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New NP insecurities

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I recently started my first job as a primary care NP. I am working alongside an experienced NP that has precepted students in the past. I have been using the 2014 version of family practice guidelines book to help with my treatment plans. When I present my plans to my mentor for review, she always has a different plan in mind for the patient that she thinks is better. I then check her advice against UPtodate. She is usually right according to UPtodate. Any ideas on reliable resources to keep me safe during this first year?

Yeserday I gave a mother advice to give her child liquid Sudafed for a few days to help with nasal congestion associated with a URI just like my family practice guidelines book suggested and later when I checked UPtodate I learned that there is no evidence to support using decongestants in children for URIs.

Also, I am being told that I am functioning at the level of a 1st semester NP student. How can I pull out of this? I want to do the best for my patients, but I don't know all the answers. Do I need to go back to school?

Riburn3

Specializes in Internal Medicine. Has 10 years experience.

Sounds like the first thing you need to do is use Uptodate or cross reference it before presenting your plan. You clearly have access to it, and checking it after the fact has thus far been futile. As you go you'll start memorizing this stuff and need to look at it less and less.

Feeling like a deer in the headlights or an imposter is a common thing reported here amongst new nurses in all specialties, NPs included. Stay positive and it'll get better.

BirkieGirl

Has 25 years experience.

i have found that one huge help for me (still in school) is to utilize my real-life experiences. i have two kids who have had just about every single thing you can think of between them. just having dealt with that for the past 12 years has been extremely helpful!

i agree that we all have to start somewhere. why don't you ask your colleague for some basic flowcharts or treatment plan charts of HER preferences and you can reference those? that would help a lot.

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 9 years experience.

UpToDate is a worthwhile and (IMHO) critical tool for both novices and experienced providers (NP/MD/etc).

Remember your experienced mentor is there for that exact reason. In a year you will have seen most common things several times and know exactly what the Uptodate recommendations are.

Sent from my iPhone.

burnedoutRNinSC

Specializes in Family Nurse Practitioner.

If you live in a state where you have to have a collaborative agreement with a supervising physician there should be a list of references that should tell you what guidelines to use when you practice.

I'm right there with you as I just survived my first day as a hospitalist NP. Besides pulling teeth getting my credentials switched over in the electronic record, and having someone else write my controlled substances because my federal DEA has not yet been processed it was not a bad day.

There is definitely that anxiety element that can be overwhelming. Having to think like a NP is a big leap from being a staff nurse.

Give your self a break though. You have all the formal education you need to be able to do your job. However, you might want to consider getting some CEU's it might help with how you feel. Besides, you have to get CEU's anyway to maintain your certification. Your masters or DNP is only going to give you preparation to perform minimally. Grow yourself professionally by attending some conferences. What do you have to loose?

travelcrazyRN

Has 12 years experience.

Boston and Riburn- I see you post a lot, and have enjoyed reading your responses to other's questions. Thanks for being such active members to these boards. Besides Uptodate do you have other references that you recommend for novice NPs?

BostonFNP, APRN

Specializes in Adult Internal Medicine. Has 9 years experience.

Boston and Riburn- I see you post a lot, and have enjoyed reading your responses to other's questions. Thanks for being such active members to these boards. Besides Uptodate do you have other references that you recommend for novice NPs?

UpToDate is something I use multiple times every day; well worth the investment at the student rate if your clinical sites/program don't offer access. Hopefully your work will pay your sub once you are working.

For adult primary care, the Buttaro text is an excellent clinical reference, especially with differentials and work ups.

The 5-minute Clinical Consult app is also quite good and I have several students that use it. Once you are worming you may get a pharma rep that will give you free access, if your facility allows them.

The USPSTF website is a great resource.

Your state's prescriber gateway or prescription monitoring program is very important.

When I was first in practice the Prescriber's Letter was very helpful

as well.

Sent from my iPhone.

Riburn3

Specializes in Internal Medicine. Has 10 years experience.

I tend to use Uptodate and epocrates, the latter more for quick pediatric info.

Boston added anything else I would have said and then some.

The reality is uptodate is going to be the go to reference for most occasions. Since I am new I use it often, and the other providers I work with use it regularly as well.

orangepink, NP

Has 3 years experience.

