Is this experience typical for a new grad NP situation?

Specialties NP Nursing Q/A

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Specializes in Tele/Interventional/Non-Invasive Cardiology.
Is this experience typical for a new grad NP situation?

I am a new grad NP who took a job as a cardiology NP for a smaller, private practice. My background has been both inpatient and outpatient cardiology for the past 6 years. But obviously this is a new role to which I need to acclimate. I have been here for 5 weeks so far and I really have my misgivings LOL. Not sure if I am crazy, if my experience is the norm or whatever. But this just doesn't seem right. 

My first day, right as I walked in, I see mounds of papers on my desk. Patient studies, surgical clearances, device interrogation reports etc. The senior MA placed them there and said that the Dr. said to look them over. I have NEVER given surgical clearances. While I have given test results, the verbiage on these reports are vague and different. And I never really dealt with interrogation reports. And this is where it starts. 

From the second day, I have been seeing patients in clinic by myself, with little to no guidance or oversight. Yes, my supervising MD is there, but he is also the owner, so he does business related stuff during clinic. He also comes late and schedules patients before he gets there and I am expected to see them. Even when he is there, I am told how to what to do, but I have no training or instructional time to develop my clinical judgment. At some point, I will expected to make these decisions autonomously, so I need to know the "why?" 

Then I find out my credentialing for a local LTACH is complete and I am told I will start going there with another doctor in the practice. I get ONE afternoon and then I am told to go alone. These patients. are medically complex. The supervising MD is available by. phone, but not always right away. And when I do speak with him, his responses to me sound really condescending. Needless to say, of course, I've made a couple of mistakes like contradicting myself in a note and I missed an abnormal result on a study. 

I take ownership and I felt awful. Conversely, it is my opinion that like medical errors, there are user (individual) issues and systems issues. Basically I have not been given the adequate training, oversight, and guidance that I believe would lead to success. 

I am terrified to think that my hospital credentialing will be complete next month. My greatest fear is that I will be left to my own devices in the inpatient setting. which will lead to more serious errors.

Another big problem of mine is that I am not a good advocate for myself. I either am too timid or come off too aggressively. Any experienced NPs that can help to provide some insight? Is this experience typical for a new grad NP situation? Should I be able to handle this? If this isn't, how do I express my concerns. 

Any help is greatly appreciated! Thanks all! 

Signed, 

- Terrified New Grad NP ?

44 Answers

Specializes in ACNP-BC, Adult Critical Care, Cardiology.

I felt compelled to respond (after a long absence from this website) since I am working in Cardiology  for over a year now after transitioning from a Critical Care NP role which I did for over 15 years! Cardiology is a broad field with various subspecialties under it's larger umbrella so depending on the focus of the clinic or practice you joined, the learning curve could be steep.

Despite you working in Cardiology as a nurse prior, the transition to provider role and all the decision making involved won't be easy. It is obvious from your post that there is a disconnect between the expectations you are held to by the practice and the reality of you're unpreparedness to take on the responsibilities being given to you.

Typically, the interview process is where you establish those expectations and sometimes we must act confident to get the job offer. However, you now have to face the reality that given what you said on the post, you have a real risk of making mistakes that can cost your license. This is a no-brainer and if I were you, I would immediately seek a meeting with your Cardiologist to understand what your learning needs are and what responsibilities you can take on.

Good luck. For what it's worth, my transition from Critical Care to In-Patient Cardiology wasn't so bad because I had great support from the physicians I work with.

Specializes in ACNP-BC, Adult Critical Care, Cardiology.

I also want to add that sometimes physicians mis-use NP's and don't understand our role. The fact that someone piled a bunch of results on your desk to figure out is not a role for a provider. This is like being asked to answer messages from patients and triaging them without knowing the background of those patients. Even if you understand what those mean, it will take digging into the EMR to even figure out what the context was on those tests. I would have said hell no to that.

You need to do a fellowship ASAP. This is reality. Sure they did you dirty the first week but those 500 clinical hours are going to be put to the test and even a couple week of orientation isn't going to help much.

These places don't hire NPs to train them, they want production right away.

Compared to NP school my fellowship was 100x more productive for learning. I am nearly independent in my role but NP school did not prepare me for it. Structured residency education did.

Specializes in Emergency Medicine.

This doesn't sound like the best environment, and I agree that some physicians don't understand what we do, or anything about our scope. 

