Vance

What's the point of credentials? Wouldn't it be better if we judged 'novice to expert' by metrics such as time in service, clinical record, skill and testable expertise. For instance, compare and contrast the hypothetical: a brilliant, highly skilled articulate, CRNA exuding leadership having published research advancing the practice vs. a dottering DSc/PhD who's somehow obtained CRNA credentials (or vice versa) but wouldn't be your choice of anesthetists in any case. I propose we choose to evaluate the individual and ascribe their level of competence according to a 'clinical ladder' whereby expertise, knowledge, competence is graded by levels and must be renewed on a periodic basis. Aircraft pilots work within this sort of framework. They must demonstrate and renew their proficiencies before piloting an aircraft with souls on-board. Degrees and tattoos are just ink. Wink wink

We use Critical Care Nursing: Diagnosis & Management (4th Ed.) in Albany NY

We use Critical Care Nursing: Diagnosis & Management (4th Ed.) in Albany NY

LMWH compare favorably to UFH in prevention & treatment of venous thromboembolism and are associated with less thrombocytopenia. In addition to the preloaded syringes it's available as 100mg/mL and 150mg/mL multidose vials; pH5.5-7.5 and rather expen$sive too.

In Albany NY we use Critical Care Nursing: Diagnosis & Management (4th Ed.) for critical care certification. It's comprehensive.

What is your career goal or what do you 'see' yourself doing in 3 years?

Community hospitals are wonderful. The gap isn't as wide as it's made out to be. What will you miss really? In turn, you'll reduce your stress, expense and maximize your time. Yes, indeed, get the CCRN and every other certificate that's important. Then, when there's nothing left to do locally, consider per diem or P/T at the teaching hospital to fill in that last piece of the puzzle. Hope this helps. You know what 'they' say about free advice

Open, forthright communication with your manager could help your situation. Every new grad is a work in progress, it takes much time and expertise to get us up and running; every manager is well aware. So, it's in the unit's best interest to salvage your experience - retain your future contribution. Propose a schedule/process that would work best for you and ask for assurance that the conditions will be honored as much as possible. If it's not possible, look else where. It seems to me, any hospital that has it's own SON will be smarter about how they manage new grads.

From experience, although not mine, you might report to HR the manager who has been giving bad reports. Request a generic letter as a remedy and be assured you'll hear no more from the disgruntled manager. You can always have someone call, and possibly tape, a mock reference check to find out exactly what is being said. In the meanwhile, don't publish the managers number for contact; use only HR's main number. Best of luck.

No counter argument here...

Your argument for better pain control is valid. The physicians in this case are either unpracticed and/or indifferent. Our nursing role is to intelligently advocate for the patient, making the team aware of your findings and identifying alternatves or additional resources. The family can be counseled to request a consult for this issue. We're not limitted to administering below therapeutic doses of narcotic analgesics. Alternatives exist. There may be valid clinical reasons for not increasing the narcotic dose and/or frequency. GI, respiratory, renal, hepatic and/or cardiac comorbid conditions will complicate drug therapy. Sounds like the liver is injured so drug metabolism will be impaired, requiring lower or even higher doses; morphine metabolites are a source of increased analgesia well above the parent compound. Renal impairment would suggest lower doses, etc.. Yet, the probability of adverse reactions should be weighed against the value we and the patient ascribe to mitigate suffering. Nevertheless, if we're concerned about hemodynamic status, augmenting with a stimulant such as amphetamines can achive synergy, requiring less narcotic. Or, as you suggested, a +chronotrope can be added to reduce the risk of bradycardia. Possibly, changing to a different narcotic would suffice. Patient's often experience differences in efficacy across various analgesics. Try hydromorphone or oxycodone or oxymorphone or fentinyl. How about epidural anesthesia, regional blocks, local infiltration, et al.. We'r not limitted here, we have options if we care to investigate a little. Godpseed.

I understand that barbiturates are neuroprotective in CNS/brain injury. Why don't I see their use, particularly when sedation is warranted? Instead, it's seems propofol and/or a benzodiazapine are used, without further consideration. Have barbiturates been retired from use in critical care? Thank you for your reply.

What are the limitations on NPs in the practice of medicine and surgery compared to MD/DO in the same clinical setting? For example, in a hospital ER or tertiary primary care setting, what skills/procedures/treatments would an NP be excluded from that an MD/DO could perform? Thank you for your reply.

