DavidRNNV

Hello All! I was hoping to get a little advice on a pain management position offer. I'm a new NP (ACNP) and all the positions I've been applying for want previous experience. This is a pain management clinic, I will do trigger point injections, large joint injections, they have X-ray on site, etc but at the end of the day, it's a pain management clinic that want to see your through put of patients at 24-27 per day. Salary about $100K with incentives. It is in a higher-end part of town, so presumably a decent clientele. Sounds like they need someone right away, so I have a good feeling I will be offered the job. I am interested in pain management, but with this high volume of patients it seems like I will be doing injection, documentation, injection, documentation, etc. Two main questions. Does this sound like a decent opportunity for a new NP? Has anyone done a similar job and can give me some insight on potential pitfalls?For example, I was told there is an incentive and the MD would determine if I would get in based on my performance. What should I look for in the contract that should clue me into a bad situation? THANK YOU for any advice you can give! David

Tony, You made a lot of right decisions. I just finished my ACNP and currently work at the VHA ED in Nevada/Las Vegas, so I know what you would have been walking into. The NP that would have been training you is very good, but in the long-run you will be much more marketable in the future. Also, the VA is run by administrators, not medical staff! Very frustrating for all medical staff!

First, islandsyndrome thank you for the excellent question, because I am (and I expect many others) are in a similar boat! I very much agree with djmatte's above response. I would like to add to it as well. I have noticed that many new NPs are not in their first job for very long. I expect there are a number of reasons for this, but one major one would be unrealistic expectations. What is the expected number of patients you will see in the IM and pain management positions? Obviously, I would expect more in the pain management, because it would typically be less comprehensive. For this position, or any position you take in your career, you should ask questions at the end of the interview to determine if the doctor or direct report is someone you can work well with. Finally, I think many NPs leave their first job because organizations say they are willing to hire a new NP, but then they realize how little hands-on experience we get in clinicals (~550 hours total), but expect us to work at a 4th year resident level (15,000 + hours hands-on experience as a resident). Then everyone gets frustrated and upset. The NP leaves and goes somewhere else, where they build on the knowledge they gained in that frustrating environment or go to a "lesser job". At least this is my perspective about what is happening...viewing from a far, because I am applying for my 1st jobs too. There seem to be A LOT of hospitalist jobs, but I realize that is one of the toughest jobs in medicine. That is why it is being offered to us NPs. I am strongly leaning toward a comprehensive pain management clinic. I was concerned, at first, that I would be limiting myself. However, pain is universal, but there has been very little training devoted to it...even for doctors. Not only can I use this to springboard to a more generalized position, but I will not be overwhelmed. I will be able to pick and choose where I want to go. From what I can see these positions mostly just want SOME NP experience. I will have that, when I want to "move up". Or I can open up my own pain clinic, should I choose.

Hello Everyone! I don't have a CCRN certification. Should I take the ANCC instead? or should I just get a CCRN review book before taking the ACNP-AG? Thanks for any opinions you can provide!

I just opened my account at allnurses.com for the first time in six months, eight months? It's been a long time I know that for sure. It seems you have a lot of good advice in response to your question. You are lucky not to have any major obligations at home to tend to while entering a graduate program in nursing. One person mentioned that it wasn't too bad until clinicals hit, and he described it very well. The best way I can explain it to someone who hasn't been in it yet is to say you start off at a good even pace. It is almost like going to school part-time (or maybe a little bit more) at first. However, once you get into clinicals you are going to school full time, and then some! I am in my second rotation and clinicals right now (with one more to go in the ICU) and I can tell you work is no longer a priority for me. Every day I spend an clinicals I learned an extensive amount of information that I can't get anywhere else. Therefore, I would rather call in sick to work once a month, because I'm exhausted, then to miss even a minute of clinicals (prior to school, I never called in sick). Probably the best advice I can give you is to always find time for yourself. Even if it's just a few minutes a day. Also, do the best you can to get ahead in classes, so when issues come up or you're extremely exhausted or sick, you can have a break for yourself. There are a number of frustrations that come up in your path during nurse practitioner school and it doesn't matter which school you attend. Right now, my biggest frustration is the fact that I didn't get the really good books until midway through my clinicals. Grrr! Life would have been so much more easier for me with the books I have now. When I say really a really good book I am talking about one that provides updated information, is easy to read, and provides the detail that you need to treat a patient effectively. The book that I like the best is called Symptom to Diagnosis: an Evidence-Based Guide (Stern, Cifu & Altkorn, 2015). Another excellent book is Current Medical Diagnosis and Treatment (Papadakis, McPhee & Rabow, 2015). I would have given my left pinky to have received these books at the beginning of nurse practitioner school! Finally, if you're going to an online university I would highly recommend YouTube videos to supplement your education. Look up MedCram and Strong Medicine on YouTube and you will learn a lot! Good Luck! David