If you don't think someone there is willing to provide you adequate training and orientation, you may have to decide it's not the best fit. Don't stay somewhere that compromises your license.

Specializes in Emergency Medicine.

I get that you feel that way, but nothing is worth compromising your license. Nothing.

You might feel like there are no jobs available out there based on online listings, but the more you get out there and start networking the more you will realize that there are a lot of jobs available that are unlisted and open via "back door" entry. 

I really understand needing the job and desiring experience, but please know this is not your only option. Join your local NP association, attend meetings. Usually they announce positions there at meetings. Since you are newly out of school, you may still be in contact with old preceptors; contact them! 

usually, I would say give it time- because transition sucks. I know I'm in the middle of it myself but you should not be left to make these decisions on your own without being able to reach someone for consult, even another more seasoned NP. It's dangerous, for patients and you.

Think about it. Hang in there *hugs*

AlwaysTiredNP said:

This doesn't sound like the best environment, and I agree that some physicians don't understand what we do, or anything about our scope. 

If you don't think someone there is willing to provide you adequate training and orientation, you may have to decide it's not the best fit. Don't stay somewhere that compromises your license.

What do you consider adequate training? 2 weeks? 6 months??? The job expects her to come in and work as a provider. Did her school not provide that? NPs want to have their cake and eat it too (especially with independence). We need an education revamp so stuff like this doesn't happen.

55 minutes ago, CardiacRNLA said:

If medical school alone made physicians ready to be providers, there would be no need for residencies. And being an RN does not count. While being an RN brings some clinical judgment and medical knowledge, the role does emphasize diagnosis or higher level of clinical judgment. There’s a definite learning curve. 

it’s not an issue of length of training. I received NO training. And furthermore, I’m being held responsible for things I never did before. That’s fine if I am given guidance and feedback. I’m not looking for a lengthy or indefinite training. Is it too much to be able to ask my supervising physician questions? Am I allowed to expect feedback on my performance? 

I would caution you to not think that professional organizations speak for all nurses or NPs. As a new NP, I welcome guidance and oversight from a physician. However once I gain experience, I would expect a level of autonomy. 

So I’m sure what has you pressed? 

 

1. Problem is you willingly entered a profession focused on independence. This is well known to employers who want production right away, APPs are supposed to be cost-effective apparently. This is the truth whether you like it or not.

2. NP education is essentially a joke

3. Yes MDs have residencies that are govt funded and give incentives for hospitals to train them. The private sector cares little about training someone to be a provider who is licensed to act alone out of the gate. MDs do not know your training, they know you can dx and prescribe that's it.

4. Would 2 weeks be adequate? That is standard for any provider job. I am not quite sure what you are expecting. Yes asking questions from time to time is okay but you should know the role of a supervising doc is mostly administrative, that's reality. It's going to be on you otherwise. Not asking questions such as what antibiotic to order, when to send someone to the ER or when to be concerned about an imaging finding.

5. I am pressed because thousands upon thousands of nurses leave the bedside to flood into the NP/grad school realm and have no idea what they are doing. I am not talking about YOU but just in general. Schools lap this cash cow up and combine it with weak low quality online education (even in person is weak) and 500 BS hours of clinical which is a drop in the bucket when compared to med students even.

6. My hospital refuses to hire NPs anymore that are newish because the quality is that bad. I don't want MY profession to look bad. We need to return to the CRNA model where schools are in person, not part time BS and there are STANDARDS which are enforced.

1 hour ago, CardiacRNLA said:

Oh, I get it now. Your get off my lawn” attitude doesn’t help anyone. First I’ll have you know that there are many nurses (including myself) who went to “in person” programs. How completely ridiculous that you would believe that asking for feedback/guidance somehow = lack of knowledge or skill? But I’m sure you were perfect IMMEDIATELY after graduation (in your own mind). 

If you think NPs are of low quality, then maybe it is YOU who had a low view of your profession. Using your logic, would you be okay with new grad RNs just being thrown into floor work with minimal guidance? After all, I went to RN school full time and 2 years of clinicals. 

Where I do agree is that the bar is set too low for entry to advance practice, heck, I’ll even say for nursing in general. But there’s a difference between lack of knowledge/ability and ensuring an adequate role transition. 

Does NP or CRNA school prepare you for every situation? Does schooling prepare you for the myriad of ways NPs are utilized? For every specialty? No, it doesn’t. For lack of sounding boastful, my concern is not a lack of ability. Quite the opposite. My employer (in my opinion) has too much confidence in me given my background and training. 
 

