New nurse practitioner here Please help

[amc248]

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. 

[Iheartwoundcare, MSN, APRN, NP]

On 1/5/2021 at 4:48 PM, myoglobin said:

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).  

Yes. I am in Texas and this is the agreement I have with my collaborating physician. I get 70% of the reimbursement and will see around 18-20 per day 4 days a week. They are primary care and wound care patients. I feel very blessed. 

I hate to hear that new NPs are being mistreated this way. 

[PaulL]

Feelings of anxiety and insecurity in your decisions are NORMAL when taking on a new role with this much autonomy! Utilize the resources available to you and ASK when you have questions. Learning is a process which never stops, if you don't feel confident in managing the conditions, speak with your peers on which resources they used to learn and consider checking uptodate as well!

[AnnieNP, MSN, NP]

You can do this.  I was very nervous the first 3-6 months (I'm in a practice that is half primary care and half pulmonary).  

Contact the Insulin Pump companies and ask them to have a Rep reach out to you. They can provide alot of helpful information. Good luck.

 

[Rnis, BSN, DNP, APRN, NP]

This seems like a very stressful working environment.   Honestly I work in family medicine and I never have any day in the week where I see more than 16 patients in a day (usually less) .  There is a trade off for this and I have more patient contact hours but see a lot less patients than other scheduling grids. 

 When I first started my job many years ago, they had started a new orientation process that had included input from the newest advanced practice providers that had started before me.  I was on orientation for about 12 weeks.  I spent about a month shadowing, then I spent a month seeing patient's off other provider's schedules (like a clinical rotation)  then they threw a handful of patients on my schedule but I had to review the plan when someone on my team.   They told me they would tell me when I didn't have to do that anymore.....LOL, I eventually just stopped because it felt annoying.

I felt very supported and honestly, we have hired one APP since me and only because we were growing because people rarely quit/turnover is low.  

I would try to find a mentor, that person you can run your patients by  and talk to them about how they  increased their knowledge confidence.  I honestly was put on probation by up to date when I first started because I was using it so much they thought I was sharing the account  ?  try to sign up for virtual conference on the conditions you are most frequently seeing.     

Endocrinology is a hard field and there is a large shortage of providers.  Giver yourself some time and grace.  Good luck !

[FiestyNP]

On 1/3/2021 at 7:36 AM, 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...

That comment was less than helpful. She's not stupid. She's overwhelmed and needs some support. She didn't say she can't manage patients on her own....that was an unfair assumption by you. I sure hope you're not in a managerial position if you show this attitude to your employees.

 

[FiestyNP]

On 1/3/2021 at 11:32 AM, RN/WI said:

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

Do thorough research on any company or entity that offers you a job. Look at websites that have employee reviews of the company. Run a search on a private practice to see if there have been legal issues with them. Ask in the interview if there is a lot of job turnover in the company. Look at body language. If interviewers are fidgety, refuse to look at you when you talk, or look bored, run away from that job. Also, if there is a sign on bonus involved run far away. Usually there is a bonus when the job can't be filled because management is terrible. Not always, but more often than not. Also, if you accept a job and get a contract, hire an employment lawyer to help you understand what is in the contract and what that means for you. Good luck to you!

[FiestyNP]

On 1/3/2021 at 12:09 PM, 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.

You are right that one should see what the employment prospect is before quitting a job. However no NP should be put into a situation that is set up for failure at best, hurting patients at worst. Yes, another situation could certainly be worse, but if a person is feeling overwhelmed with no support and that starts to affect the person's mental and physical health, and puts the license they worked so hard for in jeopardy, the job is not worth it no matter what.

[Tegridy]

1 hour ago, FiestyNP said:

That comment was less than helpful. She's not stupid. She's overwhelmed and needs some support. She didn't say she can't manage patients on her own....that was an unfair assumption by you. I sure hope you're not in a managerial position if you show this attitude to your employees.

 

She said she was not ready for independent endocrinology practice so yes she did say that. If you can’t practice without consistently consulting a physician you are not self managing

[FullGlass, BSN, MSN, NP]

On 1/16/2021 at 12:39 PM, Tegridy said:

She said she was not ready for independent endocrinology practice so yes she did say that. If you can’t practice without consistently consulting a physician you are not self managing

Someone just starting in endocrinology is going to need help and support. 

[JBMmom, MSN, NP]

On 1/3/2021 at 6:30 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.

Thank you for providing such a thorough and thoughtful response! As someone that will be graduating and looking for a new job within the next six months, I appreciate this feedback and will also take these things into consideration when I find a new position. Your time and efforts are greatly appreciated!

[2BS Nurse, BSN]

I can't believe you are seeing 20-25 patients per day. That's ridiculous! It takes more than 15 minutes to discuss an insulin pump!! I know of an endo who works with a PA. They see that many between the two of them. 

[aok7, NP]

How is it going?  How have you adjusted and do you have advice after a few months?

I am in a nephrology specialty.  The physicians rarely see more than 16 patients per day.  I am one of three NPs in my group and I have not seen more than 10 patients in the day.  As for learning, while it is understood there is so much to learn we each learn on our own for the most part.  I read notes of the physicians, excellent way to learn in specialty.  Additionally, I subscribe to specialty organizations/journals.  LOL it is a Saturday and I am in fact "casually" listening to a podcast on anemia and reading NephSAP on hypertension.  NP school did not prepare me for specialty practice, nor did my school even promote it.  I was advised primary care as first job, and what I did (internal med/hospital).   I will be a a year in May in nephrology and I love it.