Working as an RN and NP in the same facility???

Trauma Columnist · Dec 18, 2007

My RN experience is mostly level one trauma center which I absolutely loved. When I became an APN (May 06), my idea was to cont prn in the ER. However, in my APN job I am credentialled at the hospital where the ER is that I want to work at and the hospital said I could only be employed in one role.

The other issue (from a friend who is a lawyer), is that I would still be held to the standard of an APN even though I wouldn't be in that position. In other words, my assessment skills and nursing skills are those of an APN and I would be expected to act in that scope of practice. I know that would not be a problem if I was an APN because I would have the time to do the APN assessment, etc.. However, in the world of staff nursing, the assessment that I do is a focused one for the ER patient. So...with 5-6 pts, my RN role and workload wouldn't permit me to do an APN assessment.

I hope I'm explaining this so that it makes sense.

ruralnurs · Dec 20, 2007

traumaRUs,

That is kind of what I thought. Perhaps the nurses that I have met work in a separate facility. But even then, like you said, you may be held to the higher standard if something bad happens.

It kind of makes me sad, because there is much of what I do as an RN that I love, like OB, but could not do as an FNP.

Trauma Columnist · Dec 20, 2007

Exactly - I'm sad too. I miss the ER a lot.

I do like the pay and benefits though.

PMHNP10 · Dec 20, 2007

I do like the pay and benefits though.

as an RN or APN? Surely the pay is better for you as an APN, right?

core0 · Dec 20, 2007

The other thing you have to think about is would this be a Stark violation. You generally can't refer to yourself. So if you were working in the ER and sent a patient to the floor assigned to the hospitalist group that you also worked for then you might be in violation. Just another vagary of federal law.

David Carpenter, PA-C

Trauma Columnist · Dec 20, 2007

Sorry - meant that the pay and benefits are much better as an APN.

David - that is very true. I work for the ONLY nephrology group in central IL so if anyone with renal issues needs to be admitted there is only one choice.

CraigB-RN, MSN, RN · Dec 20, 2007

Having been a DON at one of the Critical Access Hospitals, I tell you that once you start practicing as an APN, there prob won't be much time to work as a staff nurse.

One thing to remember is that as an APRN, you are still an RN. You will do wonders for how the staff think of you if you don't forget that, especially in a small rural community. The best APRN's that worked for me, were ones that weren't afraid to get their hands dirty, and helped get the patient admitted and didn't think it was below them to do those basic nursing skills.

The other thing to consider is how well your coworkers can handle the possible role confusion. ie, are you working as an NP or as a staff nurse. When working with your administrator make sure that you spell out reimbursmnt for any time spent on the floor. This is important when it comes to the Cost Report at the end of the year. Medicare gets pretty weird over things sometimes. The Administrator may decide that it is to much like work to handle that.

Out of curiosity are these clinics rural health clinics?

As to Davids comment about the Stark Violation, that won't affect you in a Critical Access Hospital, since it's understood that you are pretty much everything anyway. That in general is only a problem in places with multiple groups of practitioners. Since there is only 1 group in most Critical Access Hospital, there is no one else to refere to.

As to being held to a higher standard of care, that is correct up to a point. You are looked at at the level you are currently working at to a point. You shouldn't be expected to do a full ROS assessment, but you would be expected to recognize things that a staff nurse might not. It's a gray area, that always gets a lot of heated discusions. You can get lawyer's opinions that will go either way, depending on who's side the lawyer is on. I know of at least 6 APRN's who work as Staff RN's to make some extra money without any problem in the same hospital, but not the same unit they are APRN at.

Congradulations on becoming an APRN. Good luck and enjoy learning your new job. Don't hesitate to ask for things in your contract, make sure you get plenty of CEU time as well as vacation, and a book allowance can be helpfull also. Keep you in the latest PDA and software. :)

Dont worry about working as a Staff Nurse for awhile, just focus on becoming the best APRN that you can be.

Editorial Team / Admin · Dec 20, 2007

As to Davids comment about the Stark Violation, that won't affect you in a Critical Access Hospital, since it's understood that you are pretty much everything anyway. That in general is only a problem in places with multiple groups of practitioners. Since there is only 1 group in most Critical Access Hospital, there is no one else to refere to.

Stark Law violation occurs when:

You refer a patient to a health care entity with which you or a member of your immediate family have a financial interest
The referral is for one or more designated health services (DHS) that are covered by Medicare or Medicaid
The referral is made in a situation where no exception to Stark applies

There are exceptions to this Law when/if the area is a healthcare provider underserved area.

