Texas NPs

[Missy89]

Anyone currently practicing as an NP in Dallas or even Texas overall? Graduate next Dec and looking to relocate. How is the job market for new grads? Typical salary? Currently interested in surgery, derm or specialty care. Thanks!

[nomadcrna, DNP, CRNA, NP]

carachel2,

Texas is extremely restricted for NP practice. Can you write prescriptions on your own? NO

Can you sign death certificates? NO

Can you even sign handicap parking? No

Can you practice independently? No

Can an FNP work in ER? Lots of issues there.

Can you admit your own patients to the hospital without a physician? NO

[nomadcrna, DNP, CRNA, NP]

Dont project your lack of acute care training onto other FNPs. Many FNPs have training and have been practicing for years in acute care. That is the whole point, the FNPs working in acute care DO HAVE ADDITIONAL TRAINING.

Much of acute and primary overlap and remember, not all of us are in urban centers where there are options. Many small towns the FNPs have to do it all.

So your OPINION is just that, an OPINION without any basis in fact.

Here is a FACT. 70% of all NPs working in the ER are FNPs. Do you really think they would be doing that if we were not safe?

I'm both saddened and embarrassed that we have to fight our own. Even if YOU don't want to work in an acute care setting does not mean others may not have the training and education do work in ER or cover their own inpatients.

How about you support the NP cause? Nurse make me think of crabs in a pot. When one is climbing out, the others do their best to pull him back down in the boiling water.

Ah, well...I LIKE those restrictions. I don't think an FNP has any business in acute care unless they have a lot of additional training. But I know others feel differently. Glad to hear that is all that is a big deal in regards to "restrictions." I felt I was missing some big important point, lol!

[carachel2]

Dont project your lack of acute care training onto other FNPs. Many FNPs have training and have been practicing for years in acute care. That is the whole point, the FNPs working in acute care DO HAVE ADDITIONAL TRAINING.

Much of acute and primary overlap and remember, not all of us are in urban centers where there are options. Many small towns the FNPs have to do it all.

So your OPINION is just that, an OPINION without any basis in fact.

Here is a FACT. 70% of all NPs working in the ER are FNPs. Do you really think they would be doing that if we were not safe?

I'm both saddened and embarrassed that we have to fight our own. Even if YOU don't want to work in an acute care setting does not mean others may not have the training and education do work in ER or cover their own inpatients.

How about you support the NP cause? Nurse make me think of crabs in a pot. When one is climbing out, the others do their best to pull him back down in the boiling water.

Nowhere in my FNP program was I trained to do advanced procedures that are needed in the inpatient critical care setting. So I feel VERY strongly that no one in MY program should be allowed to be an acute care NP. Go back to school and do the additional hours IMO. If you have the training at the masters level then by all means. But I don't count your years as a critical care RN to be advanced training.

[carachel2]

carachel2,

Texas is extremely restricted for NP practice. Can you write prescriptions on your own? NO

Oh, well, I just wrote like 20 yesterday with no one looking over my shoulder. I did them all on my own. I'm not sure what you mean by "on your own." See my note below i guess.

Can you sign death certificates? NO

This has come up like...NEVER in my career in family practice!

Can you even sign handicap parking? No

Thank goodness! I've been an FNP now for almost 4 years and I've had 2 requests for these. What a major pain. I gladly put those charts on the docs pile and just kept moving thru my day

Can you practice independently? No

I have a collaborating physician. We both signed the document. He is in the same building as me. I choose to discuss some cases with him just like he chooses to discuss some cases with me. For the most part I move through my day with only saying "hey how was your weekend? " I consider myself very independent. I see my own patients, write my plans, order tests, interpret labs , etc. etc. without anyone looking over my shoulder or otherwise making me feel like I'm not "independent."

I guess I have NO interest in all of the headaches of practicing independently. Heck, most licensed MDs can hardly practice independently these days! They are all being swallowed up by big corporations so they can negotiate better with the big insurers! Thank goodness. I do my job and go home and I'm done. He, on the other hand is on call, has to worry about the building, utilities, paychecks, staff issues..the list goes on. I have a life. So yes, I guess if you want all of that it might be hard in Texas.

Can an FNP work in ER? Lots of issues there.

Really? I have at least 3 friends doing that right now and I've never heard a peep of complaint from them. They make really good $$ too!

Can you admit your own patients to the hospital without a physician? NO

Again, that's never been a big deal to me. Most of the physicians I know don't even admit their own patients anymore. I guess if I felt like it was a big party I wasn't invited to I would be upset...but no one I know really does that and they were glad to give it up. Hospitalists were a great invention! Heck, my OWN doc doesn't admit me and come see me in the hospital !

[hopefulwhoop]

I'm in FL and want to relocate to TX. I have been applying for jobs, but have had no luck. I am also a new grad., so that might be the problem there :-/ *SIGH*

[nomadcrna, DNP, CRNA, NP]

Nobody said anything about critical care setting although many FNPs do critical care.

We are talking about ACUTE care. Although critical care is a small portion of acute care, that is really not what is being discussed.

