New NP mistake

Advanced Practice Columnist / Guide · Oct 10, 2013

First off, I am not a primary care NP nor an ED NP. I am a critical care NP (my field is more along your previous wheelhouse maybe). What I will say about situations like this is that this is a learning opportunity. Whenever you are asked a question by a provider (physician, fellow NP, PA) such as is there "trismus"?, the intent is never to make you look stupid in the first place. It is to delve deeper into the clinical picture. You will need to think quickly on your feet and figure out why you are being asked the question. Obviously you didn't know what trismus meant.

But if you do know what it is, what always works for me is to try to put my brain in the same frame of mind as this physician. For example, in this situation, is he asking me this because Clindamycin has the same bioavailability if given IV vs oral and that "trismus" will be the limiting factor in not prescribing the medication orally and not admitting the patient? Obviously it will take time for a newbie to make nerves go away way so that you can think logically given the stress of being put on the spot.

What I would always do is just be honest about what you don't know and ask the rationale each time a question is being asked. Respond in a calm and eloquent manner if you can and don't offer information that is not there. Be honest in saying you don't know the answer or you didn't examine the patient for that particular sign or symptom. I wish NP students spend more time being "pimped" on rounds and that's what we typically do to medical students and residents and it works well as far as improving their manner of presenting a clinical scenario.

Regarding that physician. He'll get over it and if I were you I would look forward to working with him again so that next time you have chance to change his impression of you.

core0 · Oct 11, 2013

Prior to being an NP I was an ICU/CVICU nurse for 6 years and felt I was good at it. I went into ER and have worked 5 shifts so far.... I love it so much but I made a mistake and got yelled at already... I feel so so stupid and don't know what to do now!! I need some advice please...
Condensed story....I had a patient that needed admitted for IV clindamycin for a periodontal abcess that was crazy....So I went to the dr and told him all her symptoms and my plan.... He said "is there trismus" and I said "excuse me" and he said it again.... And stupid me said "no... She has" blah blah and said all her symptoms again. Then he said "do you know what trismus means" and I said "no but I'm going to look it up" and he said wasn't happy. He said "never ever answer a question without being 100% sure of the answer, this makes me not want to trust you". I mean I was wrong, I don't know why I even said no, I panicked and was nervous. Now I'm so worried to work with him again.
Advice?

First question would be where are you in orientation? If you have worked 5 shifts I would assume that you are still on orientation. The expectations are lower here. However, as Juan stated when you are presenting there are only three answers yes, no and I don't know. The first two have to be correct. That being said you need to learn from your mistake and move on.

Compared to the ICU, there are some aspects of EM that are much more difficult. The patients come in undifferentiated and you have to figure out what is going on. I occasionally moonlight in small ERs while working in a tertiary SICU. I have no problem with critically ill patients. I have a harder time with the little stuff like sore throat. The EM version of 5 minute clinical consult for me is very helpful. Among other things it has physical finding you have to look for and differential diagnosis to use.

jamiejo05 · Oct 11, 2013

First question would be where are you in orientation? If you have worked 5 shifts I would assume that you are still on orientation. The expectations are lower here. However as Juan stated when you are presenting there are only three answers yes, no and I don't know. The first two have to be correct. That being said you need to learn from your mistake and move on. Compared to the ICU, there are some aspects of EM that are much more difficult. The patients come in undifferentiated and you have to figure out what is going on. I occasionally moonlight in small ERs while working in a tertiary SICU. I have no problem with critically ill patients. I have a harder time with the little stuff like sore throat. The EM version of 5 minute clinical consult for me is very helpful. Among other things it has physical finding you have to look for and differential diagnosis to use.[/quote']
Thank you, I completely understand and I regret saying No.... I don't even know why it came out of my mouth.
As for the question about orientation.... There was none. I mean I "shadowed" the head PA for 4 shifts, then I was on my own. I was told, go to the doc if you have a question, need to run something by them or are admitting.
As for moving on... I really want to, i just have a fear the doc won't and will hold it against me.

SlyFoxRN, BSN, RN · Oct 11, 2013

Thank you, I completely understand and I regret saying No.... I don't even know why it came out of my mouth.
As for the question about orientation.... There was none. I mean I "shadowed" the head PA for 4 shifts, then I was on my own. I was told, go to the doc if you have a question, need to run something by them or are admitting.
As for moving on... I really want to, i just have a fear the doc won't and will hold it against me.

He'll come around. Lots of people - MDs, Med students, NPs, RNs, PAs - make mistakes. He understands you're new, and I think he's just a little concerned that you answered without knowing. If you're really worried, go talk to him when you have time. Tell him you were nervous and spoke without thinking, and that you will not make that mistake again. Tell him you know you made a mistake and that you will try to earn his trust so you can work together well.

I'm sure he will appreciate that, and look for him to try to trip you up again and see how you handle it. Say you don't know!

allnurses Guide · Oct 11, 2013

It is a mistake: probably not your first or last. We learn from them. The physician told you this so you will learn from it, not because he has lost all faith in you.

As a provider, it is always ok to say "I don't know" but it is never ok to say you know when you don't. I bet you will never make that mistake again.

This is a humbling profession, much more so than being an RN (at least from my experience). It's ok not to know all the answers; just know who to ask to get them.

Trauma Columnist · Oct 11, 2013

Totally agree with other APN opinion above....you will get thru this and believe me you won't repeat this. As CoreO stated trismus is the defining factor of admit versus go home in this instance.

We all make mistakes when we are new. They are doing you a disservice by not providing orientation...big no no for any new APN. Are you suturing, injecting, etc..? These are not skills you just run by the doc.

Please take care...

VTach2013 · Oct 11, 2013

Don't worry about it. It was a mistake and we all make mistakes! Just remember that that doc at some point made mistakes that made him look like a fool in front of someone else . Learn from your mistakes and move on!

jamiejo05 · Oct 11, 2013

Thank you all for your comments. I greatly appreciate it.

As for orientation... I study daily, I did take a suturing class and did suturing in school. What type of orientation should I have been provided?

BostonRN13 · Oct 12, 2013

I feel for you! I could see myself, as a new grad NP, doing the same thing for the sake of not "Looking stupid". The MD will forgive you, just keep on doing your best and time heals all..

allnurses Guide · Oct 12, 2013

Always remember...

Being embarrassed is temporary.

Making a mistake pretending you know something you don't may be much more permanent.

core0 · Oct 12, 2013

Thank you all for your comments. I greatly appreciate it.
As for orientation... I study daily, I did take a suturing class and did suturing in school. What type of orientation should I have been provided?

It really depends on the expectation. For our ICU if you are going to be there alone at night our orientation is eight to nine months. If you come out of a critical care post grad program its two months. For EM there are a couple of ways of doing it. You can do long orientations or you can do progressive orientation which seems to be more common. Start with relatively easy patients ESI 4 and 5. Then add ESI three until people are comfortable then take ESI 1 and 2. For new grads thats probably six months to a year. I would expect someone experienced to be up to speed within a month. Someone with experience but not in EM, 2-6 months.