From Bedside Nurse ➡️ NP Student: Looking For A Job

When looking for a nurse practitioner job, you have to ensure you are looking for a position that suits your individual needs. Are you looking for a position with a ton of autonomy where you update a physician in a summary layout, with generalized updates over several patients? Or are you looking to work with a physician directly with each and every patient encounter? Each position provides a different level of responsibility, yet each opportunity is available to nurse practitioners. When looking for a nurse practitioner position, you have to ensure you obtain information on the environment, compensation, teamwork, metrics, and shiftwork. As a nurse practitioner, you are a part of a larger team, and you must ensure you have the proper support to provide high-quality care. You are transitioning from student to provider, do not take this lightly. You have to ensure to have all the information in order to make an informed decision.

Environment

When seeking employment, there are various environments you, as a nurse practitioner student, can seek to work within. From office to hospital to clinic, there are multiple settings you can work in. The goal is for you to find an environment that works best for your professional needs. Are you over the hospital setting and want more of an outpatient setting? Or are you working at a doctor's office and seeking to enter the hospital setting? It all comes down to preferences and needs. Ask yourself, "Will this setting be something I can successfully work within in 2-4 years?" Everything in life changes over time. But the setting, the structure of employment... well, that's solidified and concrete. If you have an issue with the environment from the beginning, you are going to have a difficult time. I love critical care, but I got burned out and went into outpatient. I enjoyed outpatient but ultimately went back to critical care because I missed the hospital setting. It doesn't matter how much money you make if you are missing something your current position can't provide.

Sample questions: 

• Would I be in the hospital only or would I also have hours in the clinic?
• Is there a certain amount of time or days I would need to be in a certain setting?
• Is the expectation that I present every patient to the physician? What is the process?

Compensation

When looking for a job, it's best to put many feelers out in order to get in touch with the market and find out the general pay range for your area. If you don't feel like going on several interviews, join a Facebook group about nurse practitioner students seeking employment and find out what other organizations are paying for similar positions. I had no idea where to start compensation-wise. It wasn't until I joined a Facebook group for students that I found out where to start. The goal here is to find out what to ask for because when you are asked the golden pay question, you want to ensure your number is competitive. If your number is too low, you won't recover, ever! No amount of bonuses or incentives will ever allow you to catch up to your counterparts if you start at the bottom. Time is not on your side when it comes to compensation. You have to negotiate and be purposeful in your pitch. You aren't begging for a job here. You went to school, worked your butt off, and now it's time to show just how awesome you are. I know, you want to start your first nurse practitioner job as soon as possible. But, don't allow your eagerness to trap you into a low-paying job you will later regret. Trust me, there are many organizations and businesses looking to take advantage of a nurse practitioner student looking for his or her first job. The hours are long and the patient workloads are heavy. Make sure you are compensated appropriately.

Sample questions:

• Does this organization provide bonuses or incentives for productivity?
• Is the salary determined by years of experience or another metric/scale?
• Is overtime paid out on the following pay period or at another time?

Teamwork

In terms of healthcare, work is a team effort. You have to find out what your team consists of. Will you be working with nurses, medical assistants, office managers, etc.? What does the workflow consist of where you want to work? This section is often ignored. It's not interesting or sexy and depends on you asking a series of boring questions. But, if left unanswered, can lead to your being overwhelmed in the daily tasks of general patient care. Are you expected to simply see your patients, enter orders and write notes? Or are you doing the check-in process and vital sign procurement? Don't laugh. I know many of providers who do EVERYTHING because the setting is lacking the general team. Less people mean less money, and we all know how organizations love to save money. Some places push responsibilities unto providers and boom, you're taking time to check in patients and you haven't even started the visit yet. That wouldn't matter if you didn't have to see a certain number of patients daily but most places have metrics they want you to meet. Lacking a team will cost you time and it's good to know that up front.

Sample questions:

• Does the organization provide support in the form of medical assistants or nurses?
• If there is an issue, who would I be reporting to? Can I see an organizational chart?
• What is the process regarding electronic inboxes? Is there a required response time?

Metrics

No one talks about the metrics when you are in school. You just learn about them once you start working. Most organizations expect you to see a certain amount of patients daily. Being productive means the organization is productive and utilizing its assets appropriately, and that asset is you. We all want to help people and work towards their well-being. But let's not kid ourselves here. This is a business, and these organizations treat it as such. When looking for a job, you have to ask what metrics will you be evaluated on. Some places not only have a number of patients you need to see, there is also billing and coding requirements. Some organizations might want you to have teaching hours, while others might want you to have volunteering hours. Each place will be different, but there will be a scorecard you will be judged on, and you want to make sure you are okay with that level of critique. Nowadays, organizations are looking for well-rounded employees, so they are looking for more than mere patient encounters. Asking these questions up front allows you to see what is important to your prospective employer.

