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 ?

[CardiacRNLA, BSN]

If only, I wish I could do a fellowship. But there aren't really any here in Florida, oddly enough. And when I brought up an out-of-state fellowship to my husband right after I graduated, let's just say he wasn't on board LOL. 

[CardiacRNLA, BSN]

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.

Well, I really wish I could find something else.  But my market here is saturated it appears. And I've only been doing this for 6 weeks. At times, I really DO feel as if my license is being compromised. 

Prime example: this past Friday I went to the LTACH were we see patients. I tried to reach out to the "supervising physician" by phone and by text and he never answered back. Supervision of a new NP by phone, sigh. 
 

I'm balancing my comfortability, patient care ethics vs the reality of my finances. I'm not sure what to do. I'm going to speak the owner (the head MD) and see if anything changes. 

[CardiacRNLA, BSN]

1 minute ago, Numenor said:

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.

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? 

 

[CardiacRNLA, BSN]

26 minutes ago, Numenor said:

1. Problem is you willingly entered a profession focused on independence. This is well known to employers who want production. 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 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. Not asking them what antibiotic to order to when to send someone to the ER or when to be concerned about na 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 hour of clinical which is a drop in the bucket when compared to even med students.

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

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! 

[CardiacRNLA, BSN]

Well, let's just say this. I did make a comment on a public forum, correct. However, your initial response and subsequent responses made a lot of presuppositions. You say you are tired of precepting 20-somethings with meager experience wanting to leave the bedside. I totally understand that and this is valid. But I am NONE of those things. I am 40 and have 8 years nursing experience. Yes, part of my reasoning was that I was tired of the grueling work at bedside. However, another part was to learn and apply greater clinical reasoning. School starts the process (or at least it should) and then you hone it on the job. 

My employer does have an expectation, correct. Is it reasonable? In my opinion, no. Here are some examples: 

1. I have always been in the inpatient setting, including NP clinicals. I am currently working the clinic (private) awaiting my hospital credentialing. My first day as soon as I walk in, my desk is topped with surgical clearances. As either a working RN or as an NP student, I have NEVER cleared patients for elective outpatient surgeries. So should school have prepared me for this? Do I make my own decision without asking anyone since I am supposed to be independent? 

2. I am rounding at an LTACH (after less than 3 hours of shadowing). My supervising MD, who refuses to reach out to me or tells me he's busy writes ambiguous things in his notes. A patient is s/p ischemic CVA with no evidence of hemorrhagic conversion, has known Afib, no documented bleed elsewhere. He writes that during her STACH stay, the hospitalist stopped her AC saying she wasn't a good candidate, but it should be considered later. He goes to state that the pt has a CHA2DS2-VASc score of 7 and states "she is at high risk for stroke, and ideally she should be started on anticoagulation." He even says she should be started on warfarin and gives a goal INR. 

Does he start the AC? No he doesn't. Is there any reason why she shouldn't be on it? No, not that I see anywhere in the chart. So when I call and text him for clarification and he refuses to answer do I: a) start AC on my own unilaterally? b) just assume he doesn't want to restart it and hope the patient doesn't stroke out again?  

In the above scenario, if I just start the AC on my own and there was some reason that only the MD was privy to, and something happens to the patient, am I protected? I practiced autonomously, which in my state is ILLEGAL in the inpatient setting. What if the patient has another stroke or a PE or whatever? 

Does school prepare anyone for this? Even residents who are actual physicians would never make a decision and say "I need to discuss with my attending." So why as a mid-level would I not want clarification? Just so some doctor won't think I am dumb? 

Finally, I would love to have done a fellowship. I wanted to do a fellowship. It's not a matter of convenience for me. My husband put the kibosh on that both for financial and personal reasons. Otherwise, I would've felt more secure doing that. Again, I understand your frustration. I have seen and also heard of many NPs that make the profession look bad. I am not wanting to be coddled. I realize that this was going to be tough. But the lack of collaboration, guidance etc from my physician counterparts is not only frustrating, it is illegal. They sign off on my notes (which is usually days later and I know they aren't reading them) and I must have a collaborative agreement with them. 

I take my role super seriously. I want to deliver quality and competent care that they deserve. Not every new NP is solely looking to escape the bedside or motivated by money, etc. But thanks for the conversation. This again provides a reality check.  Have a good one. 