Hello All, I will be starting clinicals soon with GCU as an ACNP student. I have a few basic questions for those who may have already been in the program or are in it now. The primary reason for asking, is I'm feeling worn down and feel I could really use a month off, just to relax and refresh my brain. This constant taking classes with only 3 or 4 day breaks, does not seem physically feasible...without something breaking at least! To that end: 1) How are Clinicals and the accompanying Didactic classes different from the other classes? I have absolutely No Clue how it works! Since we are picking our own clinicals, are we still with the same people as the regular courses? This makes a big difference for me, because I have 2 others I can trust and vent to (online and on the phone) which is very helpful. But if they are not going to be there, I don't see why I shouldn't take a month or so off - and even more reason to do so! 2) Maybe it would be better to take a break before my assessment class? Which I will be starting in a couple weeks. 3) What are the advantages to not taking a break? Thanks, In Advance, For ANY Info or Advice You Can Give! DavidRNNV

In looking over the postings for FNP and ACNP at GCU, I'm seeing similar ones to the ones I found almost 2 years ago when I enrolled. Seems like everything is pre-patho and then comments drop off completely. Probably because it is such a hard class, there are so few functional neurons available after you are done! So I thought I would put something to help those looking. For me, I'm an ACNP student (we have FNP stuff too, so I don't think it is any different) and I'm in Advanced Pharm now and almost done, next class is Assessment and then clinicals. I got a B+ in Patho, because I bombed the 1st test – a number of us did in our class. Hopefully, the info below will prevent you from going through this horror! (FYI – a lot of the info below would apply for any patho class and some for any online NP class regardless of the university. Also, I didn't put anything about group projects – that is a completely different beast and it is the same issue in every class-lazy group members! Bottomline - find good classmates and stick with them! ) For Pathophysiology the textbook is horrible! So there is NO Confusion the book I'm referring to is: Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7e, by McCance and Huethe” it has 4 out of 5 stars on Amazon, but I think it is bogus. When I gave it a detailed two star review, immediately (within a few days) it was flooded with a dozen 5 star reviews that had little or no detail! Very peculiar! I use to really trust Amazon reviews – not so much anymore. Anyway…. The text is more like an encyclopedia than a textbook (1725 pages not including the index). Which might be a good thing, but it is very poorly written. Reading it is like ditch digging…very boring, monotonous, and labor intensive! It not only jumps around topics, but will change how it references different topics. Almost as if the authors had students add multiple paragraphs to a topic, but they didn't make sure it flows with the rest of the topic, just cut and paste and move on. This makes many of the chapters very choppy and disorganized! There are typos throughout and there is waaaay to much detail! If you need it for a class rent it or get the e-book. At least with the e-book you can reference things quickly and use it as a reference book. Do you need it for the class? Not really. Why? Because diseases don't change from textbook to textbook-Just how they are presented. And McCance and Huethe do a very poor job presenting! What about the tests? Although open book, they are not an exact match for the textbook. That is, if you read a question on the test, the phrase is NOT in the textbook similar to the test. I didn't know how useful it was recognizing phrases this way until I took Patho! I had the e-book for the open book, which helped cut search time in half, but still very, very few phase matches to search or to key your memory. I'm guessing they get the questions from a test bank on the different diseases, so, again, because diseases don't change between textbooks - not sure you really need the text. But I definitely understand the security factor in having it. What to do? I recommend 4 things when taking patho (for any program) 1) get Robbins Basic Pathology, it is 900 pages and very well written. It has the same information and A LOT easier to read than the GCU assigned book! 2) YouTube – I really miss having old school” lectures to help bring things together and/or prime me for the reading, so I supplement with YouTube lectures – I like MEDCRAM – detailed, but not overly so, well explained and easy to listen to. Also, professorfink has some good videos on youtube as well. Same as MEDCRAM – easy to listen to, well explained, but his videos are longer. They are filmed in an actual classroom, so usually about an hour or a little more. (FYI – He is teaching dentist, but EVERYTHING is the same! Don't get hung up on it! He's Excellent!) Those are the two I use regularly, but find one or two that you are comfortable with and cover most patho topics. 3) Most important for Patho! Try to study before the class starts! I wanted to do this and didn't – Procrastination! I REALLY wish I did SOME studying – pulmonary, cardiac and renal diseases would have made things much better! 4) Have an active system – and try to work it out before you get too far into the class…and try stick to it! Do what works best for you – watch a video, then read a chapter, etc. By "active system" I mean you can't just read the text or watch the videos, you NEED to interact with the materials! Making flash cards, taking notes on paper with your own pictures, or putting them directly into the book. Online classes don't have this intuitively (except for the DQs and papers), like old school” classes, but it is Very Much Needed! Especially if you want to absorb the information in a short period of time. Yes, it requires a little more effort up front, but it is much easier to review your own creation than text on a book or computer screen. And expect it will be much easier to review before boards. FYI – Highlighting doesn't count! Hope this helps! (Remember #3 is the most important – don't procrastinate!) David

