How Much Should You Conform Your Employer's Practice Recommendations?

Medical practices and often the individual clinicians working within them have their own practice styles and personalities. Some clinics and hospital departments allow each individual clinician to diagnose, prescribe and manage a workflow very independently, aligned with individual preferences. Other practices, in contrast, are more standardized with the employer directing providers to practice aligned in things like prescribing habits and workflow management. In this setting, where do you draw the line when your practice preferences as a nurse practitioner differ from those of your employer?

Working in a practice that strives for standardization among the provider group can strike a chord with some nurse practitioners. While standardization can ensure a level of care quality and customer service in an organization, many NPs disagree with this structured practice environment. The NP may feel that their own style is superior or feel uncomfortable being asked to prescribe or treat patients in a way that the NP doesn't agree with. 

A few months ago, for example, one NP posted this on the MidlevelU message board: 

Hi All,

I’m a new ACNP with a small Cardiothoracic group. I have known the PAs for several years from working as a bedside nurse in ICU. They are wonderful people and heavily recruited me to join the group. Now that I have, I am trying to integrate myself without being a disruption to their flow. It’s been about 3 months and they have been very supportive. However, my training as an NP and experience as a nurse leads to subtle differences in thinking/practice. The problem I’m encountering is that they want me to completely conform to their way of thinking and practice down to where I sit and write notes. I have done everything they have asked of me- use their note templates, orders per expectations- all on me to do for sure.  I also ask questions constantly, and make it well known that I realize I have a lot to learn and want to safely practice. 

However, I am also quite independent and need a quiet space to work- hence my want to not always be in the office where it can become loud and distracting. I also like to be on the units when writing notes and orders so that I can collaborate with nursing and refer to  monitors, patients etc. Basically, I am trying to find my own way to practice while integrating myself, not disrupting the flow, but still be myself. This is proving to be quite difficult. 

Any advice appreciated. 

Thank you!

I thought this question deserved a blog post of its own as it is a pretty complex question. I've talked with a number of nurse practitioners who struggle with similar issues and also felt the strain when my own professional preferences differ from those of my employer. 

Based on my experience, this algorithm is an effective way to think through the dilemma: 

Step 1: Is this a clinical or an employment/management issue? 

Typically, practice styles differ in one of two ways, clinical vs employment issues. Clinical issues include things like what medications you prescribe, how much imaging you order compared to colleagues to make a diagnosis, and if you prescribe branded or generic medications. Employment issues tend to center around facotrs like patient volume, your workspace setup, and how support staff are managed. The first step to solving your practice issue is to decide if it falls more under the lines of a clinical or employment-related problem. 

Why? Clinical problems can usually be solved by looking up best practices from an objective outside clinical source like UpToDate. Employment problems are typically issues that relate to management skill and structure. There are fewer objective barometers with employment issues so these may require more thought/discussion with your employer. You may have to acquiesce more often when it comes to employment issues as these things are less likely to be 100% right or wrong. 

Step 2: Is the issue important?

Clinical issues that relate to patient safety, outcomes, and a patient's best interests (ex. cost of care) are ethical and important. If the issue you have with your employer's practice protocol negatively affects patient safety, you should not follow the norm and bring it up with your employer for further discussion. 

Employment issues are not as black-and-white. If you don't like or disagree with the managerial and employment norms in your practice, ask questions (in a respectful manner) about why these norms are in place to determine its importance and adaptability. You may find there's a solid reason things are done a specific way in your clinic or hospital, such as for billing purposes. If there's not a good reason, pick your battles. Working as a nurse practitioner is, well, a job. So, unless you own your own practice, sometimes you have to do things the way your boss wants them done. If you have ideas about improving management, efficiency etc., having an open conversation with your employer in a professional manner can be productive and beneficial for both parties. It's best to avoid being a squeaky wheel, but when important issues come up that are central to your efficacy as a NP, discussion is warranted. 

In thinking through practice issues, you might be surprised at how open your employer is to your thoughts and preferences. Or, you might find that things you agonize over aren't a big deal to your boss so it's okay to do things your way. On the other hand, seek to understand what factors into the decisions made in your practice and maintain an openness to modifying your practice style to fit with the rest of the group. You just might learn something new and develop fresh skills in the process. 

 

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