As to being held to a higher standard of care, that is correct up to a point. You are looked at at the level you are currently working at to a point. You shouldn't be expected to do a full ROS assessment, but you would be expected to recognize things that a staff nurse might not. It's a gray area, that always gets a lot of heated discusions. You can get lawyer's opinions that will go either way, depending on who's side the lawyer is on.

Liability carriers insure the APN at the highest level of education. All RNs who are also APNs must carry that coverage.

Like you say, this is a very gray area. One must ensure that one's entity has explicit role delineation with job description and performance of duties. Also, the APN should not work in the same area of APN specialty. This just begs confusion and can lead to many problems if the APN cannot act according to the highest standard/level of education and/or clinical expertise.

The other thing to consider is how well your coworkers can handle the possible role confusion. ie, are you working as an NP or as a staff nurse.

Exactly. This will reduce many areas of concern if your fellow nurses know in which position you are practicing. This includes name tag recognition not only for your fellow nurses, but for the patients as well. Clearly defined role(s).......

ruralnurs · Dec 20, 2007

WOW!! You folks are all a wealth of knowedge and experience! I do work at a critical access hospital, it is 75 miles from any other health care. There are 3 health clinics in the area but they are all under the network of the hospital. Perhaps I may be better off looking at working in one of the clinics and not as an ER provider at this time.

Actually one of the things that may come up would be pressure from my DON. We have just enough nurses, no PRN staff and if we were "short" during a shift or had a sudden influx of patients I can see my DON saying that because I was there and can "pitch-in" the other nurses will be fine. Where this would get really hairy is that I am one of the very few RNs here that do OB (most are not trained in it) and if an OB came in and I was working as an APN and started to manage labor I could get in big trouble, that is really out of my scope (unless there were absolutely no MDs around and then it would fall under and emergent delivery).

As far as referral, I think being a critical access hospital does protect us. In the ER if a pt has a primary we always refer to him/her, if not sometimes the hospitalist agrees to see them, but again, there is little choice where we are.

This gives me lots to ask about. Our CEO is an RN and an Attourney so she may have some insight as to where we can actually go with this.

CraigB-RN, MSN, RN · Dec 20, 2007

I'm impressed, a CAH that has a hospitalist. Hmm having a CO that is and RN and a Lawyer could be a good thing or a bad thing. :)

Don't let the DON push you around. Make sure that your contract has clear deliniations of authority. In most CAH's you work for the Chief of Staff and not the DON even though your budget line iten for the ER is probably buried in the nursing budget.

Use your BON as a resource also. Check with them, they may have a better picture of how that stuff workd in your specific environment. Of course I'm sure you already have your own copy of the Nurse Practice Act and any other pert rules and regualtions. Check out the different associations, ie the state NP, and there is prob a CAH group in the state also. Is your hospital a VHA hospital. This association has lots of resources and lots of people from around the country that can help.

The world of Critical Access Hospital is like no other in health care. The cost based reimbursment means it has a whole different set of rules that are based on strange accounting practices that only accountants can understand. And then they are goverment accoutnants that are a different breed altogether. You need to keep that in mind when getting information from public sources like this. It's great for getting information that you can use as a startign point in your own research.

The other possible wrinke in things is, are the clinics "Rural Health Care Clinics" this is a specific CMS disgnation with rules like 50% of the coverage must be by midlevels and such.

Call aroud and talk to other APRN's who are woking in CAH's . Check the rural nursing folum here for possible leads.

Again good luck, and whatever you decide, have fun.

DaisyRN, ACNP · Dec 21, 2007

with regard for the time issue and working both as an apn and rn... i just gave up my prn er position because i just simply do not have time. my schedule is not too bad as an np, but in all honesty... i like not working all the time! *haha* go figure! it'd probably be different if i were working a job as an np that wasn't m-f 8-5... if i had a 12-hr shift position, where i worked 3-4 days/week... i might could pick up a few hours.

i thought i'd miss staff nursing... but ya know... i'm kinda liking the idea of growing into an "expert" in my area and concentrating on that. i'll never forget my nursing things... like riding a bicycle, i guess :) but i like the idea of incorporating that into my np career and moving forward. afterall, that is what i went to school to do, ya know? i think you might find once you start working as an apn that you may feel the same way.

it also helps that my md kinda reminds me of a nurse... its all in her approach to her patients. so, i still feel connected to my "inner nurse" when i'm seeing patients with/for her.

best wishes!!