Things you need to do RIGHT NOW!

Jules A, MSN · May 28, 2015

While I can't agree with everything you wrote, namely physicians attempting to abuse us which has never been my experience and likely goes back to allowing oneself to be abused, I applaud you for starting this thread and definitely appreciate most of your sentiments, especially:

1. Do NOT suck Although in one way I enjoy being known in my area as a heavy hitter it embarrasses me and hinders our profession when NPs practice in a way that is less than competent or professional. Yes I know there are many physicians who suck also but it is more of a stigma on us, imo.

2. Do not take jobs that aren't adequately compensating you for your geographic area and in my opinion under no circumstances would that entail working for a similar rate to what I made as a RN. I presently make almost twice what I made as a well paid RN.

3. Learn about and embrace finances. For the love of Pete this is the way the world works and people who haven't made it their business to understand simple finances drive me batty, ok more batty lol. Things like the difference in being an employee vs. 1099 independent contractor isn't rocket science and you will be taken advantage of by employers if you aren't somewhat savvy.

4. Definitely become involved in your state's NP organization. There is nothing less appealing to me than sitting around with a bunch of whiney chicks, just seeing if you are paying attention lol, after working 10 hours in a day however wonderful things can happen for our profession if you have a few sharp NPs in office. Not participating is counterproductive and selfish because you will reap the benefits of their labor.

5. This is my only original thought here: please embrace the uber smart physicians you encounter. They can propel you both with regard to knowledge and professional contacts. Like it or not, and I happen to like it, Docs are the Big Dogs and I intend to run with them not nip at their heels.

Trauma Columnist · May 29, 2015

I agree with most of the points also.

The business end of medicine is where its at. We, as APRNs must be profitable. That means knowing the revenue that we bring in, knowing how to bring in more revenue, making ourselves a positive commodity for our practices/hospitals.

I've been a nurse for 23 years now, an APRN for 9 of those years. I have come across only one physician that was dangerous to me as an APRN - the consequences of his actions cost me dearly. This was in the early days of my APRN career. Advice for this situation:

1. Document EXACTLY what the MD tells you.

2. Don't be intimidated by anyone regardless of the initials behind their name

3. If in doubt, don't do it - get some advice from a second practitioner be that an APRN or another MD

4. Question orders/requests - if something makes the hair on your neck stand up - listen, stop and think.

5. If something happens that results in a bad outcome from an interaction with a physician again you must document and seek counsel.

6. ALWAYS ALWAYS ALWAYS CARRY YOUR OWN malpractice insurance!!!! Your insurance company is the one that will look out for you!!!!

And I probably should have put #6 first because that is the only thing that will save you and your career!!!!

automotiveRN67 · May 29, 2015

I agree with most of the points also.
The business end of medicine is where its at. We, as APRNs must be profitable. That means knowing the revenue that we bring in, knowing how to bring in more revenue, making ourselves a positive commodity for our practices/hospitals.
I've been a nurse for 23 years now, an APRN for 9 of those years. I have come across only one physician that was dangerous to me as an APRN - the consequences of his actions cost me dearly. This was in the early days of my APRN career. Advice for this situation:
1. Document EXACTLY what the MD tells you.
2. Don't be intimidated by anyone regardless of the initials behind their name
3. If in doubt, don't do it - get some advice from a second practitioner be that an APRN or another MD
4. Question orders/requests - if something makes the hair on your neck stand up - listen, stop and think.
5. If something happens that results in a bad outcome from an interaction with a physician again you must document and seek counsel.
6. ALWAYS ALWAYS ALWAYS CARRY YOUR OWN MALPRACTICE INSURANCE!!!! Your insurance company is the one that will look out for you!!!!
And I probably should have put #6 first because that is the only thing that will save you and your career!!!!

