Transcript: Understanding New Grad Nurse Practitioner Job Offers

​Liz Rohr:
I just have to share personally that I didn't know what I was doing either when I was a new grad, when I was finding a job. I was like, "I just want a job. Somebody please hire me." And so I was very, very lucky that I did not end up in that situation because it very could have easily happened to me too.

Well hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

In this week's episode, I'm going to be talking to you about job offers as a nurse practitioner. I think it's really important to talk about this. I love talking about the clinical stuff, and I love talking about the role transition like leadership and boundaries and all of that stuff, and I think it's also important to talk about these real-world topics of what it's like in the real world once you get out there. We sort of talk about some of the things in school, but a lot of it you have to learn after the fact. So this is one of those topics and I do want to give the disclaimer that I am not an expert and that I can only share from my experience and what I've seen. And then the other thing is that, this is such a broad-ranging thing of knowledge and skills to really navigate the career pathway in a savvy way, that there are people who have tons and tons of resources to help you with these topics. And I'll link to a number of them down below.

But specifically, I do want to name my friend, Amanda Guarnieri, who has the company called The Resume Rx. She has so many resources to help with the job search, finding it, negotiating contracts, all of the things. But I do want to give an overview and there's two things I want to share before we get into it. So one, this came about because I was sharing on Instagram, I was on stories, I mentioned something about administrative time or admin time and somebody sent me a DM and said, "What is admin time?" And so I was like, "Okay, I want to make sure that we're all on the same page about this." Because the other thing that occurred to me is that sometimes, I'm so in my own knowledge that I'm like, "People know what I know," or people know a lot.

It's hard to remember what people know and what they don't know. But then I'm reminded again with questions like that and I'm also reminded for the second reason of making this episode is that, in forums online for nurse practitioners, I will see people and I've also worked with mentees in real life where this has happened, where somebody has taken a job, it's taken them forever to find a job. They take the first thing that comes to them because they're so grateful to have a job and they just didn't really know what they were doing. And they've kind of gotten themselves into this situation where it's either really toxic, there's no support, it feels dangerous to practice there and they're about to leave their job after a couple of weeks or months and they're just really regretting it. And I just have to share personally that I didn't know what I was doing either when I was a new grad, when I was finding a job. I was like, "I just want a job. Somebody please hire me."

I was very, very lucky that I did not end up in that situation because it very could have easily happened to me too. I just want to share that from a very humble perspective of like, I'm just trying to help. If you're in that situation, just lots of self-forgiveness. You didn't know. Anyway, let's talk about some job offers of things to watch out for because this is such a pet peeve of mine and Amanda's not from a judgmental place. We're not judging the people in that position, but we feel very heartbroken for people in those positions because it's so sad to go from really high hopes and enthusiasm and excitement about being an NP to being kind of dropped into a really bad situation, and it happens so often. So hopefully, this can help. Anyway, let's jump in.

Let's talk about offers. There's a couple of differences between getting a job as a nurse and getting a job as a nurse practitioner. This is how it went for me and probably was similar for you or maybe if you're thinking about finding a nursing job and you're in NP school or you're in nursing school right now. When I got a job as a nurse, I went to job boards. I looked to see who is hiring. I applied to a whole bunch of them. I went for an interview, I went for a couple of interviews. They were like, "Hey, here's a job offer. Here's your hourly rate. We're going to pay you because everyone at your level gets this amount and when you get to this level of experience, you get this amount. That's it. You get paid time off, you get vacation, sick time, 401(k), maybe," blah blah blah.

That's typically how that works. And in the job searching process, I was like, "I'm trying to vet this unit to see if it's a good cultural fit. Are they supportive? What's the orientation process like?" There were a couple of other questions I thought about, but that was kind of contained. That was pretty much it. When I became an NP, there's like all these other things to think about and just bottom line, if you can take one thing away from this episode, it is not about the salary, it is not all about the salary. Salaries are amazing and they're really important to get a good, healthy, wonderful, fulfilling salary. And also think about all the other things in addition. So hold that thought. First things first is when you find a job, typically, you can find jobs on job boards. However, you may more likely have to do a lot of backend type of networking, connecting, cold calling to find a job for you.

That's how it's always happened for me, pretty much in every job that I've gotten or any lead, any interview I've gotten because I've only had two NP jobs. But that's a little bit more involved. And again, those resources that I mentioned talk a lot about that too, so that might be the way that you actually find a job instead of a job board. The second thing is that when it comes to an actual offer, there are a number of things to consider. One, you get a salary instead of an hourly rate, typically. And again, this is not legal advice, I'm not an expert, I'm just kind of sharing from experience. Typically, you get an annual salary. Great. It is what it is. The next thing, the most important thing to think about though is when you're looking at this offer, whether or not you have a contract, you may or may not have one, please seek out legal advice if you are getting a contract.

But the next thing to think about is clinical time versus administrative time. Clinical time is typically how it's referred to, is the time that you spend face to face working with patients on a schedule in clinic. Obviously, you can do things in between patient visits like all the paperwork and stuff like that. But that's pretty much what that means. You're on site, seeing patients or doing telemedicine from home, whatever. Administrative time is something that not everybody gets and it's paid time. Operative word here is paid. I might want to say that 3000 more times but it is paid time where you get to do non-patient facing care for your patients. So finishing your office notes, reviewing lab results, reviewing imaging results, reviewing consult notes, patient phone calls, responding to messages, medication refills, prior authorization paperwork, all the other random paperwork that we do in primary care, that is paid time, not seeing patients that you get to complete all of those items.