I REALLY need help with the best way to approach GCU Online classes. It seems I spend a lot of time reading and formulating thoughts and posting...and so many other people are just cutting and pasting. Then there is the group projects, (Insert your favorite curse word here!) What secrets are being held from me here?! Why am I the only one that stresses about doing a good job?! I'm always dragged into being the leader and it is just horrible. Can I just tell the members at the being of my next group: "Please don't copy and paste! Do you your part in an ethical manner! If you don't think this is appropriate get out of my group now!" Everything just consistently feels like being a student at GCU involves developing a completely different skill set than what I previously used when I went to a brick and mortar school. Maybe one of those skills is being a little bit of a jerk, so I don't have to drag people along? Or is it that I need to learn to do the whole group project? Do I need to learn to recognize the junk people turn in immediately rather than a day or two before, when there isn't any time to get them to do a decent job? Maybe I need to learn where to not think too hard and where to focus my attention. I have not gotten the secret GCU Online Student Manual that tells me how to handle these situations. I've asked my advisor and all she says is she understands my frustration. So if anyone one has ANY Suggestions, please let me know. THANK YOU! David, RN

With such broad degrees (RN and FNP) I can't image that you could be pigeon holed? Unless you have a narrow field of practice? Otherwise, sky is the limit! I agree with Zenman, figure out what you don't like about patient care....and what you do, otherwise, you will end up being right where you started. Also, talk to administrators, find ones that have made similar transitions. Ask them, "what would you told yourself, xx years ago, knowing what you know now about transitioning to Administration?" Bet you will get some VERY VALUABLE information that way!

Your license and dignity are probably worth a lot more then the drop in pay.

Thanks Juan, I did look up that Journal article and it was very helpful. I would prefer Internal Med and the job postings list ACNP here, because 90% of the locations here are organizations that are nationwide. The ACNP is a newer degree here and it looks like the overall consensus to have ACNP to be the primary NP in a hospital or specialist environments. Again thank you very much! I am much more confident that I picked the right NP program.

