New nurse practitioner here Please help

Posted

Hi! I'm looking for some advice from this community. I graduated in May 2020 from a MSN FNP program. I have 7 years of nursing experience. Most of this was intermediate hospital care- Tele. I was in charge of a very busy telemetry unit. I was a go-to person on the unit, and I loved my job. It was hard to leave my coworkers during this pandemic. I started my first NP job 2 months ago. It's a private endocrinology practice. Upon graduation, I felt that primary care is where I wanted to work, but when the opportunity came to work in endocrinology, I was really excited for the challenge.

Unfortunately, I am having a very difficult time. I work with 3 physicians, 2 other NPs, 2 PAs. My first week was overwhelming as expected. I started learning the EMR which is brand new to me. I rotated between the NPs and PAs. Mainly observing for 2 weeks. On my 3rd week, I had my own patients (like 4 per day). This has steadily increased each week. Now I am seeing between 16-17 patients per day in my 8th week. Next week, I will begin seeing 20-25 per day. There has been no clear orientation process. I have been going early to start my notes and essentially look up all my patients so that im as prepared as possible. I just feel very scared. Im studying as much as I can, but I am feeling very discouraged. I have received very little feedback from any of the physicians, and they are signing all my notes. My education was great. As a FNP, I feel my education was well rounded and comprehensive. However, I certainly have so much to learn. I do not feel proficient in managing these chronic conditions "on my own". The physicians and NPs are approachable when I have questions, but I just feel like I have been thrown to the wolves. It feels unfair to me and more importantly to these patients. I need more time for education and management of these conditions.

Next week, I am expected to see a patient for a brand new insulin pump start. I have observed one of these so far. My first exposure to an insulin pump was when I started this job. I have learned a lot about the insulin settings, but I honestly don't understand much of it. I feel stupid seeing these patients who have been on insulin pumps for years, and I can barely decipher the pump download let alone make insulin pump setting changes. 

Last week, I expressed my concern to the office manager who then spoke with 2 of the physicians. They agreed that going from 16 patients one week to 25 the next is too much, and my schedule was adjusted to seeing 20-22 patients. I am remarkably overwhelmed and anxious. The other advanced practice providers are nice enough and approachable also, but I just feel like this is crazy. I tried asking if this is the typical process, and they said yes. They don't seem to have much sympathy for me LOL. Side note, they also hired a brand new PA one month before me. His "orientation" has been similar. He seems overwhelmed also, but I haven't been able to ask him directly how he feels about things. 

Thank you for reading. I'm just searching for some help. I don't know what to do at this point. I want to quit so badly, but I don't want to be a quitter either. I just feel like this is insane. My mental health is suffering as I have always taken pride in my work. I want to provide good care. Thank you again. 

Tegridy

Specializes in Former NP now Internal medicine PGY-2. 364 Posts

You say your education was great but then say you can't manage patients on your own I am confused?

 

Pick up an endocrinology book and start reading, for the sake of your patient's lives...

4 minutes ago, Tegridy said:

You say your education was great but then say you can't manage patients on your own I am confused?

 

Pick up an endocrinology book and start reading, for the sake of your patient's lives...

You're confused? Nurse practitioner school isn't a factory that spits out providers that are 100% ready to practice independently. Thanks for your supportive comment LOL. Just what I needed.

Tegridy

Specializes in Former NP now Internal medicine PGY-2. 364 Posts

I am assuming they are punting their DM1s and DM2s who are either difficult to manage or have lazy PCPs to you as most endo clinics do. Leaving the endocrinologist with the more rare stuff/patients who only want to see the doctor.

Ask your other coworkers what they did in regards to learning how to manage the most common things they see. Ask for a list of the most common pump brands seen at the clinic then go on the website dedicated to them and figure them out. Most DM2 patients aren't that hard, either the PCP is just lazy or they can't get preapproval from insurance for certain meds and send them to you for that.

 

The good thing is endo is pretty narrow spectrum (most everyone is just diabetic) so if you can master that you'll be OK. Good luck

Seeing 25 patients a day? Are you kidding me? Are you working 12 hour shifts? I certainly hope we don’t allow the NP role to follow the path of what the RN has become. You worked hard for your title, do not allow yourself to be ruled by management that did not complete the career path that you chose. Put your foot down and tell them how many patients you will see safely in a day. 

