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 ?

3 minutes ago, CardiacRNLA said:

First off, I have no ire towards anyone. You commented on MY post. You and others are making broad based assumptions on ALL NPs because SOME, hell I'll even be generous and say a plurality, suck. You mentioned advocating for residencies. That is great. I feel like that residencies should be a mandatory part of NP training.  And you are making my original point. Even if you went to Ivy League A+++++ DNP In-Person program, most are not 100% ready to be a provider IMMEDIATELY after school. (nor should you be in my opinion). 

It has been well researched that "role transition" is difficult for new NPs across the board. You mention the quality of NP programs/NP students, that is only ONE side of the equation. How about fixing the system that cuts all APPs short of mentoring or additional training, just so more patients can be seen (read: more billing)? 

Unless NP and RNs accept that not every RN can be a provider, class sizes to need shrink, standards to increase in every facet possible, clinical hours need to be 2k, residencies need to be required and advocacy groups need to hush for 5 min...all of that "role transition" meaning is just as much fluff as the majority of NP school.

NP programs need to look towards CRNA programs as a first start then go from there.

11 hours ago, CardiacRNLA said:

Role transition is not "fluff." It has also been studied with new grad RNs. The research goes back to the"good old days" before the advent of online learning. In addition, despite all you advocate you cannot change how an employer perceives the NP role or how to utilize an NP. Most employers don't give a rat's behind if you went to Yale, had 5 residencies and studied at the Sorbonne. They only care that are a less expensive way to create revenue. We are NOT physicians and we will NEVER be seen as colleagues due to the healthcare hierarchy. Which is okay, I am not an MD, I realize the limits of my training and I wanted to be a NURSE. 

While I agree that clinical standards should be beefed up and nursing "theory" classes should be reduced, I don't think the CRNA model is realistic. First, CRNAs don't do a residency, but they do have more clinical hours and have a more rigorous curriculum, no doubt.  However, CRNAs while smart, valuable and much needed, they are not being called upon to meet access to care gaps in rural areas, underserved urban areas, etc. NPs are being tasked with doing this. 

This does not excuse diploma mills, direct-entry MSNs, etc. I think that there should be more clinical hours, less "theory classes," certain mandated residency or mentorship, and certain # of hours working under an MD before allowing independent practice.  

I am sorry you have come across all these terrible NPs. Not sure if it is due to your location, employer, etc? Maybe it's your perception of NPs? Most of the NPs I have come across are thoughtful, intelligent, and hardworking. There is certainly a way to advocate for improving NP studies without sounding like "I am too cool for school" 

First, CRNA is much more intensive than NP school. My roommate was a CRNA. It made our curriculum look like a joke, not even close. 2nd CRNAs train for 3 years and thousands of hours in a primarily niche area of medicine, NPs spend 500 hours and are supposed to cover the entire spectrum of medicine in many cases. There is not a NP Program in this country up to an acceptable standard in my opinion (Yale included), and the few dozen residencies are a paltry bandaid. There is 0 incentive for residencies from the NP credentialing bodies and hospitals have to foot the bill. This is a DOA situation.

I’ve worked for a decent amount of time and have seen enough in a variety of areas to come to my own conclusions. It’s not one area or hospital. It’s systemic

CRNAs absolutely fulfill the same rural role to some degree (more than NPs), that is a completely false notion. I have been at rural/inner city hospitals that are 100% independent CRNAs only.

Okay, you aren’t an MD, what are NPs then? What’s the purpose? We half heartedly diagnose? Or do we just get hand held until the MD comes by to do actual medicine. You can’t have one foot in and one foot out.

11 hours ago, CardiacRNLA said:

Role transition is not "fluff." It has also been studied with new grad RNs. The research goes back to the"good old days" before the advent of online learning. In addition, despite all you advocate you cannot change how an employer perceives the NP role or how to utilize an NP. Most employers don't give a rat's behind if you went to Yale, had 5 residencies and studied at the Sorbonne. They only care that are a less expensive way to create revenue. We are NOT physicians and we will NEVER be seen as colleagues due to the healthcare hierarchy. Which is okay, I am not an MD, I realize the limits of my training and I wanted to be a NURSE. 