Sample questions:

• How many daily patient encounters will be required? Is it daily or based on AM/PM clinics times?
• Is there a difference in new patients versus established patients required encounters?
• Would there be a requirement for training, teaching, lecturing, and/or volunteering hours?

Shiftwork

I've worked day shift only, night shift only, and a hybrid of the two. And let me tell you something, it can make or break a job. It doesn't matter how much money you are getting paid. If you can't physically do the shift or it doesn't work for your lifestyle, it's not going to work. You must ask about this as most places love to tell you what something "should" be. Oh, this should be most nights or this position is mostly days. Don't accept vague answers. We are looking for specifics here. I have three children with special needs. I must know a work schedule on a granular level in order to see if it's going to work for me and my family. This sounds like a stupid thing to ask, but you will be surprised by what you find out by merely asking about the start and end times of a position. Not every office opens at eight in the morning. Not every hospital shift is twelve hours long. You can't assume anything, and don't allow someone to make you look like a fool for asking. This search is for a prospective job, a new relationship if you will, and all questions are appropriate and necessary. 

Sample questions:

• Is there a certain amount of night shifts that are required per month? 
• Are there on-call hours and if so, are they a weekly or monthly requirement?
• Would I be alternating with one individual's schedule or is there more than one person?

BONUS LEVEL: Contract

Please, please, for the love of Florence Nightingale, read the contract multiple times and ensure everything that was discussed has been included in the contract. So often, we are so desperate for a job that we sign and overlook general documentation. Treat the contract like a document at your nursing job. Read, review and verify all the things. And remember, if it is not documented, it did not happen. You won't be able to re-do this part of the process if something isn't included or mentioned. You will be bound to this contract for several years and don't get me started on non-competes. DO NOT sign a non-compete. Ever! The job market initially seems vast. Then you start working and realize your community is small and non-competes block you from getting general employment. If you can help it, do not sign one. You never want to think about leaving a company but when it's time, you don't want any legal barriers. 

From Bedside Nurse ➡️ NP Student: When To Apply For A Job?

When I was looking for a job as a nursing school student, I did so without passing the NCLEX-RN yet. When I was looking for a job as a nurse practitioner student, I did so without passing the acute care or family nurse practitioner boards yet. Students looking for employment should start looking right around the time of the graduation ceremony but before completing state licensure exams. I know it's a weird time, but many organizations hire before licensure is required on a contingency basis. And if you are working in a tiny market, there might only be one of two positions for the entire graduating class. It is best to start early and get those applications out there. When I graduated, about five others and I were looking for the same jobs locally. It seemed like a small group, but no place would simultaneously hire five new nurse practitioners. At least get there early, so you have a fighting chance. Yes, you will have the stressor of needing to pass boards on the first try. But that is a good pressure to have. You will already have a job lined up and waiting for you.

Critical Care Nurse Practitioner: Night Rounds Note

This is the night progress note I write when I conduct nightly ICU rounds. This format keeps me aware of all the highlights and things going on with the patients. This quick note also allows me the ability to track any concerns and document any problems that occur.

Critical Care Nurse Practitioner: Rounding Sheet Template

I've been an acute nurse practitioner for a few years now, and being organized is how I don't go crazy juggling 294 things at once. Below, you will find the cheat sheet I use to track the goings-on of the patients I'm caring for. I dislike walking around with tons of papers and opted for one sheet format. It keeps on aware of all the little details, so I make decisions with all the background and context needed to make the right choice.

Click Here To Download

Critical Care Nurse Practitioner: History & Physical Note Example

Note writing is something I had minimal training on while in my graduate nursing program. Yes, I knew disease processes and appropriate interventions. But, when it came to assembling, formulating, and getting those thoughts on paper professionally - I wasn't prepared. I had to intentionally request that my employer educate and train me on this process. Note writing is not merely writing what occurred, without format, intention, and purpose. Specific items must be included in the note for billing purposes. As an advocate for your organization and your patient, you want to make sure your group receives the appropriate compensation for services rendered and that you meet all the medical requirements on your patient's behalf. 

