Nurse Practitioner – Hospital-based Setting

NP Need Evaluation

Establishing your presence as an nurse practitioner in a hospital-based setting involves careful evaluation of the needs of a specific inpatient service. When developing a new role, consider the following questions:

  1. Is there a NP already on that service? What are his or her responsibilities?
  2. What is the composition of the inpatient team? Attending, fellow, residents, medical students? Of them, who would you work with the most? Who would you be learning from?
  3. Are the physicians on this service familiar with PNPs?  Be prepared to educate other providers on NP scope of practice.
  4. Does the service interface with many areas of the hospital? If so, who are your key contacts in those areas? How would you be communicating with them?
  5. What does a typical day look like?
  6. How are/could be the NP responsibilities be unique compared to the residents or other physicians?
  7. Will the NP be billing for services?
  8. How much opportunity is there for teaching RN’s and families?
  9. What are the potential opportunities for professional growth?
  10. Are there opportunities to participate in research activities?
  11. Are there opportunities to provide formal educational offerings within the division? (e.g. journal club)
  12. Talk with other NP’s who work in a similar service in another hospital. What were their challenges? What would they recommend in starting a position?

Many inpatient services do have NP’s, but their roles greatly vary depending on the service. Although physicians who have worked with NP’s previously may have a better idea of what they think the role should look like versus a specialty service that has never had a NP, you can take responsibility over the long term of your role as a NP.  The following are some basic responsibilities:

Many times the NP is the continuity for the inpatient service. This is especially true for teaching hospitals with residents that rotate every 1-2 months. However, if a service also has a fellow, the NP and the fellow will most likely provide the continuity.

There may be specific patient populations within the service that you will be responsible for (i.e. complex, chronic patients or discharges).

Rounds are an important time to not only learn from the attendings, but also to discuss plans of care with patients and families. Determine the structure of the team rounds and the best way for you to contribute to rounds.

Discharging patients home from the hospital is a complex process. NPs are uniquely positioned to be instrumental in the patient discharge process. What is the discharge process? What are the expectations of the hospital for discharges? How is this communicated and documented to families? Who performs discharge documentation? Who makes the follow-up appointments/referrals? What are the available support services? Case management, social work, PT/OT, nutrition.

With a busy inpatient service, there will be times where you need to communicate to the chief resident/fellow/attending. How is this best accomplished?

Education of families is paramount to the NP role. This can be difficult for an NP in an inpatient service, so you want to know who to best delegate to and allow time for this.

One of the biggest difficulties for an inpatient NP is clearly delineating your role from that of the intern. You don’t want to be considered a “permatern” where the team thinks you are just another resident. Clearly define your role and how that will differ from your peers.

Will you be responsible for any procedures? How are you trained? How is this documented and how will procedural competence be maintained? How many procedures per year are required for competence? Who will oversee your procedures until you demonstrate competence?

Career growth is an important part of an inpatient NP role. Ask about opportunities to present at local and national conferences; to participate in research; and participate as a member on hospital-wide committees, or the hospital advanced practice council.

Leadership in your role will always be important. Who will be your advocates? Is there a MD lead, lead NP, director of professional practice, director of advanced practice?

Some inpatient NP’s may also have outpatient responsibilities such as running an NP clinic, triaging calls from the outside providers, or refilling prescriptions. It’s important to know how your time will be divided and if some of those responsibilities could be performed by a nurse or nurse coordinator.

Think in terms of team dynamics, does everyone on the team know your role? Do you take responsibility for communication to patients, families, physicians, and nursing staff? What do you want to communicate, how do you communicate, are you professional, what should that look like/ The more you own your career and thus what you communicate, the more others will respect you, recommend you, and think of you when they have a job or opportunity.

Once you have done your research and begin to have some of your questions answered, you will need to create a document outlining your roles and responsibilities. Shadow other NPs in as many areas of the hospital that you will interact with (e.g. radiology, emergency department) and learn from other inpatient NP’s.  Keep a procedure log and continue to set up regular meetings with your physician supervisor to evaluate the role and discuss any needed changes.