I would agree with you if we were talking only about critical care to a point. I think FNPs can easily add critical care education without going through a ACNP program.

I don't see where anyone mentioned using years of RN critical care experience either? Or am I missing a post? Not talking about that either.

You are jumping from acute to critical care and back. Acute care is NOT only critical care such as ICU/CCU. I may have missed it but I don't think I saw any discussion about critical care. Inpatient care is not necessarily critical care.

ER is the only critical care area discussed but that really is different from ICU/CCU.

On the procedures, that is the easy part of critical care. I can teach a monkey to intubate or place a central line. Ok, maybe a bit of exaggeration but pretty damn close. Same with a chest tube. The procedure is not hard to do, it is knowing when to do them.

Again, just because YOUR FNP program did not train you for any advanced procedures does not mean other FNP programs do not. There are also many, many different avenues to get the proper training. What you don't seem to comprehend is the huge amount of overlap in the ACNP program and FNP programs. Do you really think it is an entirely different education? You would be amazed at the exact same classes and education. Of course some is different but my point is that it is VERY easy to get addition education and training without going back for a new certification. For both ACNP wanting to do primary care or FNP wanting to do acute care. Absolutely idiotic to make them do the whole program.

Training at the masters level? What does that mean? We all have Masters or higher degrees so any program should be at that level. Why go back to do say, CCRN? Or another RN education program. No offense intended but maybe when you get some more and/or different experience as a NP.

Juan posted an ER certification through AANC (i think) for ACNP and FNPs. A good start to being able to show the BONs that you are educationally prepared for ER.

There is a ER program though West Virginia University school of medicine directed at NPs, PA and non-ER trained physicians. Great program, 2 years of about 4-5 credits a semester and skills lab.

So you see that you just can't make blanket statements like this. It does hurt our profession. We all need to support the NP practice.

Nowhere in my FNP program was I trained to do advanced procedures that are needed in the inpatient critical care setting. So I feel VERY strongly that no one in MY program should be allowed to be an acute care NP. Go back to school and do the additional hours IMO. If you have the training at the masters level then by all means. But I don't count your years as a critical care RN to be advanced training.

[nomadcrna, DNP, CRNA, NP]

An Overview of APN Prescriptive Privileges in Texas

There are three primary limitations on prescriptive authority for APNs in Texas.

1) Prescriptive Authority must be delegated by a physician through a practice agreement protocol;

2) Physicians can only delegate prescriptive authority at certain types of practice sites; and

3) Controlled Substances are limited to Schedules III - V and certain limitations apply.

So you CANNOT write a prescription unless delegated by a physician. I can write for whatever I choose without any physician involvement.

Death Certificates. Ok, so YOU don't need to do it. But others MAY want or need to do them. I occasionally have to sign one.

You HAVE to have a collaborating agreement. Do you not see what this does to our profession? Nobody is talking about whether or not you are capable of independent practice. I would hope that you are since you are a NP. But again, it is NOT all about YOU. Try thinking of the profession.

So you don't want to do handicap parking cause it is a pain. So as long as the restrictions don't bother you, it is ok? What about the other NPs that want to be able to have a full and complete practice?

On ER, so you have 3 friends doing it but just above you were saying that noway, nohow should any FNP work in acute care? Is it different since they are your friends?

Admitting patients. I would absolutely love to be able to admit to a hospitalist. Unfortunately, that is not reasonable in rural areas. So again, it is not about YOU but our profession. There are many different types of practices, your is just one tiny part of them.

Do you see a pattern here? "I don't do it", "I don't need to do it", "I don't want to do them". IT IS NOT ABOUT YOU.

carachel2,

Texas is extremely restricted for NP practice. Can you write prescriptions on your own? NO

Oh, well, I just wrote like 20 yesterday with no one looking over my shoulder. I did them all on my own. I'm not sure what you mean by "on your own." See my note below i guess.

Can you sign death certificates? NO

This has come up like...NEVER in my career in family practice!

Can you even sign handicap parking? No

Thank goodness! I've been an FNP now for almost 4 years and I've had 2 requests for these. What a major pain. I gladly put those charts on the docs pile and just kept moving thru my day

Can you practice independently? No

I have a collaborating physician. We both signed the document. He is in the same building as me. I choose to discuss some cases with him just like he chooses to discuss some cases with me. For the most part I move through my day with only saying "hey how was your weekend? " I consider myself very independent. I see my own patients, write my plans, order tests, interpret labs , etc. etc. without anyone looking over my shoulder or otherwise making me feel like I'm not "independent."

I guess I have NO interest in all of the headaches of practicing independently. Heck, most licensed MDs can hardly practice independently these days! They are all being swallowed up by big corporations so they can negotiate better with the big insurers! Thank goodness. I do my job and go home and I'm done. He, on the other hand is on call, has to worry about the building, utilities, paychecks, staff issues..the list goes on. I have a life. So yes, I guess if you want all of that it might be hard in Texas.

Can an FNP work in ER? Lots of issues there.

Really? I have at least 3 friends doing that right now and I've never heard a peep of complaint from them. They make really good $$ too!

