient experiences for 12 weeks prior to clinical rotations and these students vastly outperform students without the experience.

There is a pretty tight job market here, even out into the more rural areas (>50 miles from city). The quality programs in the area have job placement of near 100% at 6-9 months while other programs have rather dismal statistics. There is one major local employeer that hires exclusively from a single program, more than 15 a year.

nurse4life4ever · Mar 30, 2017

Hello:

I have a question: Should I do Acute Care NP program after the completion of my FNP program?

Background: I'm completing my FNP/MSN program in a few months. I don't feel like I'm very well prepared. I wanted to focus on adult geriatrics. I'm rotating thru urgent care, nursing home/hospice, and an awesome internal medicine clinic with complex geriatrics patients. I only have 5 years as RN as a school nurse for elementary schools. I don't have much hospital RN experience other than the clinical rotations in RN school. I think I should do Acute Care NP after my FNP to gain more experience and exposure.

I asked my instructor. She told me it's best that I start working as an FNP with a good mentor who would guide me rather than taking on Acute Care NP program which may not translate. I just want to be prepared.

Please let me know.

Thanks!

allnurses Guide · Mar 30, 2017

Hello:
I have a question: Should I do Acute Care NP program after the completion of my FNP program?
Background: I'm completing my FNP/MSN program in a few months. I don't feel like I'm very well prepared. I wanted to focus on adult geriatrics. I'm rotating thru urgent care, nursing home/hospice, and an awesome internal medicine clinic with complex geriatrics patients. I only have 5 years as RN as a school nurse for elementary schools. I don't have much hospital RN experience other than the clinical rotations in RN school. I think I should do Acute Care NP after my FNP to gain more experience and exposure.
I asked my instructor. She told me it's best that I start working as an FNP with a good mentor who would guide me rather than taking on Acute Care NP program which may not translate. I just want to be prepared.
Please let me know.
Thanks!

I think the two biggest questions are 1. what do you want to do and 2. what do you think?

It doesn't son'd like your faculty/preceptors have big concerns about you so I will assume that you aren't floundering in school or clinic. It is not uncommon for novice NPs to struggle with the role socialization be that with a lack of confidence or with imposter syndrome or role confusion or the like. The best counter for that is experience in practice in a structured environment.

If you want to work in primary care or an outpatient clinic I think most novice NPs are best served by starting practice in a structured environment with a good mentor(s)/support and slowly ramp up a patient load over the first year. I don't think a post-masters in ACNP would hurt you save for putting distance between what you learned for primary and primary practice, but it's not likely the best route for you at least on paper. If you want to work in-patient then its probably a worthwhile thing to do.

You are in control of your own preparation. I feel like a broken record sometimes saying it, but self-reflective practice is vital to being a good provider. If you can start practice with a lot of support and you are an active learner and engage in good self-reflective practice, odds are you will have a smooth transition into the role. Confidence comes with experience (or should come from experience I should say) and right now you need more experience: no novice provider, NP/PA/MD/DO enters practice fully ready and no provider is ever done learning and evolving.

I hope that helps you, best of luck. Feel free to ask away if you have more questions or if I missed the mark.