[AlwaysTiredNP, MSN, APRN, NP]

On 5/26/2022 at 3:23 PM, Numenor said:

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.

then I guess an FNP shouldn’t take a job in cardiology and we should work on getting some cardiology NP programs going so they can be ready to go so school can specifically prepare someone for cardiology because if someone is an FNP they were prepared to work in family practice. 

[CardiacRNLA, BSN]

Numenor said:

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. 

That's great you realize it's a systemic problem. However your initial messages had a blaming tone of the NP: "20-somethings wanting to escape the bedside" "you're supposed to be autonomous.” Again you are conflating poor educational training with lack of mentorship and guidance. You don't think physicians get that? Physicians get a whole 4 year mentorship before acting independently. 

The NP educational programs have always have the same number of hours and credits. What has changed? The proliferation of diploma mills with low bar to entry. That can be changed. And in this we agree. However your responses made it seem as if an NP should get no mentorship, training and should be ready to make ANY decision immediately out of school. Perhaps I am misunderstanding? 

I don't think that is a realistic or safe expectation. Medical professionals of any discipline, there should always be room to ask for assistance. Even seasoned physicians will ask each other for guidance in difficult cases and refer if they aren't trained to treat the case. Why should NPs with less training be able to do this? 

Again, my post was my concern from lack of oversight, collaboration, and guidance. To think this shouldn't be provided AT ALL is as rather interesting perspective. 

[Freckledkorican, MSN, APRN]

On 5/18/2022 at 7:26 PM, CardiacRNLA said:

If only, I wish I could do a fellowship. But there aren't really any here in Florida, oddly enough. And when I brought up an out-of-state fellowship to my husband right after I graduated, let's just say he wasn't on board LOL. 

Hello, fellow Floridian! Northern transplant of one year here. Yeah, I thought there would FNP residencies all over FL, but alas no. I found two FL VA primary care ones and attending one in September (yeah!). It's a few hours away from me, so I have to move, and in my eyes, totally worth it. My husband is not crazy about it, but he knows me. I refuse to practice without it. He'll stay behind with our middle schooler while I get my butt-kicked on the daily. I have never been more excited!

Your situation is one I wanted to avoid. I'd be terrified of making a mistake. Maybe have another conversation with your husband about the out-of-state fellowship? It's what, a year in length? The knowledge and skills you will gain in a protected learning environment is invaluable.

Either way, I wish you good luck?.

[Tegridy]

Numenor said:

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.

Yeah we see all these NPs should have independent practice posts followed up by how hard appropriate patient management is and how they can't hack it. 

[CardiacRNLA, BSN]

Tegridy said:

Yeah we see all these NPs should have independent practice posts followed up by how hard appropriate patient management is and how they can't hack it. 

I always love this site because anonymous people with snarky attitudes love to apply their opinion broadly to every NP. So if I told you, I don't want independent practice at this point in my career, I actually WANT to learn and collaborate with my MD colleagues, would an appraisal of my situation any different? 

[Guest1144461]

On 5/27/2022 at 7:13 PM, AlwaysTiredNP said:

then I guess an FNP shouldn’t take a job in cardiology and we should work on getting some cardiology NP programs going so they can be ready to go so school can specifically prepare someone for cardiology because if someone is an FNP they were prepared to work in family practice. 

Probably should, most specialty APPs I have worked with (with exceptions like ortho PAs) were essentially there to write generic notes/plans the attending would later addend and correct to their liking. So yeah...

Note, there are exceptions to this as listed above. I have met some stellar GI and nephro APPs. Cards not so much.

On 7/30/2022 at 1:49 AM, CardiacRNLA said:

I always love this site because anonymous people with snarky attitudes love to apply their opinion broadly to every NP. So if I told you, I don’t want independent practice at this point in my career, I actually WANT to learn and collaborate with my MD colleagues, would an appraisal of my situation any different? 

Tegridy was a NP turned MD/DO. I think they have a good grasp of the situation. Truth can be snarky if you take it that way I guess.

[CardiacRNLA, BSN]

4 minutes ago, Numenor said:

Probably should, most specialty APPs I have worked with (with exceptions like ortho PAs) were essentially there to write generic notes/plans the attending would later addend and correct to their liking. So yeah...

Note, there are exceptions to this as listed above. I have met some stellar GI and nephro APPs. Cards not so much.

Tegridy was a NP turned MD/DO. I think they have a good grasp of the situation. Truth can be snarky if you take it that way I guess.

"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?