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Choosing an NP practice setting can be one of the most important and challenging decisions of a nurse practitioner’s career. There are multiple pitfalls. Most of which no one tells you about in NP school.
Some things to watch out for are not only if you’re going to be challenged and supported as you transition to practice. But, also if you are looked upon as a valuable colleague and member of the team.
In my opinion, one of the biggest mistakes new nurse practitioners make is not doing enough research ahead of time. The second is not completing some soul searching before you take the job. In this post, we’ll explore a variety of NP practice settings and rationales for why each setting may or may not be a good fit for you.
I’ve personally worked in all of these settings and can provide honest and professional insight to help guide your journey. Let’s dive in.
Pro Tip: Don’t just consider salary.
General recommendations before you choose your NP practice setting
1. Take an honest assessment of your strengths, weaknesses, and where you are in your career. Before you start the job search take into account your preferences. For example, if you’re not a night person, don’t include night shifts in your search. Do you prefer outpatient to inpatient practice?
Make sure you align your NP clinical track with the posted job description and patient population being served. If you’re a new NP, perhaps an isolated practice setting such as a retail clinic is not ideal.
2. Make a list of what you want to accomplish during your employment at the site. What priorities are important to you? Do you want an opportunity to suture? To interpret imaging? To participate in research? Take inventory as to the breakdown of clinic responsibilities, research, and administrative time. If a practice setting doesn’t allow administrative time, then that’s a red flag.
A few thoughts on administrative time
You’ll need time to return patient calls and messages, review labs, diagnostics, and charts. Time will need to be allotted to prepare for clinic and complete your documentation. Be sure to skim job descriptions for these details. If they are not posted, then ask during the interview process.
You don’t want to be waylaid at work long after the clinic day has ended completing all these tasks because your clinical calendar is fully booked from the time you arrive to the time you leave for the day. Keep in mind that the majority of the time, you’re not going to leave work on time anyway.
3. If a practice setting doesn’t have a health insurance plan, skip it. During the interview process, be sure to ask what type of health insurance is provided. I’ve actually had an NP job that did not have any type of health insurance or subsidy for health insurance.
The rationale provided was that the physicians in the practice could treat and cover any ailments for myself and my immediate family. DO NOT take a job like this. You need healthcare insurance. Not to mention privacy concerns in the work place. If you were to be hospitalized for any acute illness or surgery, holy mackerel! Run for the hills, my friends.
4. Be sure to ask about essential practice certification allotments. Will the setting provide malpractice insurance and which type? Will it be paid for by your employer or will you need to cover your own malpractice insurance, licensure fees, and CME or continuing education? Will time away be allowed to attend relevant conferences?
All of these items are a necessity to keep your licenses and certifications up to date. If these items are not included, then these are potentially more red flags to be considered.
Various NP Practice Settings
1. Private Practice
Private practice is an independent practice setting led by an individual or group of individuals.
Pros– Collaborative practice with access to mentors. Private practice settings provide the opportunity to establish a mentee- mentor relationship with a physician colleague or even fellow advanced practice providers if the practice employs multiple APPs.
This can be extremely helpful in fostering the development of much needed assessment and diagnostic skills. Autonomy. Usually, private practice settings are searching for an advanced practice provider to operate with near-complete autonomy. You will usually have your own calendar and patient schedule.
Cons– Less ability to choose the types of patients and populations that you would like to see. Many times you may be coming on board a private practice setting that is well established. This means that you may have less ability to choose your patients, as you may be designated as an “overflow” provider. You’re at the mercy of the practice owners with regard to policies and procedures. Be very careful here. Not all practice owners are judicious and fair.
Unless of course, you’re the owner of the practice then you can establish your own standard operating procedures. Owning your practice right off the bat is not recommended if you’re a new grad. I’d recommend gaining at least 2 years of experience before moving on to your own practice.
2. Retail Clinics
Retail clinics are commonly located within or affiliated with a retail chain store such as pharmacies, grocery stores, or big box stores. Hence, the retail name. An example is CVS’s Minute Clinic. Unfortunately, these clinics have attained the deprecated slang term, doc-in-a- box. These clinics actually provide valuable and much needed services in that they provide timely and effective care.
Pros– Retail clinics typically treat a set number of conditions. This makes it easier to focus your assessment and diagnostics. They offer transparency with regard to fee for services and tests.
Autonomy. You’re completely the sole provider in this setting. You’re sometimes paired with a medical assistant. However, in some clinics, an assistant is not provided. Of note, retail clinics typically see patients aged 2 to end of life and employ family NPs. Keep that in mind if you’re thinking that you may want to work in this setting.
Cons– Autonomy. Set number of conditions treated. There are only so many upper respiratory infections you can treat. However, I did enjoy learning more about travel vaccines and preparation for travel safety overseas.