As a critical care nurse practitioner, my notes include everything and anything related to my patient. I take the time to sit with the patient (and their loved ones) and let them tell me what happened. I don't know what is important until I hear it. So I just listen. I write the full story and my notes are broken down by body systems. Note writing requirements differ depending on what specialty you work for. Some providers write notes based on problems only. The top two options are body systems (e.g., neurological, pulmonary, cardiovascular, etc.) vs problem-based (e.g., DKA, SIRS, acute respiratory failure) documentation, in my experience. An example of my body system based formatting will be below. 

Seems crazy long, huh? I have a template, it takes me 10-25 minutes. I do this 2-5 times per shift (on night shift), depending on how many admissions and consults I receive. I also use M*Modal verbal transcription too, which makes it even faster. Now, each organization and specialty is different. What works for me might not work for you or your organization's needs. Always ask your employer was is needed. For example, when I worked on a cardiothoracic surgery service line, and the surgeons required a 10- to 13-point review of systems for all consultations. Any fewer and proper reimbursement couldn't be achieved. Even if you think you know, ask anyway. Now, these notes don't include my current ICU patients, who can range from 16-28 individuals that require monitoring, prompt follow-through and efficient management. Meaning, I can't spend an hour writing a note. The goal is proficiency and timeliness.

Note: This is an example - not factual, not an actual patient, not an actual experience. Don't expect to diagnose anything with the information below. They are just words in a somewhat cohesive order (haha) to show my formatting. Don't overthink it.

History of Present Illness

Due to clinical condition, HPI obtained from patient's wife, medical records and medical staff

Patient is a 50-year-old male, with PMHx of CAD s/p PCI (DES to mid LCX, mid LAD), severe AS (s/p aortic valvuloplasty), PAF (s/p ablation), NICMO, HFrEF (EF 20-25% as of 04/2020), HTN, CKD stage 3B/4 (baseline creatinine 2.2-2.4), COPD (2L oxygen dependence) and IDDM2, who presented to the ED (via EMS) post-cardiac arrest. The patient had initial complaints of dyspnea and SOB (at rest) x 24 hours (while on 2L N/C oxygen at home). The patient's wife called 911 for support. En route with EMS, the patient went into PEA. CPR was performed and epinephrine IVP x2 was administered with ROSC achieved en route (total time was 8 minutes). CXR upon arrival revealed multifocal pneumonia with moderate BL pleural effusions. In the ED, the patient received cefepime, vancomycin and lasix 120 mg. Upon ED arrival, the patient did not withdrawal to pain and did not follow commands. Therapeutic hypothermia protocol initiated.

Upon ED assessment: GCS 6, patient VSS (on vent - CMV 24/500/8/50%), does not follow commands, does not withdrawal to pain, in no acute distress. The patient to be admitted to ICU for further monitoring and management of care. 

*Home medications unknown at this time, wife will bring list tomorrow.

Review of Systems

Unable to obtain d/t clinical condition

Histories

Information obtained from patient's wife and medical records

Past surgical history: PCI x 2 (DES), valvuloplasty, ablation

Pertinent family history: Noncontributory

Living situation: Lives at home, with wife

Tobacco use: Never, denies 

Alcohol use: Seldom, socially 

Illicit drug use: Denies

Assessment

Cardiac arrest, PEA-ROSC (8 minutes)

    Respiratory vs. CHF etiology

Encephalopathy s/p ROSC

Multifocal pneumonia, POA

Bilateral pulmonary effusions

AKI on CKD

    CKD stage 3B/4

    Baseline creatinine 2.2-2.4

Hyperglycemia 

Leukocytosis 

Gray zone troponin 

Elevated proBNP 

Elevated procalcitonin 

HTN, chronic

CAD, chronic 

    DES - LCX, mid LAD

HFrEF (EF 20-25%), chronic

NICMO, chronic

COPD, chronic

IDDM2, chronic

Severe AS, chronic

    S/p aortic valvuloplasty 

Plan

Neurological

-Neurological assessments per unit protocol

-Pain & sedation infusions

    RASS Goal -1 to -2

-PT / OT / Speech evaluations ordered

-CT Head results noted:

    No evidence of acute intracranial abnormalities.

-Therapeutic hypothermic protocol initiated

-EEG / MRI once off sedation / rewarmed

-Neurology consulted

Cardiovascular

-Arterial line / CVC inserted

-Maintain SBP > 90 < 160 & MAP > 65

-Flotrac monitoring 

    Hemodynamics q4hr

-12 Lead EKG q8hr

-Lactic acid q6hr

-ECHO

-BLE Doppler

-Serial troponins

-Cardiology consulted

Pulmonary

-IPPV, wean as tolerated

-Maintain O2 sat > / = 92%

-Scheduled BD / ICS

-Lung protective strategies

-CXR & ABG in AM

-CXR results noted:

    Mixed interstitial and alveolar airspace opacities throughout the lungs.