This is not standardized, this is really clinic to clinic. And there's a couple of reasons why it would be one or the other, but just hold that thought. I'm going to give you a couple examples. So for a full-time job, all of the ones that I interviewed for in the state of Massachusetts had, for a 40-hour position had 32... Actually, that's not true, not a hundred percent of them did, but most of them had 32 clinical hours, meaning eight hours per day, four days a week on site and then one full day, eight hours that was paid the same hourly rate to work from home and catch up on all that stuff. That is not the case everywhere. I did a very informal poll, that was very anecdotal research and about two thirds of people got four hours or less and four full-time hours.

And then about a third of people got eight hours or more. Why would it be one or the other? I want to talk about another piece next. Another thing to think about in your job offer is how many patients per day you are required to see? Is this included in your contract? Is it not included in your contract? And what that means is that how many patients are on your schedule in a given day? Are you absolutely going to be scheduled for 22 per day, 24 per day, 30 per day? Please tell me it's not going to be 30 per day. Please don't take a job as a new grad with 30 per day. That is too many. That is my opinion. How many are you going to see per day and do you have any rules about double booking, triple booking? Do you have a quota for the week?

If you haven't met your quota by Friday and you work Monday through Friday, are they going to stack your schedule to make sure you hit the patient numbers for the whole week? And that's one of the main considerations for determining administrative hours. My personal opinion is that everybody who works full-time hours should have 32 clinical hours and at least eight hours to go with it. That's the ratio. And if you go down to part-time, the ratio should stay the same of administrative time to part-time clinical hours. If somebody, for example, there's a lot of conversation on Instagram about this and so some people wrote in and were saying things like, "You know what, I actually only see 10 patients per day. I'm in a pediatric specialty, I see 10 patients per day and I don't have any admin time and it's perfect for me."

That's amazing. That's a really phenomenal reason not to have paid administrative time is that you have enough patients on your schedule that it doesn't feel overwhelming. Again, pediatric specialty tends to get more time. Specialists tend to get more time than primary care. Another unfortunate scenario though that I hear far too often is that new and experienced nurse practitioners will see 22, 24 plus patients per day and get zero administrative time. Unless you have a skyrocketed salary to match, that feels very unsustainable. I really want to caution you against that. I mean the numbers kind of change. I'm not really great with numbers off the top of my head, but for example, if you have a baseline salary, if you calculated your annual salary down to your hourly rate and you made about $50 an hour with your 32 clinical hours and your eight administrative hours, but the same person who had their straight 40 patient hours with zero administrative time, especially if they're seeing 20 plus patients per day, they also make $50 an hour.

You can see there, there's a value difference. It's the same amount of money, but the work being done is very different. That's why I keep saying it's not just about the salary, it's about the work conditions as well. Because if you change that hourly rate just to reflect your direct patient care time, your hourly rate is a lot higher if you see 32 clinical hours versus 40 full clinical hours per week. I think one last kind of bonus offer thing I want to throw in. This is not a complete comprehensive detailed guide to negotiating your offer, but I just want you to be aware of these things that are pretty standard to be included. Another bonus kind of one is about continuing education. Typically, clinicians will get both dedicated time off. So for example, in the past I've gotten 40 hours, in addition to my vacation and my sick time, 40 full hours a year, to dedicate to continuing education activities.

Whether I went to a conference, whether I did continuing education at home, I got paid for those days, five full work days. In addition, I also have gotten, and many people get this as well, is a budget to spend on continuing education activities because it is a requisite part of your job. We have to do it. My opinion is that we should all get this as part of our jobs. The amount that people get in terms of time and money varies widely as well. Which again, is one of the reasons why you want to think about. It's not just about the salary, it's about the whole compensation package and offer to look at. There are plenty of other things to think about for an offer. There's your kind of standard sick time, vacation time, do you have a 401(k), do you have disability?

Things like that. But those are kind of the three main differences is about how you get paid a salary, how many patients you see per day, and the amount of admin time versus clinical time. You can get a lot more fancy with this, a lot more detail, get a lot more strategy involved. And again, this is why I am not the expert specialist in this field. I do have two resources. One again is Amanda Guarnieri, has the whole gamut from creating your resume all the way through the job offer and career fulfillment, to Monica Carter is a friend of mine as well, and she has a course specifically dedicated to contract negotiation called the Compensation Course. I'll link both of those down below and hopefully, those can be helpful too. But I guess my moral of the story is just please, please do your homework when it comes to thinking about what type of offers you might see, how to negotiate for them.

You don't have to get a specific training; I didn't, I just kind of practiced haggling and it worked out well. But if you don't know what you're getting into, you won't know what to ask for. You won't know what to look for. One bonus thing to think about is productivity. I didn't mention this when it came to patient visits, but a lot of times, especially if you have a written contract, is something about do you get extra money depending on something called RVUs, which is a calculation based on how many patients you see and how sick they are according to the billing codes mixed together. And you can get statistics of how complicated the patients you're seeing are. So if you see more complicated patients all the time, you get more money from the company. And then the other thing is, how many patients do you see per week, per month, per year?

And there can be productivity bonuses for seeing more patients. That's all I'm going to say about that. Again, I'm not the expert and I really rely on those two people that I mentioned, for their guidance and their resources, to help me in those processes. So hopefully this is a helpful introduction though. And I'm happy to do kind of more overview videos or episodes about career-related stuff. Again, overview is the emphasis here because I really want to stress that there is a lot to know and learn to make sure you're really setting yourself up for success. Thank you so much for tuning in.

If you haven't grabbed the Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else.

Thank you so much and I'll talk to you soon.