Am I doing the right thing?

[amalay, MSN, RN]

Hi everyone...I'm having a bit of a mental meltdown. I'm a primary care PNP from a direct-entry program now working in primary care. I wasn't an RN before I became and NP so I only really have primary care experience. Recognizing that acute care is a weakness of mine, I recently went back to school to get my acute care NP certification...but this seems to have exacerbated my worry/anxiety about not being smart/good/experienced enough.

Many of the NPs in my program are all seasoned RNs, who despite having a primary care PNP (pediatric NP) certification, work inpatient as an PNP. I'm sort of the odd one out and now I'm worried that I'm just wasting my time and money trying to do something I don't have experience in to begin with.

In clinical rotations, I'm getting the sense that we should be getting opportunities to do things like thoracentesis, chest tubes, lumbar punctures, arterial lines, etc. My clinical rotation is the ED but they have my role more like a medical student, and usually there's always interns, residents and fellows. I'm just not sure that an NP like me is ever going to get that opportunity? My preceptor is an MD who hasn't precepted an NP before, so I can't tell her comfort level in standing by me and letting me do some of these things or even how comfortable she is in letting me take/help with some of the more acute cases.

It's school and it's supposed to help me gain that missing experience, but it just doesn't feel that way. I feel like I'm stuck in that conundrum of "we don't want an inexperienced person doing that" even while I'm trying to get that experience. How can I better advocate for myself as student?

Is it weird that I want to get my acute care coming from a solely primary care background? I feel like everyone looks at me weird when they find out I want my acute care certification, like I just shouldn't be here.

[Sour Lemon]

It does seem like you're trying to fix a round hole with a square peg. I'm not an NP, though ...yours is a cautionary tale for people who want to become advanced practice nurses without being regular nurses first.

I wish you well.

[amalay, MSN, RN]

It does seem like you're trying to fix a round hole with a square peg.

Thank you for replying. When you say that, do you think that if I do well in primary care and I'm enjoying my job, that I should just stay put..and just give up?

[LadyT618, MSN, APRN, NP]

You are a primary care PNP working in primary care. Do you mean a clinic? Are you only seeing pediatric patients? What kind of "acute" cases are you encountering in this primary care setting? I'm trying to understand what it is you are feeling inadequate about. Your primary care PNP program should have prepared you for primary care of children. If you're seeing adults, that could be the problem right there and probably should've gone the FNP route. You've piqued my interest.

[amalay, MSN, RN]

Hi,

Yes primary care working in a clinic seeing only pediatric patients (oldest I've see is up to 22-24 but this is rare). At times, especially during the flu season, I see a fair number of kids coming in with some level of respiratory distress (sats in the high 80s/low 90s, increased work of breathing, etc) that requires stabilization and transfer to a hospital.

It was actually cases like these that made me curious to look into acute care programs because the idea of being able to work in the ED or other inpatient settings interested me. But since I'm primary care trained, I obviously would not do well without more training in those settings.

[LadyT618, MSN, APRN, NP]

Ohhhhh, you've been bitten by the curiosity bug. There's nothing wring with that. I don't think it's weird. You've never worked as a RN so I think it's actually natural to wonder what goes on after you send them to the ER from the primary care office. If you have the money to go and get further NP training, knock yourself out. But being in the ACNP, you're missing the pediatric aspect of the acute care side. I sense another post master's certificate on the horizon :)

[amalay, MSN, RN]

Ohhhhh, you've been bitten by the curiosity bug. There's nothing wring with that. I don't think it's weird. You've never worked as a RN so I think it's actually natural to wonder what goes on after you send them to the ER from the primary care office. If you have the money to go and get further NP training, knock yourself out. But being in the ACNP, you're missing the pediatric aspect of the acute care side. I sense another post master's certificate on the horizon :)

Thank you for the reassurance. I'm actually in a post master's program for pediatric acute care now. The learning curve is steep, which is why I feel incompetent, especially when I'm comparing myself to other NPs who DO have that inpatient experience.

[LadyT618, MSN, APRN, NP]

Ohh, so it is a pediatric acute care NP program. Well, I suppose it is natural to feel overwhelmed, having no acute care experience as a registered nurse beforehand. Hopefully it will get better for you sooner than later. Best of luck to you! :)

[pro-student]

It can be challenging to make the transition without specific experience and there is a pretty common bias that you need certain specific RN experience to move into an NP role. There's no evidence that this is the case but it's one you're likely to encounter nonetheless.

It's not unusual to feel some apprehension about transitioning into a new specialty. I would focus on the knowledge you do have and how you can leverage that in your new area. You should have a solid understanding of the 3 Ps (adv. pathophysiology, adv. pharmacology, and adv. physical assessment) particularly as they relate to pediatrics. Even though your experience is in primary care, you should be able to confidently assess kids, have a good understanding of the disease processes, and a solid understanding of treatment approaches for common conditions (especially those you're likely to see in the ED). Try to let your preceptor see the knowledge and skills you do have and be clear about the things you still need to learn. Procedures and clinical management in acute care are much easier to acquire with that foundation and preceptors will tend to value that kind of knowledge and experience more than that experience at the RN level (I say that in no way to diminish RN experience but there's very good reason we don't just promote the best RNs to advanced practice). In fact, one of the most common criticisms of new APRNs (or even APRNs in general) is that they know procedures and algorithms but lack a deeper understanding of how these relate to underlying disease processes and the bigger picture of treatment approaches.

Don't be afraid to be honest with your preceptors and instructors/adviser in your program about where you need support. But don't discount what you bring to the table either.

[Rocknurse, MSN, APRN, NP]

Most acute care programs assume that you have already got acute care RN experience prior to you coming into the program. I'm about to graduate as an adult acute care NP and I'm currently doing my 2nd rotation in the ICU. I have to say, that even after 30 years of nursing, most of it in the ICU and all of it in acute care, it is still a very challenging program, and honestly I don't think it's appropriate to admit someone to the program without prior experience. Indeed, most schools, my own included, won't even consider someone without a minimum of 2 years experience.

Having been doing this myself now for some considerable time, and as someone who has a certification in critical care and 10 years ICU experience, I just don't see how someone with no experience can come into to an acute care program and glide through. There's just so much to know and so much to see. Can you walk into an ICU or critical area and glance at the monitors and machines and know instantly what's going on with them? Can you scan the long rack of IVs and understand in a second each med and what they do and scan the rates for appropriateness? Can you gather reams of information on every body system and formulate a plan quickly and safely, or know what to ask and WHO to ask when things turn bad? Even I at times can be overwhelmed with the sheer volume of information. In acute care it's less likely to come across a focused problem, and more likely to come across multiple problems over multiple systems and the need to know and understand everything simultaneously is vital.

I don't wish to criticize your choices, nor discourage you, but I live and breathe this stuff every day and I think you're setting yourself up for a very difficult situation.

[Roy Hanson]

mental meltdown?? Plain English would be better..I know PC, PC! We called it Temper Trantrum. PRACTICE your art. Start at the basics and work your way up. Put away the phone, and practice talking to people.