I am currently an ER RN with experience in LTC and Med/Surg. I am looking into NP programs and would like information on the ACNP (Acute Care Nurse Practitioner). I am aware that the FNP is more flexible, because you are trained to handle all age groups. They only have FNP in my ER, because we see all age groups. However, I am not very interested in OB/GYN assessments on a regular basis. Also, I'm not the type of nurse that seeks out working with children, don't mind it much, just not my passion. Therefore, I am seriously considering the ACNP, but I'm having a hard time finding out about its viability. Specifically: - What type of environments/jobs can an ACNP work in when they graduate? - Is it that different from an ANP? - Is the ACNP a strong degree? That is, will there be job opportunities when I graduate? (I only see FNP around.) Does it have a Long Term Viability like the FNP? - Will I get paid consistently less than an FNP? - I am looking at Grand Canyon University, I any thoughts on this program or any other suggestions that I might look into? (I live in Las Vegas, NV so it will probably be online) MANY THANKS FOR ANY INFORMATION YOU CAN PROVIDE!!! DavidRNNV

It sounds like you are running into the Catch 22 of nursing early in your career. That is, there is not enough time to do EVERYTHING exactly how you learned it in school. When you are at ANY job it takes longer at first, but in nursing it feels like you are agonizingly slow the first few months, because sick people are depending on you! Unfortunately, sick people only think of themselves a lot of the time. I think some nurses keep trying to get better and faster at their jobs and some just kind of give up and say "I'll get done what I can, then I'm done....this is a 24 hour facility". This is like taking teamwork to the extreme negative. Still, it is not all their fault for becoming that way, per se. An environment that has good team work, makes things much, much better. You learn from other nurses how to do things faster, but without jeopardizing the patients. One advantage with LTC is you get to know the patients (e.g. residents, sorry I work in acute care now). As all of us do, they have habits and want to maintain their patterns as much as possible. When you can, you can accommodate them and to your advantage. I had two or three that wanted their meds early, because they went to bed early. I let them know that I was not suppose to give meds early, but if they insisted (they usually didn't, I was just making a point) my job was also to do what I could to make them comfortable. None of the meds would jeopardize their health having it a little early. I told them that today, I could give the meds a bit early, and most likely tomorrow, if they insisted, but I take care of a lot of people, so I can't guarantee that every time. Also, I don't work everyday and they should not expect other nurses to do the same. So we would take it on a day by day basis. Of course, they agreed. Those 2 or 3 I would give meds first and there were others that wanted their meds later. So this helped a little with getting things done. And it helped them keep some of their dignity and independence. I found out later that another nurse was not doing all of his med passes. He was combining two different med passes. This is wrong for so many reasons , I'm not going to begin to list the reasons. This is a good example of how some nurses "will take a mile, when you give them an inch". It was unsafe for many of the residents to have that done. He was skipping cardiac meds, etc. So you need to use good nursing judgement when making decisions that will make things simpler and faster to get your job done. And more importantly, not abuse the trust that has been given to you. The answer to the Catch 22 is to work in an environment that is truly a team environment. You are always going to have "slackers", but they should be the minority. If they are not, then you should look elsewhere. It sounds like the job you are looking at has a high probability of being such a place. And, again, that is not ALL the nurses fault. It is management that molds the environment. Is the DON on the floor helping out or are they in the office all the time? Do they at least walk the floor to see how nurses are doing? Do they look for slackers? Or are they just upset all the time to everyone? This is where you could have asked a less direct question in the interview to find out what the DON/Manager was like as a leader. At the end of every interview you have an option to ask questions. ALWAYS ASK QUESTIONS! Example: "Can you tell me what your management style is like?" If they are the type of person that walks the floor or jumps in when needed, they will tell you, because they are proud of it! Still, you could follow up. This is my best question..."At work, what are your pet peeves?" You can learn a lot about a person and their attitude toward things with this question. For example, if a manager says, "It annoys me when nurses don't come to me with their problems or questions." I would want to work for that person! They will be supportive. Or "The only thing that annoys me is when state comes around." They are just focusing on the bare minimum. I DON'T want to work for them. Sorry for the long response, but I hop it is helpful. Best of luck!

That's a great CNA!