While your points are valid, and we all have the same concerns about the risk of malpractice, I am a little confused about why you thought this personal experience added to the OP's original post. Trying to scare the daylights out of NP's, based on your experience, should probably be a thread of its own

automotiveRN67 · May 29, 2015

1. Do not settle for meager pay
This is the first step you can take right out of school. Many nurse practitioner graduates settle for horrendous contracts in order to get his or her foot in the door. While there is some rational behind this, a few of the offers I have seen people accept are completely terrible and make me want to vomit. Do not settle for subpar pay, do not even apply to these jobs. In no way should we ever get paid less than we did as an RN. Not with the level of responsibility we have. While this may vary by geographic location, the rule of thumb is that you should be making more per HR than you did as a nurse. Accepting anything less is an insult to your fellow nurse practitioners.
2. Move to states which allow unlimited practice
By doing this you are putting strain on the physician population which seeks to abuse us. Why should we have to pay somebody to act like they are looking at charts just to provide a signature to say they agree with us? While this may not be possible for everyone, as a whole, we need to move to the states that promote private authority for NPs.
3. Join your professional organization
By doing this we are supporting our cause in numbers. Physicians are often more strongly supportive of their professional organizations. If we do not show that we support our fellow members, how will we ever gain a foothold in the rest of the states for full practice authority.
4. Keep up to date on current practice
To be taken seriously, you cannot suck. One must continually try to keep uptodate on the best practice information. If you do not know something, there is no excuse that you cannot research it online with some of the great options out there for reference material. GET TO WORK. We are often not a procedural type provider, more of a knowledge based, so the internet is a great resource.
5. Become technologically literate
While some may argue this point, many people believe that technology itself will influence patient outcomes and healthcare as a whole more than biological advances. If you are not apt at using the internet, finding information, do not understand the latest types of communication, etc. GET TO WORK.
6. Learn the basics of business
Like it or not, business knowledge is important for all nurse practitioners. Knowing the ins and outs of business can greatly increase your earning potential. Understanding concepts such as billing, insurance, how practices work, etc is very important. Pick up a few books and start reading.
7. Educate the public
We must also educate the public on the roles of the nurse practitioner. Many people still believe we are glorified floor nurses, when we are actually independent providers. While our education model may differ from that of a medical doctor, we share many more similarities to physicians than of our RN coworkers.
8. Do not belittle yourself
Make sure people know that you know what you are talking about. Many people still believe that nurse practitioners are a stepping stone between a nurse and a doctor. Provide them the proper information on this incorrect theory.
9. Be competitive
When I say be competitive, I do not mean that we should simply bite around at each other. But try to be the best in your class. Many state that it is wrong to compete with one another, but we are human. We have been competing for scarce resources for thousands of years and we are very good at it. Let that natural drive push you forward.
10. Learn finance
The world revolves around money. Like it or not this is a fact. Money is a scarce resource that can have many uses. It is not to be sought after directly or obsessed over, but one that does not have the power to earn money will often not be able to have the impact that they should in the world.
While many of these do seem rather basic, many people fail to follow the above principles. Think about it and take into account which ones of the above you apply to your practice, and comment below and provide feedback and additional thought.
SO GET OUT THERE AND START KICKING BUTT IN LIFE AND DRINK COFFEE

Given the time of year, I am assuming you are just graduating NP school. While some of your points are valid, you do contradict yourself when it comes to money. And let me tell you why.

Your first point doesn't fit well with your last point. When I have been in the hiring position, I would offset the experience of a new graduate with the volume I expected them to be able to generate. Most new graduates, even "superstars", come out of the box a little slow. The first 6 months is generally a loss, even when you hire an NP at a fairly low starting rate. A new graduate who holds out for more, in our office, didn't get an offer at all. Last thing we want in the office is a "know-it-all" NP who thinks they are worth more than they really are.

You have to consider that MD's and DO's, work for peanuts (relative), for 3-6 years or more in residency and fellowship. But they can come out of the box completely honed and ready to work. I have not found that with new graduate NP's. And with the increase in online degrees, new graduates are even less prepared.

But an organized practice will generally offer a fairly low starting wage, with the promise of 3 month and 6 month evaluations with either bonus, or wage increase to match productivity. Show us what you can do, and we will make sure you want to stay.

If you get a low-ball offer from a practice that impresses you, use that time to learn and prove yourself. And make sure you ask about productivity increases. It shows the group you are willing to work for something more.