Maybe you were ready to jump in the deep end straight away. Good for you. Not everyone is like that. Role confusion is a well studied and long documented issue with advanced practice professsionals. Even BEFORE the proliferation of diploma mill NP schools. But to conflate this with “lack of standards” is patently absurd and rather insulting. But you do you and stay perfect! Hope you continue to enjoy the exodus of healthcare professionals! 

Note, I did comment on poor-quality in-person programs. Trust me the poor regulation of NP education doesn't start and stop online.

If you want to take this personally, that's on you. They don't have too much confidence, they have an expectation. Completely different. MDs and admin have 0 idea of our training, just that we have a license and are cheaper than a MD. MDs are forged out of residency to hit the ground running. New residents are given a full patient load day 1 of PGY-1 year. We make double a resident's salary in most places, we should be able to do the same unless we are just chart monkeys at the end of the day.

If you recall,  I never said I was prepared out of school which is why I did a residency. I was shocked at how mediocre the education was and the "board" exam difficulty was lackluster at best. Did you gloss over that? Take the emotion out of this. You came here to ask a question at the end of the day. Not all responses in a public forum will be coddling. I agree feedback is necessary and a 2-week orientation is appropriate. A full load on day 1 with a mound of paperwork is not reasonable, 2 weeks in is. But other than that, they expect production after a general orientation period unless it is explicit that it is a training program.

Being a RN is completely different than a provider, like not even close. 

Best of luck, I just tire of precepting people who have no idea what they are getting into or fielding daily questions with early 20-somethings wanting to hit grad school 6 months into bedside like it's a saving grace in healthcare. 

For everyone reading: Do a fellowship. I understand people have lives and moving isn't fun but almost every MD has to move for med school and residency. I don't understand why it is always a foreign concept to NPs or deemed too inconvenient. Convenience is why we are in this NP education mess. 

Specializes in Emergency Medicine.
CardiacRNLA said:

If medical school alone made physicians ready to be providers, there would be no need for residencIes

Right? Imagine! We all should be perfect out of school! 

Some people around here forgot what it was like to be new and based on comments on this thread and others I have seen doesn't seem to be too fond of NPs unless they are CRNAs. 

AlwaysTiredNP said:

Right? Imagine! We all should be perfect out of school! 

Some people around here forgot what it was like to be new and based on comments on this thread and others I have seen doesn't seem to be too fond of NPs unless they are CRNAs. 

You should tell the nursing credentialing bodies this and also tell them to enforce more hours and residency requirements. Because guess what, they are selling us like we are supposed to be competent out of the gate. 

This is a systemic problem at its core. I am indeed a NP, not a CRNA. Sorry to burst your bubble. 

Specializes in Psychiatry.

I advocate for independent practice but I feel it should only be accessible to NPs who went to not for profit programs, completed a residency, and have ample post school training. Independence after 500 clinical hours is laughable.

1 minute ago, CardiacRNLA said:

"NP turned MD/DO" means what exactly? I have met plenty of crappy MDs. The thing is though, that MDs close ranks and protect each other (even at times when they shouldn't). Juxtapose that with nursing, and suddenly everyone is an "expert" or thinks that him or her is better than their profession. 

Instead of crapping on your colleagues on an anonymous blog, why not actually do something to help the profession if you feel so strongly?

I personally advocated my school change its curriculum and I have also personally precepted dozen of NP students (where I pushed fellowships/residencies) in addition to teaching current NPs in a residency program. I have done my part.

I am not crapping on anyone, I am pointing out the obvious. I am not going to close ranks on a money-driven academic pyramid scheme. I am not going to support substandard RNs becoming providers because they hate bedside or they want the provider title while doing the least/ most "flexible" sort of education.

Your ire shouldn't be at me, it should be directed at the myriad of schools across the country and lazy/entitled RNs wanting to be providers all the while putting in the least effort possible.

The NP profession has created a monster where a mediocre RN with an online BSN and a deposit can essentially get into most NPs schools out there. Programs with no on-campus visits, no monitored clinicals and part time (one class at a time) programs to cater to single parents or whatever. Imagine if med schools or even PA schools pulled this stuff. Not EVERYONE is in the needed life position or has the academic/mental fortitude to be a provider.

This affects me because it makes the profession look like a circus. Sucks going into every job having to prove yourself first because the NP who came before you was awful.

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