I just graduated as FNP , soon to test. I certainly hope not to expect what you are describing:)

caliotter3

38,332 Posts

It is understandable that you feel a strong urge to quit but what are your employment prospects otherwise?  And who is to say that a new work environment won't actually turn out to be worse?  I would make a strong effort to deal with this in order to come out at the other end.  Or, you can defer to the alternative of finding yet another RN job, the default option.  At least you have that open to you, but it should only be your last resort.  Best wishes as you hang in there.

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 4 years experience. 2 Articles; 1,395 Posts

I am very sorry you are going through this.  Most new grad NPs feel this way at first.  I felt the same way for the first 3 months, then things gradually improved.  By the end of 6 months, I was pretty comfortable, and by the end of 1 year, I was reasonably confident.

What helped was my first job had 2 doctors who were excellent mentors.  One of them saw how nervous I was and told me to ask a lot of questions and that is what he is there for.  My fellow NPs told me the same thing.  They did not see it as a sign of ignorance or weakness.

There is no endo specialty at any NP Program, so don't feel bad.  Yes, you are going to have to do some studying, so do it.

Here are some suggestions:

1.  Ask one of the doctors or experienced NPs to be your mentor and set up regular meetings to review your progress and go over more complex patients.  Ask for feedback on how you are doing and areas for improvement.

2.  Make friends with other providers - NPs are generally sociable and then you can talk with them while out of the office.

3.  Do some analysis, and ask about, the most common types of patients and conditions.  If most of the patients have DM2 and have poor health literacy, that is an area for you to focus on learning.  If the 2nd biggest group has thyroid issues, then that is the next area to focus on, etc.

4.  You need to examine your schedule.  I don't know how you can see 25 patients a day in an 8 hour day unless they are only giving you 10 to 15 minutes for existing patients.  Ask for a reduced schedule until you have more experience.  Another option is to go part time for awhile, perhaps 4 days a week for a couple of months.

5.  Don't let the perfect be the enemy of the good.  You should be charting as you go.  The chart does not have to be in perfect prose with all the exact medical terms.  Just write enough, and plain English is fine, so that another clinician could read the chart note and know what is going on.  You don't have to write a novel or case study for school.  Read the chart notes of more experienced providers to see what they write.

6.  Use automated tools to allow you to write chart notes more quickly

7.  It's OK to look stuff up.  I always checked UptoDate quickly - I can't memorize everything and info changes - better to check.  Get a couple of good reference books and use those, too.

8.  Make up cheat sheets of your own.

9.  For procedures like the insulin pump, ask for another provider to be with you while you do the first one.  Ask if there is a practice pump you can use to examine and understand before doing the real thing.

Hang in there!

 

5 hours ago, RN/WI said:

Seeing 25 patients a day? Are you kidding me? Are you working 12 hour shifts? I certainly hope we don’t allow the NP role to follow the path of what the RN has become. You worked hard for your title, do not allow yourself to be ruled by management that did not complete the career path that you chose. Put your foot down and tell them how many patients you will see safely in a day. 

Thanks. It's nice to see my feelings are validated by someone. We work 8 hour shifts. It's actually more like 10, but I only see patients from 8-4. I'm definitely going to try to put my foot down. Thanks 

4 hours ago, caliotter3 said:

It is understandable that you feel a strong urge to quit but what are your employment prospects otherwise?  And who is to say that a new work environment won't actually turn out to be worse?  I would make a strong effort to deal with this in order to come out at the other end.  Or, you can defer to the alternative of finding yet another RN job, the default option.  At least you have that open to you, but it should only be your last resort.  Best wishes as you hang in there.

Yeah, you're right. I mean if I quit I would make sure I have something else lined up. It's impossible to know what another job might be like. It's nice to know that I have something to fall back on. 

31 minutes ago, FullGlass said:

I am very sorry you are going through this.  Most new grad NPs feel this way at first.  I felt the same way for the first 3 months, then things gradually improved.  By the end of 6 months, I was pretty comfortable, and by the end of 1 year, I was reasonably confident.

What helped was my first job had 2 doctors who were excellent mentors.  One of them saw how nervous I was and told me to ask a lot of questions and that is what he is there for.  My fellow NPs told me the same thing.  They did not see it as a sign of ignorance or weakness.

There is no endo specialty at any NP Program, so don't feel bad.  Yes, you are going to have to do some studying, so do it.

Here are some suggestions:

1.  Ask one of the doctors or experienced NPs to be your mentor and set up regular meetings to review your progress and go over more complex patients.  Ask for feedback on how you are doing and areas for improvement.