But I absolutely agree with number 6. Learning how billing and insurance works is a key part of being successful. I have seen practices billing NP's at 85%, when they could have been billing "incident-to", at 100%. Sometimes, even the biller didn't know how to do it correctly. But that extra 15% would pay the salary of a receptionist.

Edit - And I have also seen offices tell their NP's to bill only level 3 visits, because they feel that NP's can't justify the more complex visit. Nonsense. If your decision process and documentation supports a level 4 visit, BILL IT!

Jules A, MSN · May 29, 2015

most new graduates, even "superstars", come out of the box a little slow. The first 6 months is generally a loss, even when you hire an NP at a fairly low starting rate. A new graduate who holds out for more, in our office, didn't get an offer at all. Last thing we want in the office is a "know-it-all" NP who thinks they are worth more than they really are.
You have to consider that MD's and DO's, work for peanuts (relative), for 3-6 years or more in residency and fellowship. But they can come out of the box completely honed and ready to work. I have not found that with new graduate NP's. And with the increase in online degrees, new graduates are even less prepared.
But an organized practice will generally offer a fairly low starting wage, with the promise of 3 month and 6 month evaluations with either bonus, or wage increase to match productivity. Show us what you can do, and we will make sure you want to stay.
If you get a low-ball offer from a practice that impresses you, use that time to learn and prove yourself. And make sure you ask about productivity increases. It shows the group you are willing to work for something more.

Agree 100% about the difference in the level of preparation between NPs and new Docs however and I imagine this is specialty, geographic need and experience driven to some extent but no way was I going to take a low paying job to prove myself when I got out of school. Not that there aren't facilities with an extensive orientation and mentor program, although I haven't heard of them, and people who based on their skill set need to do this I don't think this is necessary across the board.

At both my jobs when I graduated I got zero orientation and my patient load was exactly the same as the seasoned providers both in numbers and acuity. They weren't holding my hand and were billing out the wazoo so I felt entitled to have comparable wages. I also had an excellent background in my specialty and the medical director at one of the jobs had worked with me and wanted me. I guess I was worth it because I'm still at one of them. :)

Jules A, MSN · May 29, 2015

6. ALWAYS ALWAYS ALWAYS CARRY YOUR OWN MALPRACTICE INSURANCE!!!! Your insurance company is the one that will look out for you!!!!

I definitely agree and tell my nursing students that in my experience a facility will tend to throw a nurse or NP under the bus prior to going after a physician who is more difficult to replace. Its much easier to say "gee we were trusting that Nancy Nurse knew how to practice within her scope. What a shame that she was negligent. We have fired her".

Ash7187 · May 29, 2015

If my employer if offering malpractice coverage, what additional coverage should I consider getting? Should I request a copy of the malpractice policy?

Jules A, MSN · May 29, 2015

If my employer if offering malpractice coverage, what additional coverage should I consider getting? Should I request a copy of the malpractice policy?

You need your own policy like you had as a RN.

synaptic · May 29, 2015

I still wouldn't accept a meager salary when first starting. Some people accept offers for a 40 hour per week job in the 60s. Back a few years ago when i graduated we made 100k right out of the box with bennies. It isn't too difficult in most areas to make your employer money when your salary is only 60k plus some shifty benefits.... unless you see 100% medicaid maybe.

Fnpatlast · May 30, 2015

Speak up and do not let physicians belittle you. They think NPs are nurses that they can order around. You are an independent licensed provider. They will question your plan, meds, notes etc. Look them in the face and defend yourself. Rubbish. I am in it already and can only go higher from here.

Jules A, MSN · May 30, 2015

Speak up and do not let physicians belittle you. They think NPs are nurses that they can order around. You are an independent licensed provider. They will question your plan, meds, notes etc. Look them in the face and defend yourself. Rubbish. I am in it already and can only go higher from here.

Please reconsider your approach as it sounds very defensive and adversarial. Although I know there are some who don't understand our role and I would be the first to gently correct any confusion in my experience it is very rare. The physicians I work with do not act as if I'm their nurse or question my decisions. I am an attending and feel respected. Trust me when I say having a physician support network will bring benefits in the form of job opportunities, increased knowledge and credibility. Plus they do lots of fun social stuff and the invites are an added bonus. :)