While I agree that clinical standards should be beefed up and nursing "theory" classes should be reduced, I don't think the CRNA model is realistic. First, CRNAs don't do a residency, but they do have more clinical hours and have a more rigorous curriculum, no doubt.  However, CRNAs while smart, valuable and much needed, they are not being called upon to meet access to care gaps in rural areas, underserved urban areas, etc. NPs are being tasked with doing this. 

This does not excuse diploma mills, direct-entry MSNs, etc. I think that there should be more clinical hours, less "theory classes," certain mandated residency or mentorship, and certain # of hours working under an MD before allowing independent practice.  

I am sorry you have come across all these terrible NPs. Not sure if it is due to your location, employer, etc? Maybe it's your perception of NPs? Most of the NPs I have come across are thoughtful, intelligent, and hardworking. There is certainly a way to advocate for improving NP studies without sounding like "I am too cool for school" 

In addition it is a fantasy notion that NPs are clamoring for rural and underserved population positions. Majority of grad either stay exactly where they are area wise or go where the most money is. 

Plenty of rural positions sit open because it’s a meme the nursing machine pushes that NPs are somehow in it for more altruistic reasons. It’s all linguistic propaganda.

CardiacRNLA said:

There was some areas in which we had common ground. But now I realize you are not grounded in facts. And by the way, when I meant the rural role, I meant as primary care providers or even helping to smaller specialty practices in underserved areas. CRNAs by TRAINING cannot fill these roles either independently or collaboratively. 

You are providing conjecture about "nursing memes", "fluff" etc. I am glad that NPs suck. Maybe you were rejected from a CRNA program or upset you didn't go that route. Good luck and good day. I am sorry, we as a profession. don't meet your approval. 

I actually was accepted to CRNA school a while back, chose a residency instead. Could apply again if I really wanted. I'm the one who isn't grounded in reality? Heh. I'm not the defensive one here. It's okay to admit the profession is a complete and total cluster.

CRNAs are independently fulfilling a rural role within their specialty. I literally have seen it with my own eyes and many jobs on gasworks are advertised as 100% CRNA only. If you mean to compare NPs to CRNAs with regard to primary care, I am not even sure why that would even be brought up. It has no relevance like at all. Sounds like the goal posts moved in your statement.

Yes rural/underserved, whatever mumbo jumbo you want to believe. No idea how NPs are geared towards this over MDs or PAs. Where in the NP curriculum is rural care focused on? I know there are specific MD residencies for this? More propaganda from the lobbying bodies. 

Do a couple years and get back to me. You have a lot to learn. I can control what I can control, I'm content with my position/salary but disappointed with the state of the profession and people continually defending it just because they have an agenda

Specializes in Former NP now Internal medicine PGY-3.
CardiacRNLA said:

Like your partner in crime, you seem to make so many assumptions about nursing. Again I'm glad you found a profession where your brilliance can shine. 

You are incorrect in that most physicians overestimate NPs abilities. They don't care. Because sadly for most NP roles, only patient volume and being delegated grunt work is what matters to physicians. I wish physicians did make positive assumptions about NPs. 

Anyway, I agree there are a lot of medical professionals who lack knowledge. But you seem to reflect this on nursing only. So when cardiologist (practicing for over 20 years) says to order a Lovenox bridge for a patient on a DOAC...am I the dumb one for knowing the guideline or is he? 

I don't think any of them want his or her license on the line, but medicine in general has a lot of grunt work. It seems appropriate to delegate at least some of it. Whether or not it's appropriate is in details I don't have to make assumptions. 

It was mentioned it can be hard to tell if proceduralists are good or not. So I feel appropriate punches were thrown at other docs too. 

