Calling all new NPs!

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Hi friends,

So I'm a freshly graduated PNP from a direct entry master's program - got my RN and PNP in the same program. I've never had any employed inpatient RN experience, but I have worked as an RN in outpatient pediatric psychiatric centers and private clinics for about 1.5 years as I finished up the NP portion of the program. I'm just about a month onto the job -- my first employed NP position.

I just wanted to hear some feedback from other new NPs with little to no prior RN/NP experience (outside of school/clinicals) - I have to ask, is feeling a little incompetent a "normal" part of the process switching from student to working professional? I recognize that I haven't seen a WHOLE lot, much of my primary care rotation was spent doing well child visits and not so much urgent care visits. How have others adjusted? What are good resources that you tend to lean on?

Any advice or just sharing of your experience would be so helpful! I'm not the most confident person in the world, so I always tend to talk myself into these ruts where suddenly I think I'm not cut out for this. =/

Thanks!

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Specializes in Nephrology, Cardiology, ER, ICU.

I think your feelings are perfectly normal. I was an RN for 14 years prior to becoming an APN and yes, I was still very scared and felt like an imposter....

Best wishes.

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Specializes in Internal Medicine.

I have almost 8 years of experience working as an inpatient RN in a high acuity setting and think its absoutely normal to feel like a deer in the head lights. Whether you are new to nursing or not, being a provider is a very different ballgame. Many seasoned NP's here will tell you it can take a year to get the hang of things, and another year before you are truly comfortable.

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Specializes in Med-Surg, Transplant.

I think that seems totally normal. I've has a few years of experience in the specialty where I will (hopefully) be getting an NP job and I still have panicky moments where I think "why do I think that I can do this again?" I like to think that instead of my experience allowing me to know everything, it is at least giving me the ability to know what questions to ask and when I'm getting in over my head

A seasoned NP told me that it takes 1 year to get your bearings, so to speak, and 4 or 5 years to really be an expert.

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I have been an NP for just a little over a month now. I have had 6 years of nursing experience. I feel like an imposter all the time. During the first week I felt the need to ask my supervising provider if I am allowed to see the patient and prescribe medications because during clinicals in school I was doing that. Anyway, my self confidence as a provider is getting better each day the more I see patients and certain diseases. It helps if you are working in an environment where you have supportive health care staff members.

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Specializes in Cardiac, Home Health, Primary Care.

I'm just graduating as FNP and have worked as a RN for about 4.5 years. I'm nervous too and it seems surreal that I'm going to be prescribing, diagnosing, etc.

One thing I'm doing to help prepare is to make a clinical notebook. What's cool is there is an app called EverNote that you can access from your phone or computer. I've got "notebooks" for different body systems, wellness, peds, and pregnant patients. You can add text, pictures, links, etc. It's pretty nice. In the title for each "note" I make sure to add a few things so I can use the search feature and be sure to find it...like "Appendicitis - Psoas sign - abdominal pain". Then I can search for any of those terms and find the note.

You can look on Youtube for how to use EverNote as it was a bit confusing at first for me....

Good luck!

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Thank you for the responses everybody - it is relieving to know that I'm not the only new NP out there who feels like an impostor or feels ill-equipped to really "be on their own". I'm a little over a month into the job now and I can honestly say that I'm starting to get a TINY BIT more confident in the simple things. There's still a TON of things I question and double check with - I end up calling a lot of parents for follow up a lot. I'm working on not asking one of the other providers EVERY time I prescribe anything (usually I don't if it's straightforward). I tend to ask a lot more about what labs to get or what type of radiology/imaging to get. I feel like my program didn't teach us nearly enough about diagnostic labs and imaging.

Also - for any of those in primary care (FNP or PNP), what are your thoughts on managing depression in primary care? Where I am (and likely anywhere in the USA), I am finding that I get stuck in situations where a child has a psychologist who diagnoses them with depression and asks them to ask their PCP for medication management.And for the most part, there are either no child psychiatrists in the area and/or their insurance does not cover it or they do not take insurance. My question is, if it is difficult to get them in with a psychiatrist, I wonder - am I really the right person to do medication management?

All the other providers in my clinic (all doctors, "general pediatrics") are never willing to prescribe medications for patients. They claim it is outside of their scope of practice; that they are not fit to do evaluation and management and refer out to psychiatry. Now I definitely agree with them as well - but in the past, I have also seen pediatricians and PNPs who have started medication for those who have established therapists and are pending an appointment with a psychiatrist.