    Multifocal pneumonia with bilateral moderate pleural effusions. Cardiomegaly.

Gastrointestinal / Nutrition

-NPO

-OGT to LIS

-Nutrition consulted

    Tube feeding mgmt

Renal

-Strict I & O

-Monitor UOP

-Trend BUN/Cret

-Monitor / replace electrolytes

-Nephrology consulted

Infectious Disease

-Monitor C&S / fever curve / WBC

-Respiratory PCR

-Empiric antibiotics (Cefepime / Vanco)

-Procalcitonin level

-Pan Cx

Endocrine

-Insulin gtt, per protocol

-Goal BG < 180 

Prophylaxis

GI: Pepcid

VTE: Heparin SQ

DISPO: ADMIT TO ICU

CODE STATUS: FULL CODE

----------------------

Patient admitted to ICU for close monitoring due to their critical illness

Plan of care discussed with RN, RT, attending MD (Dr. John Smith)

Time includes personal review of any labs, microbiology results, EKG tracings, and/or imaging studies.

CCT: 35 minutes

From Bedside Nurse ➡️ NP Student: Credentialing Process

Someone took a chance on me and hired me. Wow, my first ARNP gig! I am beyond excited to start. I wanted to explain the credentialing process because I was unaware of what was involved and I grossly underestimated the time frame needed to verify my information. Now, each state is different, but all government agencies require this type of professional verification. The credentialing process involves the confirmation of an applicant's education, eligibility, licensure, certifications, risk potential, and professional references. Credentialing is the practice hospitals use to evaluate and verify the qualifications of their healthcare providers to ensure that each individual practitioner possesses the necessary qualifications to provide medical services to their respective patients. Once a practitioner is credentialed, the hospital will take further steps to assess the practitioner’s competence in a specific area of patient care, through a process known as privileging.

The time frame of credentialing can range from 30 - 200 days, depending on the institutional processes and how prompt you are at providing the required documentation. It's a long process and will involve you speaking to multiple people and being on top of things. I recommend anyone who is starting this process to check your inbox often and check with your medical office contact frequently to make sure you are on your way to heading to orientation in a reasonable timeframe. Because often, hospital committees meet only certain times per month. So if your paperwork isn't completed and in before the meeting documentation deadline, you will have to wait until the next meeting for consideration and approval.

Oh, and oftentimes you have to come out of pocket money-wise for the verification process, but you will be reimbursed after you're approved. Weird, I know. But do you expect a company to do all this legwork, pay multiple companies to verify your information, to then find out you're under house arrest after investing $250 in getting you credentialed? I know, it's annoying but make sure you ask this upfront. Some places cover this upfront cost for you, but just make sure you ask.

Your employer's medical office will usually manage all the verifications and document processing for you. Don't do any of this on your own. I broke down my verification process for information purposes only. Your employer will have procedures for obtaining this information. The only thing you have to independently obtain is your NPI Number. The rest will be done for you, usually.

What did my credentialing process include?

1. Copy of Master's of Science degree in Nursing (MSN)

2. Copy of college transcript for Master's of Science degree in Nursing (MSN)

3. Apply (it's free) and obtain CMS National Provider Identification (NPI) Number

• The NPI is a Health Insurance Portability & Accountability Act (HIPAA) standard. It is a 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services
• https://npiregistry.cms.hhs.gov

4. Verification: National Practitioner Data Bank (NPDB) Screening

• Information on medical malpractice payments and certain adverse actions related to health care practitioners and providers
• https://www.npdb.hrsa.gov

5. Verification: Office of the Inspector General (OIG) Background Check

• Individuals on the List of Excluded Individuals and Entities are barred from participating in federal health care plans. Hiring these individuals may result in civil monetary penalties as well as loss of reimbursement
• https://exclusions.oig.hhs.gov

6. Verification: System for Award Management (SAM) Screening

• Screening against SAM Exclusions is essential for companies that hold Federal contracts and need to screen subcontractors that will work on the federal contract, as well as any company associated with federal assistance
• https://dev.sam.gov/index.html

7. Verification & Audit: Malpractice Insurance Records

• During your nurse practitioner program (college insurance coverage information - for all years of attendance) 

8. Verification: ARNP Certification  - AANP / ANCC

9. Verification: Other Certifications - CCRN / CMC / CVRN / FCCS

10. Verification: Course Provider Cards - BLS / ACLS / PALS / NRP

11. Professional References - ARNPs / MDs /DOs only (at least three, active in roles)

12. Verification: Department of Health - State Nursing Licensure

13. DEA Registration (if applicable to position) - https://bit.ly/2BNXFCi

14. Collaborative Practice Agreement (required) - https://bit.ly/2QzGBID 

A mutual agreement between the physician(s) and the ARNP

Collaborative Practice Agreement, must include...