This may not be the ideal setting for a new grad since there is not a collaborative or collegial relationship. It’s best to gain at least 1 year of experience in a private practice setting before transitioning to a retail clinic. Retail clinics see an extraordinarily high number of patients each day. I recall seeing 44 to 56 patients in a 12 hour shift. They tend to be more business oriented as well. Therefore, it’s easy to burn out quickly.
3. Weight loss & management clinics
Weight loss clinics seemed to have come into vogue in the early 2000’s. I’m sure they’ve been around well before then, but I recall an explosion in locations around this timeframe. Essentially, the clinic is focused on weight loss management and optimizing functional medicine. Some other services include IV therapy such as hydration and nutrient administration.
Pros– Focused assessment and diagnosis with a bit of family medicine. There is satisfaction in seeing patients reach their goals. Opportunities for additional diagnoses and treatments pending initial consultation. Opportunities to learn more about and utilize naturopathic medicine.
Cons– Limited treatment options. This is a great setting, but there is potential to become “bored” so to speak since you’re primarily treating one condition and its subsets. It’s best if the weight management clinic also combines a bit of family medicine or primary care to keep you active and up to date with your assessment and diagnostic skills.
4. Medi-Spa
Medi-Spas provide aesthetic outpatient procedures.
Pros– Opportunities to learn about and complete a wide variety of procedures. Examples include Botox and fillers. The clinic may actually employ an aesthetician or aesthetic nurse that performs the majority of the procedures. But, they need an advanced practice provider to sign off on the initial consultation and to be present if any adverse reactions occur.
Cons– None really. This setting was fantastic. If you don’t like performing procedures or if you’re afraid of monitoring for adverse reactions to fillers and toxins then this may not be the right setting for you. Also, you’ll want to be sure that your malpractice insurance covers you, if you do perform any procedures and that you obtain whatever needed certification is needed to do so. Do not perform any procedures without verifying this with your malpractice insurance carrier.
5. Subspecialty outpatient hospital clinics
Subspecialty ambulatory hospital clinics cover a wide range of outpatient clinics. These can be highly specialized like bone marrow transplant, hematology & oncology, neurology, or neurosurgery. The clinics will also have a component of inpatient care as well such as on call duties.
Pros– Depending on your subspecialty you have an amazing opportunity to see pretty rare diseases and conditions. Your assessment skills will be maximized. However, many patients will come to you already with a primary diagnosis so your opportunity to compose differential diagnoses may be limited. There’s an opportunity to learn how to interpret imaging such as x-rays, MRI’s, and CT’s. Opportunities to suture and attend in the OR if you’re employed within a surgery clinic such as neurosurgery.
Cons– Limited autonomy. In this setting, you will usually see patients in tandem with a physician colleague. This can be a Pro, but also a Con if you prefer working independently. There’s very little to no control over your calendar or schedule.
6. Locum Tenens
Locum tenens roughly translated from Latin means “to hold a place”. So when you’re working in this capacity you’re completing a temporary assignment at a practice setting and holding the place of the resident provider while they are away.
Pros– Traveling to new sites. The best way to be eligible for all sorts of locum tenens positions is to choose the Family Nurse Practitioner Track in your NP school program. It’s a fact, if I had not chosen the FNP track, I wouldn’t have been able to visit the number and caliber of clinics that I did.
From pediatrics to family medicine to weight loss management to evening on call duties, all of these assignments saw such a myriad of patients that only a family or general practice provider could fit the mold. There’s total autonomy. Usually locum tenens positions are provided through a staffing agency that will cover your malpractice insurance. They do have a vetting process. But, once you’ve passed that stage you’re ready to go.
Cons – Total autonomy. I would not recommend a locums position for new grads. You just don’t know what you’re getting yourself into when you visit another clinic. I’d recommend at least 1 year of experience. Locums provide a great opportunity to check out other practice settings. You can spread your wings a bit and find out more of what you like and what you don’t.
Patients aren’t always aware that a replacement provider has been sent for the day, so you may spend a lot of your day explaining that you’re filling in on a temporary basis. If you do a good job, you may be asked to come back a second or third tenure. The longest locums assignment I had lasted approximately 3 months.
The Takeaways
There are several NP practice setting options available. The great thing about being a nurse practitioner or advanced practice provider is that you can have your pick of some really great options. Also, if an NP practice setting is not a good fit, then there are several others to choose from in the process.
Don’t let your excitement for finding your first NP job or even your second cloud your judgment. Be discerning and choose your setting wisely based on your preferences, where you are in the stage of your career, and the options available. I hope this post has been useful in guiding NPs to choose their practice setting. Do you have any advice for new grads or those looking for a change?