No u don't need to go back to school. Your mentor however wise she may be now was once a new grad too so don't let all her knowledge intimidate you. Use her as a reference and also do your part by studying more at home. I thought when I graduated that I don't have to study anymore but here I am still studying on a weekend.

I like the Johns Hopkins antibiotics app a lot, because it is constantly updated and a very quick reference. Johns Hopkins Guides: Antibiotic (ABX), HIV, Diabetes & Psychiatry

Whoever told you you are functioning at the level of a first semester NP student (a) is not being helpful, just cruel and critical and (b) does not remember just how little a first semester NP student knows! You are doing fine. Once you see some things over and over, you will have a lot more confidence.

Truly it could be worse. I simply went to work in my first job as a NP in Internal Medicine. Needless to say that is not ideal. I LIVED on up to date and family practice notebook and epocrates and micromedex and curbsided my MDs whenever I needed to in a shameless fashion. I would much rather feel uncomfortable getting the right answer than send a patient out with the wrong treatment plan. Being a novice is just painful. There is no way to get past it except the lived experience of getting more experienced. One day at a time my friend. Rome was not built in a day. Hang in there and before long things will feel much more settled. This is the practice of medicine we are talking about. It will not be easy but it will absolutely be worth it. Sounds like you are also learning how not to treat the person you will train in the future.

It's crazy to think that the feeling you have in school will translate on a couple of years out of school as well.

I love using UpToDate. Even now, I still use it. It's not an end all be all, but gives great guidance. Keep in mind, all cases are never 100% black and white. Everyone has different practice styles. You pay prescribe one thing and others may not. BUT always have a good rationale as to WHY your prescribing something or implementing a certain plan. If you don't understand the rationale behind a plan another provider gives, ask why. If your mentor has a different plan, ask her what her rationale is and why whether or not she/he feels your plan is reasonable. For viral processes, don't always feel pressured into giving a medication. Sometimes, support therapy is an appropriate route of action (unless you have some concerning findings...).

I agree with what everyone says about UpToDate. I am also a New FNP in practice. I will be practicing 6 months on April 20 (lol! I am counting). I still have my insecurities of not feeling "good enough" a lot of times and I also feel like an imposter everyday (which I will wonder when this feeling would stop). My preceptor and boss is a PA and he will be changing the schedule next week where I will be in the clinic all by myself ( I do rural health) and basically run the show and just call him or my supervising MD for advice. I'm nervous but excited at the same time. I had a really good clinical in pediatrics when I was in school. He told me to create a chart with the mg/kg dosage for common antibiotics/meds used in pediatrics and he was right! I still use the same chart today and it saves me time to calculate. You should make a chart reference (I did mine in excel), print it out & put it on a cover sheet and binder for antibiotic liquid forms: amoxicillin 400 mg/5ml, cefdinir, smz-tmp, zithromax, cefprozil, tamiflu, tylenol, ibuprofen...just have that in handy and also know the maximum dose per day....(this saved me a lot of time...i didn't have to calculate..it is really worth the trouble of taking the time to create this chart). Also print out the CDC vaccine schedule in color for kids, adults and just have it for reference along with your mg/kg antibiotics chart. I liked to use the Domino's 5 minute clinical consult for preventive care timelines gives you screenings per age group but you can also find this at the usptfs website. Uptodate is really an investment that is worth it.

cnmbfa

Specializes in OB/women's Health, Pharm. Has 40 years experience.

Go low tech. Get an alphabetized pocket sized notebook. Every evening, no matter what, go to Up-to-date and write brief notes on various conditions, beginning with the ones you encounter most often. Eventually you will have an impressive pocket brain, and the act of writing the notes will probably help you remember the information, or be able to find it quickly.

Skip electronic versions--make your own.

Every night in bed, reread some critical content from school. Hopefully, you now realize that NP school gave you the bare essentials you need to practice, and that there is far more that you need to learn, fast. Go to Medscape and subscribe to get emails on your specialty areas or any areas you are week on. My other favorites that I skim through are Health Day and Consult 360. There is no reason not to be able to keep up, and often its easier than you might think. Ask your colleagues if they have any favorite sites.

Don't be hard on yourself, but don't EVER make excuses for yourself, and work diligently to master the learning curve. The mark of an excellent practitioner is that they always wonder what it is that they don't know that they don't know! That drives them to continually learn, even years after graduation, so that they can stay on top of their field.