2.  Make friends with other providers - NPs are generally sociable and then you can talk with them while out of the office.

3.  Do some analysis, and ask about, the most common types of patients and conditions.  If most of the patients have DM2 and have poor health literacy, that is an area for you to focus on learning.  If the 2nd biggest group has thyroid issues, then that is the next area to focus on, etc.

4.  You need to examine your schedule.  I don't know how you can see 25 patients a day in an 8 hour day unless they are only giving you 10 to 15 minutes for existing patients.  Ask for a reduced schedule until you have more experience.  Another option is to go part time for awhile, perhaps 4 days a week for a couple of months.

5.  Don't let the perfect be the enemy of the good.  You should be charting as you go.  The chart does not have to be in perfect prose with all the exact medical terms.  Just write enough, and plain English is fine, so that another clinician could read the chart note and know what is going on.  You don't have to write a novel or case study for school.  Read the chart notes of more experienced providers to see what they write.

6.  Use automated tools to allow you to write chart notes more quickly

7.  It's OK to look stuff up.  I always checked UptoDate quickly - I can't memorize everything and info changes - better to check.  Get a couple of good reference books and use those, too.

8.  Make up cheat sheets of your own.

9.  For procedures like the insulin pump, ask for another provider to be with you while you do the first one.  Ask if there is a practice pump you can use to examine and understand before doing the real thing.

Hang in there!

 

Thank you for your comments. I really appreciate it. I'm hoping that things continue to improve. I will take your advice. 

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 14 years experience. 1,453 Posts

I would suggest finding a job or moving to a job market more conducive to your sanity.  Granted I'm in mental health, but I never see more than 18-19 patients per day.  I believe that you will find that states like Washington, Oregon, New Hampshire, Idaho, Wyoming, Nevada and Colorado (states with IP) have a better working environment. In such a place you could probably find a deal where you earned 65 to 70% of the revenues that you generate and see maybe 18-20 patients four days per week and easily earn in the 200K range (1099).  

Iheartwoundcare, MSN, APRN, NP

Specializes in Wound Care, Med-Surg, Rehab. Has 7 years experience. 46 Posts

On 1/3/2021 at 5:30 PM, FullGlass said:

I am very sorry you are going through this.  Most new grad NPs feel this way at first.  I felt the same way for the first 3 months, then things gradually improved.  By the end of 6 months, I was pretty comfortable, and by the end of 1 year, I was reasonably confident.

What helped was my first job had 2 doctors who were excellent mentors.  One of them saw how nervous I was and told me to ask a lot of questions and that is what he is there for.  My fellow NPs told me the same thing.  They did not see it as a sign of ignorance or weakness.

There is no endo specialty at any NP Program, so don't feel bad.  Yes, you are going to have to do some studying, so do it.

Here are some suggestions:

1.  Ask one of the doctors or experienced NPs to be your mentor and set up regular meetings to review your progress and go over more complex patients.  Ask for feedback on how you are doing and areas for improvement.

2.  Make friends with other providers - NPs are generally sociable and then you can talk with them while out of the office.

3.  Do some analysis, and ask about, the most common types of patients and conditions.  If most of the patients have DM2 and have poor health literacy, that is an area for you to focus on learning.  If the 2nd biggest group has thyroid issues, then that is the next area to focus on, etc.

4.  You need to examine your schedule.  I don't know how you can see 25 patients a day in an 8 hour day unless they are only giving you 10 to 15 minutes for existing patients.  Ask for a reduced schedule until you have more experience.  Another option is to go part time for awhile, perhaps 4 days a week for a couple of months.

5.  Don't let the perfect be the enemy of the good.  You should be charting as you go.  The chart does not have to be in perfect prose with all the exact medical terms.  Just write enough, and plain English is fine, so that another clinician could read the chart note and know what is going on.  You don't have to write a novel or case study for school.  Read the chart notes of more experienced providers to see what they write.

6.  Use automated tools to allow you to write chart notes more quickly

7.  It's OK to look stuff up.  I always checked UptoDate quickly - I can't memorize everything and info changes - better to check.  Get a couple of good reference books and use those, too.

8.  Make up cheat sheets of your own.

9.  For procedures like the insulin pump, ask for another provider to be with you while you do the first one.  Ask if there is a practice pump you can use to examine and understand before doing the real thing.

Hang in there!

 

Such an encouraging and thoughtful response. ❤️