Beginning first Primary Care position in June, HELP!

[Destined2sing]

Good morning,

I am starting my first primary care position June 6th (also my birthday...lucky me), and I could really use some help.

I have been working as an RN in a Mom & Baby (with level II NICU) unit for the past 5 years, and have also worked for a period of time in a Level III NICU. I obtained my MSN from the University of Cincinnati as a WHNP (my opinion of UC is best left to another thread). I FINALLY (YAY! ) was offered a position as a NP this past February, with a start date as listed above. All I can say is that it took a LONG time to find a job, and my background in Women's Health was far from helpful.

Since passing my NCC boards, and while looking for a job, I continued to work on my Mom & Baby floor as a Staff RN. Those of you that have experience in this area likely know how much 'care' patients typically need, so it has not exactly been the greatest way to keep my skills and knowledge up.

Since it has been a while since I graduated from my MSN (9/09) I am really feeling nervous about starting this new job. My primary concern is that they are hiring me to actually do Family Practice care. Initially I will be working in the main clinic, and seeing regular patients, but eventually they want me to work in the walk-in clinic/urgent care. The clinic is actually a Federally Qualified Health Center (FQHC), and the vast majority of patients are heavily under serviced, and there is a rather wide variety of acuity levels and complexity.

Currently the facility is transitioning away from mostly locum tenens providers. On staff currently will be 4 physicians (MDs and DOs), 2 NPs (an FNP and myself, however the CEO is looking to add a 3rd NP), and your various support staff (2-3 RNs, several LPNs, and other ancillary staff).

When I met with the CEO, along with my husband, we were both really impressed with what the direction of the facility was, as well as the overall facility and equipment. The CEO is an extremely ambitious individual, but also is VERY demanding. I know that he is really a very understanding and accommodating man, but he does really expect his PCPs to perform at a high level (what CEO should NOT expect that). He recently let go a Physician Assistant from his staff because the PA was just not working independently enough. Apparently the PA had been at the clinic, and this was their first job as a PA, for around 3-4 months (I believe). The Medical Director felt that the PA was asking them too many questions, I got the feeling that the PA wanted to clarify every Dx or treatment decision before doing anything. It apparently was so bad that it was causing the other PCPs to get behind in their patient care duties. So I am really worried about being too much of a burden.

Above and beyond all of this, the CEO is really hoping that I can come into the clinic, and within a short period of time begin to work on revising the Policies and Procedures for the NPs and Nursing staff. I did a large amount of this at my current employer because I was the chair of our practice council. In addition to this, he is hoping that I can develop into a strong leadership and mentorship role for the NP and Nursing staff, again because I did a lot of this at my current employer. I know that this seems like a HUGE amount (or at least to me) of things to expect from an inexperienced WHNP. I attribute a great deal of this to how well the CEO, Medical Director, my husband, and I hit it off together during the day we spent there. I am very proud that the CEO has this much confidence in my abilities, and I really just do NOT want to let him (or myself) down.

I have been talking to my PCP about what she did when she first established her practice. She told me that she really used the book The Resident's Guide to Ambulatory Care as a quick reference for anything she needed to brush up on. On her suggestion I purchased the book, and I must admit that it really looks like it will be a huge help for me. The facility, currently, does not have any services such as DynaMed, but they are looking into something for the future.

Are there any suggestions that you experienced NPs might have for me? Any books, journals, subscription services, computer/pda/iphone programs, or the like that you felt were a HUGE help to you?

I am worried, also, about looking stupid in front of my patients. The scenario that kind of worries me is with something like medications. If I am going to a Rx a med that I am not really familiar with I plan on looking it up to make 100% sure that it is the best treatment option for the patient. I really do NOT want to pull out a Drug Reference guide or PDR in front of a patient. Did anyone else have this kind of fear?

I really could use some help to calm my nerves down a bit.

Susie B.

[traumaRUs, MSN, APRN]

You're going to be doing family primary care? Or just women's care?

I agree that they are setting you up. It takes at least a year to feel comfortable on your own.

[linearthinker, DNP, RN]

Congratulations. When I took the Fitzgerald Review course, there were several NPs there who ere taking it to bone up for a new scenario such as you describe. Perhaps such a FNP review course would be helpful to you as well. Good luck!

[NPinWCH]

First, congrats on the job!