Contract Negotiation for Nurse Practitioners 4. Negotiating Compensation Determining Worth of Service: When negotiating contracts, it is important to determine both the amount of income that the nurse practitioner may bring into the practice and the associated cost to the practice. While there will be variability among practices due to the specialty, the location and the outstanding debts of the practice, the following guidelines will help you determine what compensation you might be able to contract. The federal government focuses on three elements when determining compensation for medical services provided: cost of service (the cost of compensating the clinician providing the service); the practice overhead (includes utilities, rent, supplies, payment to support staff etc); malpractice insurance. While the formula used for Medicare reimbursement has been based on a percentage of 48% service, 48% overhead and 4% malpractice insurance, these percentages may vary from practice to practice. (See attached example from one primary care practice) a. Ask for the percentage of practice income that goes for overhead expenses. Be sure to ask what the practice includes in the category of "overhead" expenses. b. Generally a private practice will wish to net some profit from you participation. A general figure is 15-20%. Determine if that is the case in the practice you are considering. Is this included in the overhead cost quoted to you? c. Determine if a percentage of your gross receipts are expected to be used for physician consultation. (Seasoned nurse practitioners may expect to pay 10-15% of their gross receipts for this service.) Is it included in the overhead cost quoted to you? d. It will be important to be able to access your productivity data within the practice. Determine how this will be accomplished in the practice site you are considering. DETERMINING ARNP WORTH OF SERVICE The data in this example was provided by a nurse practitioner employed in an internal medicine practice in a small city in Kentucky. The income projected is based on the amount actually received by the practice for the nurse practitioner visits. Twenty five percent of the patients have Medicare; 65% have a HMO or PPO; and 10% have commercial insurance. The nurse practitioner saw 18 patients per day. Two were new patients; sixteen were established patients. Of the established patients, two were Level 2 visits, seven were Level 3, three were Level 4, and four were annual physicals (Level 5). There were also charges for two EKGs and three microscopic urinalyses. The nurse practitioner generated income of $1075 per day - $5375 per week - and $258,000 per year (assuming 48 weeks worked). The following chart illustrates the costs incurred by the internal medicine practice to employ the ARNP. Overhead costs include additional supplies and equipment needed, plus two full-time employees at $10 per hour to support the nurse practitioner (a nursing assistant and clerical help). COST TO PRACTICE TO EMPLOY ARNP Salary $80,000 FICA 6,120 Health Insurance 4,000 Malpractice Insurance 504 Continuing Education 2,000 401K 3,200 Professional org/license 150 95,974 Overhead 54,446 Expense to Practice 150,420 Income Generated by ARNP 258,000 Profit to Practice $107,580 Patient Care/Practice Expectations a. Determine the number of patients the nurse practitioner is expected to see, remembering that a new graduate will need more time in the first six months of practice. It will also help to find out what the most frequently billed CPT codes are for the practice and the amount received for those codes. b. If you are expected to take call or make hospital rounds, determine what percent of the other practice provider's salaries are attributed to this activity. You would expect to receive a like percentage if you take rotation with other providers. c. If you are to be salaried and your clinical and administrative schedule requires longer days or evening hours, you may wish to negotiate a half-day off/week to compensate for this time. BONUS/PRODUCTIVITY/PAYMENT a. Negotiating a bonus payment system may be important, particularly as the nurse practitioner develops a large patient base. Bonus formulas can be based on productivity, quality, profit or patient satisfaction. if a patient satisfaction based formula is agreed upon, using a satisfaction tool is helpful in determining the bonus formula. b. A productivity-based bonus may be appropriate if the nurse practitioner is on at least a 50% fee-for service system. Formulas are usually based on number of patient visits per year. Quality based bonus payments may be more practical under a capitated system where profit is measured by maintaining high quality care in as few visits as possible. In this case bonuses should be awarded for meeting or exceeding quality standards. Profit Sharing When negotiating profit sharing, it is important that the language regarding the determination of the profit share is clear. It is important to negotiate the right to access the company audit and a method for handling disputes. 5. Benefit Negotiations The following benefits as a salaried employee should be included: a. Health Insurance. Health insurance is an ever-rising cost of business. If you need family coverage make sure that it is a part of your benefits, even if you would have to pay the additional costs. Some employers also have dental and eye coverage for their employees. b. Vacation. Vacation benefits should include at least three to four weeks a year. c. Sick Leave. Sick leave is generally two weeks or one day per month per year. d. Travel. Ask about travel allowance if house calls or travel to other clinics is expected. e. Continuing Education. Continuing education allowance and paid leave (one to two conferences per year is not inappropriate; be sure to include enough in allowances to allow for airfare, room and food for at least one national conference. (An allowance of $1500 to $2500 for this purpose is not unreasonable.) f. Malpractice Insurance. With malpractice insurance coverage, ask if it is an occurrence or claims made type of policy and ask the amount of coverage. Negotiate for a malpractice policy that is an occurrence policy for at least $1 million per claim and $3 million aggregate. g. Fees. Membership in professional organization; licensure, and DEA fees should be paid. h. Subscriptions. Office subscription to appropriate nurse practitioner journal. i. Retirement Plans. Retirement plans including employer's contribution and years when vested needs to be determined. j. Disability Insurance. Disability insurance is a benefit you may want to negotiate, especially if you are the major income producer in your family. 6. Contract Restrictions a. Some employment contracts include a clause regarding restrictions on competition. A restrictive covenant restricts an employee from setting up a practice within a specified geographic area for a specified number of years. After leaving the practice the concerns of losing business if an NP moves to another practice nearby has made this inclusion a greater demand. 1.) Restrictive covenants are considered legal and can be enforced as long as they are reasonable. If this covenant is challenged in a court of law, the judge will determine the outcome. The judge will consider the needs of the public versus the harm to the employer. 2.) The restrictive covenant may be a fact of life, so decide if this is an area that as a NP you may be willing to give up realizing that you may have to trade-off other practice opportunities in order to get a reasonable contract. b. A contract may include language regarding termination clauses. A contract may list specific reasons for termination with cause such as should the NP become disable, lose their license, be convicted of a felony, etc. A termination without cause contract doesn't give the NP any job security and is not considered prudent for a NP. c. Avoid contract that include clauses that give the employer or contractor the right to make modifications at their discretion without notice. d. Avoid contracts that do not have renewal clauses. e. A lawyer knowledgeable in contract law should be consulted. Authored by American Academy of Nurse Practitioners Committee on Practice: Chair, Margaret Friel, Staff Liaison, Jan Towers, Lenore Resick, Mary Jo Goolsby, Evelyn Jackson, Norann Planchock, Sue Tanner, Barbara Weis