I don't know the details about the case for the last comment. As you know it's generally not recommended (I'm assuming we are talking afib) and not needed obviously if starting therapy for a fib. Sometimes we will change it in ppl with real high cv scores for lovenox if we think someone inpatient might get poked by surgery or IR several times during a more than brief inpatient hospital stay but other wise nahh. 

Nonetheless, it may be more worrisome if even a job req a lot of grunt work is difficult. Much of it may not be grunt work then?

Specializes in Psychiatry.

I mainly agree with numenor as NP education has become laughable. Even when just typing the word nurse practitioner into Google the top hits are for for-profit programs offering easy admissions. There are schools with absolutely no standards where anyone can get in and they barely even require an application let alone test scores, references, etc. There's not a single other medical professional - dentist, vet, physician, PA, audiologist, respiratory therapist, Xray tech, etc with programs this laughably easy to enter. My goodness, even RN programs have higher entry standards than NP programs. It's a joke! And once admitted - online discussion postings to learn advanced physiology, set up your own clinical sites with almost no school involvement? It's a cash grab and the NP boards won't change a thing because it will upset the huge host of for-profit programs that make a killing churning out nurse practitioners without having to put any effort or money into the programs. Even at legit programs, 500 minimum clinical hours and half the coursework in nursing theory courses really hampers the education.

I will give one caveat, however - I think at legit programs, especially direct-entry programs (they tend to have higher admissions standards) that specialized advanced practice nurses are fairly well prepared. CRNAs obviously, but I am also generally happy with PMHNP education as having 2-3 years of specialized psychiatry training tends to lead to a pretty good grasp of a specialized field such as psychiatry and PMHNPs can generally run circles around PAs for psychiatry as they have done ALL 500-1000 hours of clinical time in psychiatry as well as specialized courses in psychiatry including dedicated psychopharmacology courses. I felt very prepared coming out of my PMHNP program and even by the end of my final clinical semester my psychiatrist clinical instructor was generally letting me work fairly independently as a student as he was impressed with my skills/knowledge. Again, I think specialization is where nurse practitioners shine with specialized courses in that subject area, but the general "AGNP" or "FNP" just tries to cover too much ground in too short of a program. Primary care/internal medicine requires a provider to know A LOT about A LOT. 

Specializes in Former NP now Internal medicine PGY-3.
MentalKlarity said:

I mainly agree with numenor as NP education has become laughable. Even when just typing the word nurse practitioner into Google the top hits are for for-profit programs offering easy admissions. There are schools with absolutely no standards where anyone can get in and they barely even require an application let alone test scores, references, etc. There's not a single other medical professional - dentist, vet, physician, PA, audiologist, respiratory therapist, Xray tech, etc with programs this laughably easy to enter. My goodness, even RN programs have higher entry standards than NP programs. It's a joke! And once admitted - online discussion postings to learn advanced physiology, set up your own clinical sites with almost no school involvement? It's a cash grab and the NP boards won't change a thing because it will upset the huge host of for-profit programs that make a killing churning out nurse practitioners without having to put any effort or money into the programs. Even at legit programs, 500 minimum clinical hours and half the coursework in nursing theory courses really hampers the education.

I will give one caveat, however - I think at legit programs, especially direct-entry programs (they tend to have higher admissions standards) that specialized advanced practice nurses are fairly well prepared. CRNAs obviously, but I am also generally happy with PMHNP education as having 2-3 years of specialized psychiatry training tends to lead to a pretty good grasp of a specialized field such as psychiatry and PMHNPs can generally run circles around PAs for psychiatry as they have done ALL 500-1000 hours of clinical time in psychiatry as well as specialized courses in psychiatry including dedicated psychopharmacology courses. I felt very prepared coming out of my PMHNP program and even by the end of my final clinical semester my psychiatrist clinical instructor was generally letting me work fairly independently as a student as he was impressed with my skills/knowledge. Again, I think specialization is where nurse practitioners shine with specialized courses in that subject area, but the general "AGNP" or "FNP" just tries to cover too much ground in too short of a program. Primary care/internal medicine requires a provider to know A LOT about A LOT. 