I'm a brand new NP myself, though I'm an FNP, most of my 15 yrs RN experience is in L&D and nursery. I just started my first ever NP position in a FQHC in rural Ohio and am feeling the same fears. I am often overwhelmed by how little I know, but there is an excellent and well experienced NP at my practice who is great at encouraging me and reminding me that I'll get better/faster and the job will get easier.

Although on my end, the docs I work with are some of the most supportive people I know and are patient with me knowing I'm new. They want me to succeed and knowing that helps sooo much.

I try to keep in mind my new RN grad days on L&D. I know I struggled then too and eventually I reached competent and then expert level. I have faith I'll get there eventually as an NP as well and if you think about it, you will to. It's hard to let go of that "expert" ideal and drop back down to novice level, but I know in the long run it will be worth it.

As far as using a drug reference, well I've been with many practitioners/docs and some are always pulling out their PDA/iphone to check on dosage, side effects or interactions and others are not. The pediatric NP my kids see almost always pulls out her phone to do her math for dosing or to check for generics or check on price and I don't look down on her for it. I hardly think most people do.

If a patient asks me what I'm doing when I do, I tell them the truth; that I'm double checking to make sure the dose isn't too much or to check if it interacts with other meds. That seems to be okay with them.

I have a Skyscape suite on my iphone, it was required for school, but it still serves me well. It has a drug reference, 5 minute clinical consult, lab reference and a few other programs. I most often use the three I listed though. I also have the Fitzgerald review book, which is a great reference for common FNP problems.

I ask plenty of questions though and most days feel overwhelmed, but it's getting easier...until I have a bad day and then I doubt everything all over again.

Good luck!

[BCgradnurse, MSN, RN, NP]

To be honest, this does not sound like the best first job for a new NP. Hopefully you will find an experienced MD or NP there who can act as your mentor, causing having that support is critical to your success IMHO. How many patients do they expect you to see on a given day? I work in Primary Care and started at 2 an hour. It took several months before I felt comfortable increasing that to 3, and a year before I let people double book me or squeeze an extra patient in. Are you going to have your own patient panel? If so, ask that they assign you less complicated patients to start with. I use my iPhone constantly...Epocrates for meds, Medscape for diseases, Up to Date for almost everything else! I pull it out in front of patients and they don't seem to care. I still use my Fitzgerald review materials for a quick reference. I'd also recommend getting a good derm book, such as Fitzpatrick's. Brush up on hypertension, hyperlipidemia, and DMII and that will cover a large proportion of the chief complaints you see.

I still ask a ton of questions and I'm so glad I'm in an environment where that is encouraged. I wish you the best of luck and hope all turns out well for you.

[TJFRN]

In to response to opening books and iphone in front of patients.... don't sweat it! I see my pcp ad FNP I go to do it and it actually relieves me. I know they don't know everything and it makes me comfortable that they admit to it. I always tell my patients that you want a healthcare provider who is willing to say "I don't know" over the one who says "they know" but really doesn't.

Good Luck!

[Lovanurse]

I just wanted to bump this thread because I am starting my first job as a new FNP at a FQHC and I suddenly got very nervous. I wanted to do this so bad and after all of the stress left me from capstone, graduating and passing certification, I'm just now realizing how afraid I am to take on this new role. I've done very well in clinical but I've become accustom to somebody always holding my hand. Anyway, I'm just venting...Anybody else feeling this way???

[silkysha]

Yes, this scanrio is me right now. Just starting as a WHNP after being out of school for 6 1/2 yrs. But I have been going to conferences, listening to experienced NPs talk, get the most up to date changes, protocols, and keeping up on the CEs. However, God has answered by prayer for this position and I know he will allow his sweet Holy Spirit to be with me. I've been praying that the staff over me and the other I work along side of will be supportive and helpful. I'd rather ask a question and ultilize my resources, instead of doing something to harm my patient. That is why I'm on this site, i was looking for what we all are looking for when entering new challenges. But we are going to be Excellent Providers because we are anxious and want to do it right. I went to the WHNP conference in Florica in October and it was wonderful; full of the latest changes; problem solving tips, scenarios like the ones above and different kinds of practices and populations. So try to go to those or get the info from the conference online for a lesser price. But it's nothing like being there. Just take God with you everyday you go in, ask him to allow the Holy Spirit to go with you and give you the Grace to do an excellent job. Believe you can, and you will.