     A. A description of the duties of the ARNP
     B. A description of the duties of the physician
     C. The management areas for which the ARNP is responsible, including:
          1. The conditions for which therapies may be initiated
          2. The treatments that may be initiated by the ARNP
          3. The drug therapies that the ARNP may prescribe, initiate, monitor, alter or order
     D. A provision for annual review by the parties
     E. Conditions and a procedure for identifying conditions that require direct evaluation

Disclaimer: I work in Florida, this is my experience. Your process could be slightly different.

From Bedside Nurse ➡️ NP Student: ANCC FNP Exam Results

So, I freaking passed! And I'm beyond excited. What resources did I end up using...

• BoardVitals Practice Questions: https://www.boardvitals.com (Best Questions)
• I did 464 practice questions, it really helped me prepare & think on an NP level
• Barkley Family NP Home Study Package: https://bit.ly/2obk8l7 (Short & Sweet)
• Leik's FNP Certification Review Book: https://amzn.to/2o9unX6 (Extended Review)
• Included 700+ practice questions, I did them all (great mobile app!)

From Bedside Nurse ➡️ NP Student: ANCC AGACNP Exam Results

So, I freaking passed! And I'm beyond excited. What resources did I end up using...

• ANCC Adult-Gerontology Acute Care PracticeIQ Questions: https://bit.ly/2tfn82X
• Barkley Adult-Gerontology Acute Care NP Home Study Package: https://bit.ly/2ysEZbN
• Barkley 100-Item Diagnostic Readiness Tests (DRTs): https://bit.ly/2MHtO1O
• The BEST Facebook Group: https://www.facebook.com/groups/231576733976379

The Facebook group really offered wonderful advice and had an amazing study guide! READ the study guide. R-E-A-D IT!

• The Boards Study Guide (it is FREE): https://bit.ly/2JVjbek 

From Bedside Nurse ➡️ NP Student: Barkley Home Study Packages

Alright, it's now to start studying for nurse practitioner boards. My school (University of South Alabama) made every student purchase the family nurse practitioner and adult-gerontology acute care nurse practitioner home study programs from Barkley & Associates. I'm grateful they did because now I can use this material to study for boards and not spend any more money. The goal is to take the adult-gerontology acute care exam first, then the family exam soon after. I own both home study programs and will be using Barkley exclusively for the acute care exam. There are tons of family exam resources out there, but acute care apparently didn't get the same love. I like the home study option because ain't nobody got time to be traveling across the globe for a 2-day course. Don't get me wrong. I take studying very seriously. But, I also have a full-time job and a special needs child. I can't be globetrotting. Luckily, I don't have to. The audio CDs are of the entire presentation that is given live. There isn't a need to travel unless you want to network or you absorb information better in a classroom setting. I personally study better alone, so the home study option was perfect.

• Family NP Home Study Package: http://www.npcourses.com/fnp-home-study
• Adult-Gerontology Acute Care NP Home Study Package: http://www.npcourses.com/agacnp-home-study

The best part of the program are the audio CDs. I downloaded all the content to my Apple iTunes program and created a playlist. Now, I can take the content wherever my phone goes. Hearing someone explain a topic over and over helps things stick. I can write something down four times or listen to it twice, and the audio content seems to absorb deeper and last longer. The manual provided keeps you on track and has sections for note taking. One significant piece of awesomeness is the fact that when you highlight in the book, the words don't smudge. You have no idea how much that annoys me. If I'm going to spend $300-$400 on something, I BETTER get a notebook and the words BETTER not smudge, haha. The cost of the home programs is currently $449.50 + shipping cost. But there are tons, I'm talking tons of codes online and on Facebook. Look around, search online. I saved myself $100 by finding a code on Facebook.

I choose this program because I was already familiar with the layout (because I used it during my graduate program) and I already owned it. But, I know of other graduates who used this program (and didn't have to buy it for school) and were successful. I trust the Barkley program based on the many recommendations I've received and it's home study option. So, here I go. Let's do this!