Can you admit your own patients to the hospital without a physician? NO

Again, that's never been a big deal to me. Most of the physicians I know don't even admit their own patients anymore. I guess if I felt like it was a big party I wasn't invited to I would be upset...but no one I know really does that and they were glad to give it up. Hospitalists were a great invention! Heck, my OWN doc doesn't admit me and come see me in the hospital !

[carachel2]

Look, nomad...my point was, the VAST majority NPs who are reading this have no desire to own their own practice and admit patients left and right to the hospital.A lot of people reading this do not live in Texas and are judging what may or may not be by your posts. If I had to get every prescription co-signed by the physician I practice with then yes I would think it was a restrictive state. If I had to have every patient seen by the physician each time I saw them then yes I would think it was a restrictive state. If I could not order an Xray, CT or MRI without someone co-signing then yes, I would think it was restrictive.

I want people to know that things you are complaining about are mostly NOT a big deal to the majority of NPs in practice in Texas. Maybe to someone like yourself in a very rural area who wants to own their own practice? Then yes, if I lived out in the middle of nowhere and wanted to own my own practice it might be frustrating. ::::shrug:::: I can do all of the things we were taught to do in school. I've never felt restricted and most of my colleagues feel the same way. Texas is not as bad as you make it out to be and I wanted others to see that. For the normal, average joe NP who wants to see their own patients, write their own prescriptions and do their own thing...eh, sooooooooooo not a big deal.

[zenman]

I want people to know that things you are complaining about are mostly NOT a big deal to the majority of NPs in practice in Texas. Maybe to someone like yourself in a very rural area who wants to own their own practice? Then yes, if I lived out in the middle of nowhere and wanted to own my own practice it might be frustrating. ::::shrug:::: I can do all of the things we were taught to do in school. I've never felt restricted and most of my colleagues feel the same way. Texas is not as bad as you make it out to be and I wanted others to see that. For the normal, average joe NP who wants to see their own patients, write their own prescriptions and do their own thing...eh, sooooooooooo not a big deal.

And those of us who work, or have worked, in independent practice states will continue to see Texas as a very restricted state. (And I'm a Texan). I know NPs there who have had to close their practice and turn loose hundreds of patients immediately due to collaborating physician changing their mind, dying, etc.

Let me give you one example of my last job in New Mexico. I did inpatient, outpatient, and CL consults. The medical director of the unit loved that I was totally independent. (The physicians who had PA's had to cosign almost all their work, for example.) I admitted and discharged patients all the time to the inpatient unit and sometimes would be in total charge of the unit for 3-4 days at a time while the director was out. I could collaborate all I wanted to but not because I had to by law.

I'm currently in Kansas and working for the military. Normally you can use any state license for a military job. However, due to poor decisions by the DEA (which could result in less NP contractors), I had to get a Kansas license. It was the most painful, other than dealing with the Texas BON, process I've been through. I almost walked away. Now, that I've put together this detailed piece of collaboration document and had it signed, it will remain in a desk drawer until it needs to be signed again next year...a reminder that I'm not independent in this state. Like you, in my daily work, no one looks over my shoulder. However, that ball and chain is still there. If I wanted to start a private practice (which I will someday in another state) my entire livelihood would depend on someone else. That's why those of us who have enjoyed the benefits of TOTAL independence will continue to think as we do about Texas. No one will change our minds.

BTW, I used to see Texas patients in NM because they had to wait 6 months to a year to see a psychiatrist.

[carachel2]

Zen, I guess with all of the NPs I know personally...it's just such a NON issue. We do all we need to do and then some. But none of us have any desire to deal with all that you desire to do, lol! My whole point was that for most NPs who want to do their thing and go home (i.e. NOT own their own practice), Texas is not a bad state.

[Annaiya, NP]

I think the reason it seems to not be that bad is because its what everyone is used to. So the extra hoops are invisible until you've worked somewhere where they don't exist. There are constant issues where I work due to the fact that NPs can prescribe schedule IIs but they have to in their role. So they will verbal the order to the RN and the RN will put the order in under whatever physician is working that day. It's ridiculous and not the safest practice but its the only way to make things work and not compromise patient care. It's not like we can just stop giving the patient sedation while the NP is putting in a line because the physician is busy with another patient. It makes no sense to me that an NP can be fully qualified to intubate or put in a line but they can't order the sedation for the procedure. I know a bill was proposed to improve this practice but I lost track to how it was doing in the legislature.

I do think it is important to know what the issues are for other NPs and not just say you're ok with your practice so nothing needs to change. It is in the best interests for the patients we serve to remove the barriers to NP practice and that should be the biggest concern. Not that you can do your current job and then go home, so you're happy.

[nomadcrna, DNP, CRNA, NP]

I am very sad that the NPs you speak of do not care more about moving NP practice forward. I say shame on the whole bunch of you.

Zen, I guess with all of the NPs I know personally...it's just such a NON issue. We do all we need to do and then some. But none of us have any desire to deal with all that you desire to do, lol! My whole point was that for most NPs who want to do their thing and go home (i.e. NOT own their own practice), Texas is not a bad state.