What are your opinions on this topic? I know I took kind of a spin on my original topic here but as a newer provider, I find that I'm not too clear on what my comfort level is yet. Doctors make it look like anything related to psych can't be touched with a 10-foot pole, even when it is obvious that the family cannot get connected with psychiatry.

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Specializes in Cardiac, Home Health, Primary Care.

In my area many primary care providers start antidepressants and manage some psych disorders. In school we were told that it does take a while to get them to see psych sometimes so you need to do what you can.

I was taught about prescribing SSRI's, TCA's, antipsychotics, etc. and tested on it for my certification exam so why would it be out of scope of practice?

I'm not looking forward to dealing with psych issues so wish I had a good excuse not to treat them but the truth is I can't.

Perhaps these providers just don't WANT to do it. Do they prescribe ADD medication? The pediatrician I precepted with did.

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That's what I always figured - what is the point of me learning about the condition, management and pharmacology if in the "real life setting", I'm just supposed to refer? Not that referral isn't needed but I am always shocked if not a little disappointed that a lot of my preceptors in the past never wanted to start or budge when it came to psych, and MUCH more disappointed that my colleagues and supervising physician don't really approve of me managing ADHD, depression, etc.

The only advice I've really gotten from my supervising is that if I think they're suicidal I should have them go for a consult at the ED -- but there's such a huge range between "normal" and "emergency".

A lot of them have stated that they are "general peds", so it's not really in their scope. I'm not sure if training for physicians are different than that of NPs?

Only one of the physician's really start children on ADHD medication. The rest "refer out" to have a psychiatrist do the diagnosing.

I guess - let me also pick your brains on this one: Do you make the diagnosis of ADHD in the primary care setting? Or do you normally defer to a specialist to really make that diagnosis? I feel like I should be able to do the diagnosing...but maybe I'm just a little too confident in myself. What do you think?

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Before ADHD is diagnosed, there are two forms that need to be completed- one for the parents and one for the school environment, etc. It is an assessment tool to see the kid's behavior throughout the day at school and at home. I was told during my review that if we suspect ADHD, we have to refer the patient for psych evaluation.

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Yeah, I've always gotten such mixed input from various preceptors and I think that is where I am finding myself a little confused about my own "scope of practice" and "comfort level". Some providers make it about what I am medically licensed or legally qualified to handle and others about what they are comfortable with...which can be a pretty fine line.

In class (and I know, theory is so so different from practice), we are taught about the screening tools, history taking and physical exam involved in the diagnosis of ADHD, and also about pharmacological management and treatment. But in practice, only the most senior of the 4 other physicians in the practice I work ever makes the diagnosis in the clinic - always refer out to psychiatry.

What I've kind of settled at for one such patient was to start on a short-acting stimulant while pending psychiatric evaluation (because getting a child in with a psychiatrist here can take 2-3 months), after consultation with my supervising physician. But I still feel a little "wrong" about doing that, or well, I'm made to feel a little wrong about it because of the hesitation I get back from some of my colleagues. Like I jumped the gun - and it kind of eats away at me because now I keep thinking I'm wrong.

Same with depression. Well, not always the same. I know I don't feel comfortable diagnosing depression vs other mood disorders, etc. Are psychologists able to make that assessment and diagnosis or only psychiatrists? Say a psychologist diagnoses depression and calls me asking to put the patient on Prozac, and I have referred the family to psychiatry, but their insurance doesn't cover psychiatric services and there are none in the immediate area who are taking new patients. Does anyone else run into this issue? I have seen some of my preceptors in the past start a child on a antidepressant while pending establishment of psychiatric services. But I feel as if this is where it gets kind of muddy in terms of what I'm "allowed" and "not allowed" to do as a PNP.

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Specializes in Family Nurse Practitioner.

Although uncomplicated depression or ADHD that has been diagnosed by a psychiatrist or psych-NP wouldn't be off the table for PCP maintenance I'd be very careful to fall into the bleeding heart nursing trap of being the martyr who justifies trying to do it all. No where do I recall that our ethical or legal obligation as a NP requires us to step out of our scope because a patient doesn't have insurance or they can't get in to see a specialist for 2-3 months. It is unfortunate but not your problem and unless it is someone I have worked closely with I would take extreme offense to a psychologist or therapist making specific medication recommendations. They are not qualified to make that call.

I would also take pause if the MDs in your office are refusing to treat something. I am a member of the medical staff, not nursing and operate as such, by taking my cues from how physicians practice. In the event of a complication I can't imagine it would look very good as a NP to attempt to justify improperly treating a disorder when your partners, who are MDs, recommended a referral to a specialist. The MDs and the hospital will not cover for you and I'm pretty sure the lawyers would have a field day with it.

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