Thanks for your post 1fastRN! Just had my first week in the ER (previous 3 years M/S) and was feeling frustrated and stupid, because we had very high acuity patients each shift. But after reading your post I feel much better and feel like I learned a lot in just one week. Still feel stupid, but, frankly, I'm suppose to feel stupid and it is motivating me to read up on new tasks/situations that I'm running into. Thanks for the post, got me in the right perspective!

I've worked as an LPN in a SNF, RN in Med/Surg and now ER (and observed in a couple of ORs). Most of our SNFs (AZ/NV) have LPNs working the floor with the ratios you listed as normal. Usually there is an RN charge nurse. Here RNs rarely work the floor. #1 it is to costly for the facility to employ too many RNs because they get paid much more than LPNs. #2 There is a stigma working in a SNF. The nurses in SNF do work very hard. Frankly, as far as I know, all nurses work very hard, just in different ways and require different levels of skills. In a SNF you have more pts because the pt are more independent (aka less acute), but that can be harder too. I used to have a nightmare that all of my w/c bound SNF pts swarmed me at my cart, all angry, slamming into my cart, asking for Tylenol, colace, aspirin, etc, etc. It was a scary dream for me, but I can't handle high numbers of patients, regardless of "acuity". 4-5 ER pt is much better for me. I can juggle that amount in head. We have "higher acuity" pts, but we have more options (i.e. soft and leather restraints), quick access to meds, (we don't have to go to a back room, in a locked cabinet, to get a tackle box with a lock and get have 2 nurses sign to pull out 1 pain pill), and I get to see positive change in my patients in one shift or less. But I rarely get a break or time to sit down, SNF nurses get some time to take a breath, because, after all the pain and abx meds are given, very, very little requires immediate care. OR nurses can have loooong breaks that they get paid for, but they are involved in the most invasive and potentially critical patients there are. They can work very long hours, with stacked up cases, one after another, after another, etc. But they don't tend to have stable schedules, consistent hours, which is another kind of stressful to deal with. So all nurses need to understand that we all work hard and none of us have enough resources to do the job at the level we want to do it (especially SNFs). It seems we are all trying to search for that "Sweet Spot" where we are paid well, not too much stress, and truly helping others improve in their health/life. Bottom line: that "Sweet Spot" doesn't exist, but you can get close to it if you know what type of pt care fulfills you and what type of stress you handle best. If you can't be positive at your job, your in the wrong job, look somewhere else. And stop tearing down other nurses in other departments and other facilities. We ALL Work Hard!

Hey Maybug, So sorry you had to go through all that. I've been in similar environments when I first started nursing and it taught me a lot. I'm sure you learned a lot from this experience as well. Frankly, I think us nurses are usually very giving individuals and some administrators (and patients) definately take advantage of that tendency. I've told myself, that some people are just naturally like that. I'm not going to change them, but I Will Not Let Them Abuse Me. That is when my words become short and I use words and phases like "this is unacceptable", "this is a non-negotiable", "this is an unsafe situation", etc. Always with the focus on patient safety, care and appropriate treatment. You will find when you stand your ground like this, and show your assertive side, briefly, to demonstrate you have this side available to you, these people (administrators and patients) will be more cooperate. When I come across these types of people and I stand my ground, briefly, I see something 'click' when their looking at me and they become more cooperative (to me) 8 times out of 10 (The other 2 x they have AMS, pts and admins , remember to document in both cases). I agree with Everything hospicechpn said as well. Very good information. You are a good nurse, you are a jewel, stand up for your patients and yourself and you will not get burnt out. I've been a Med/Surg RN for a number of years now, I'm a preceptor as well, if you come across a situation that you need a sounding board on, please let me know. I tell all my new RNs on Med/Surg if you are not questioning what or how you are doing something, everyday, for at least the 6 months to a first year and seeking advice for the answer, everyday, then you may want to check yourself for being too laizes-faire toward caring for your patients. There is a lot to learn in nursing and you can't learn it all in school. Still, you seem to have a good moral and responsibility compass, rely on that and you will be fine.