Def more useful in narrow specialties, general medicine is a lot to know and guidelines change too quickly. It's even a lot to know for a physician and too hard to keep up with everything. Honestly family medicine itself is too broad. Learning everything about kids, adults, and GYN is just too much for anyone. Better just to have medicine and OB and peds separated... for all providers. 

Specializes in Psychiatry.
Tegridy said:

Def more useful in narrow specialties, general medicine is a lot to know and guidelines change too quickly. It's even a lot to know for a physician and too hard to keep up with everything. Honestly family medicine itself is too broad. Learning everything about kids, adults, and GYN is just too much for anyone. Better just to have medicine and OB and peds separated... for all providers. 

Agreed. I think the FNP specialty should require 2000+ hours of clinical and perhaps even more credits, and focus only on primary care. FNPs should then be able to work only in primary care. Again, the other specialties are generally fine at legit schools as most do not stick to the minimum hours (my school had something like 1200 hours of clinical) and having 1000+ hours in one specialty and sticking to that speciality is, IMHO, superior to having 2000+ hours in multiple specialties. A PA who rotates through 10 specialties doing 100-200 hours in each does not have as much preparation in pediatrics or psychiatry as a pediatric NP or PMHNP who does 1000-1200 hours in those specialties. 

In other words, I think nurse practitioners have one very valuable strength and that is specialization! We are the only medical providers (PA, MD/DO, NP) who have specific programs focusing on one specialty. 

Specializes in Former NP now Internal medicine PGY-3.
On 8/11/2022 at 9:27 PM, MentalKlarity said:

Yes, I meant as part of school training. Obviously residency/fellowship is specialized but in terms of PA vs Resident vs NP the NP is the only one who comes out of school specialized in their field with a program catering to a specific population. That's a real strength but again it is squandered by FNPs with 500 hours who go work in cardiology or neurology or even primary care with so few hours. The PMHNPs with 1200ish hours in dedicated psychiatry training and dedicated psychiatry courses come out well prepared. The WHNPs I have met have been very well-versed in women's health right out of school. CRNAs know anesthesia inside and out. Specialization is the only valid argument for less schooling/hours but is rendered useless if NPs try to do too much with vague training. 

That makes sense. It all sort of converges on the issue of not getting people trained for his or her specific job early on. It seems pointless to not do specialist type training early on. As long as one knows what they want to do early on. IE it doesn’t make sense we have to do three years of internal med to do a fellowship, yet certain specialties such as derm and Neuro do a prelim year only  before specializing. The entire education system to being a provider is a mess. The whole three pathways to being a provider doesn’t make sense. It’s a messed up system that needs revamped.  Seems as physician training probably takes too long and the others in most cases are too short. But the powers that be have no motivation to change it. I doubt any of the reasonable changes will ever come to criterion though. I feel I could have been trained a lot better as an NP, but residency is honestly just too long….

Specializes in Tele/Interventional/Non-Invasive Cardiology.
40 minutes ago, juan de la cruz said:

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.

Thanks for your response! I could not agree more. Being an RN and an APRN is so different! During the interview process, I did relay those concerns. I was assured I wouldn’t be expected to be at the level of an seasoned NP. And because my credentialing would take a while that I would be brought along gradually. I’m not saying this was an intentional bait-and-switch. I believe the ideal situation and the reality of being short handed overshadowed everything. 

I really would like to make it work. But this is where I need to have a strong (and safe) foundation. I know I need to have this conversation. I need to write out what I’m going to say and have a plan to present. 

Specializes in Tele/Interventional/Non-Invasive Cardiology.

It’s kinda funny you say that about answering questions and triaging…because they have me doing that too LOL. Sigh ? 

Specializes in Nephrology, Cardiology, ER, ICU.

Listen to Juan - knows what he is talking about. 

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