working alone as a new grad

Specialties NP

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Hey all... just wanted to get some feedback on people's experience with working alone as a new grad NP. I recently turned down a job offer (for many reasons), but one was that they changed the schedule and I was expected to work alone straight out of the gate. I have also had a few interviews for urgent care clinics that also wanted me to work independently and I shied away from them.

I have been a nurse for 13 years and have almost 12 years of emergency nursing. I have also worked as a travel nurse for the last 5 years. I'm used to being thrown head first into situations and sorting it out as I go. I know what the appropriate plans of care are, but am still a newbie when it comes to procedures like suturing and formally reading XRs and billing and coding are still a mystery to me.

I know that, ultimately, it comes down to comfort level, but has anyone worked alone from day one without any issues, or would others advise against it? Did you feel supported by the physician if you did have questions, or did you rely on online resources to help with decision making?

Specializes in Family Nurse Practitioner.
This is where a residency can be beneficial but as they are so sporifice, they are not generally a viable option. I don't think any clinic should be hiring a new grad to work by themselves without another provider present and not because of a lack of education, but a lack of applying knowledge to real world situations.

This is exactly why residencies are crucial and where our education is seriously lacking. New MDs absolutely do start work with minimal orientation with the exception of course in learning the facility specific items such as EMR etc.

Specializes in Psychiatric and Mental Health NP (PMHNP).
This is exactly why residencies are crucial and where our education is seriously lacking. New MDs absolutely do start work with minimal orientation with the exception of course in learning the facility specific items such as EMR etc.

I agree we need NP residency programs. However, given that NP residencies are few and far between, none of my prospective employers expected me to hit the ground running. They all understood that I would need ramp up time and had established ramp up programs for new NPs and PAs. In addition, given that new NPs are paid about 1/2 of new MDs, the employers I interviewed with were willing to invest in reasonable ramp up. Ramp up and training is an important criteria for new NPs in selecting a job and should be negotiated as part of the offer. All of my prospective employers were glad that I was clear in requesting this because it showed I am committed to safe and quality patient care.

The analogy to new MDs is not correct, as MDs have internship and residency. A newly graduated med school student would not be able to just jump in and provide clinical care w/o any ramp up or training.

If NP residencies were the norm, then it would be expected a new NP could hit the ground running. However, until that is the case, new NPs will need training and ramp up.

This is exactly why residencies are crucial and where our education is seriously lacking. New MDs absolutely do start work with minimal orientation with the exception of course in learning the facility specific items such as EMR etc.

right. But you're talking new mds fresh out of two or more years of residency. I think that any new np in the field and anyone hiring them should so with the foreknowledge there is months of transition. Imo it's not a suggestion of lacking of np school but a lacking in the education process where residencies aren't the norm. But imo a dnp should be residency focused anyway. Spend masters getting a general np degree and have the dnp focus on a specialty.

Specializes in Internal Medicine.
right. But you're talking new mds fresh out of two or more years of residency. I think that any new np in the field and anyone hiring them should so with the foreknowledge there is months of transition. Imo it's not a suggestion of lacking of np school but a lacking in the education process where residencies aren't the norm. But imo a dnp should be residency focused anyway. Spend masters getting a general np degree and have the dnp focus on a specialty.

And most decent MD's with experience working with new grad NP's already know this and don't usually throw their new NP's to the wolves. They're aware we don't get a lengthy residency akin to physicians. If they aren't, it's our job to make sure they know that when interviewing.

It's fine to be critical of perceived education shortfalls that JulesA is so keen to continually remind us of, but in the real world, we are expected to hit the ground running without having to go through a paid lengthy residency program. That's honestly one of our appeals to the medical market.

I would imagine most new grad NP's experience some sort of orientation period for a few months in their job, and by the time they had been working a year, would tell you they're more comfortable in their shoes.

I work for one of the largest hospitalist employers in the country and even experienced NP's when they get hired go through a 3 month supervised orientation. New grads get 6 months. Expecting us to be 100% proficient from day 1 is unrealistic.

Specializes in ER/Trauma.
For any program, understanding the small details of both how the clinic specifically runs to even the small prescribing preferences we garner take time to build. You don't really learn in school how *many doses*of flexril to give for that acute back pain that you know is part of the recommendations...only that it's prn and used to help out with the run of PT you are about to order.

Yes. This is exactly what I'm talking about. I know what I need to do as far as care, but it's knowing how to specifically go about it. Like, how do I arrange the PT, how do I go about getting prior authorizations from insurance companies for medications and rehab, etc. What labs are going to be covered for today's visit, what do I need to document to ensure proper billing/coding? When does the patient require a specialist as opposed to managing their problem in office, what specialists do I refer to- is based on insurance or provider preference?

I have been an emergency department bubble where providers have any and all resources at their disposal and there is no need to worry about what insurance companies will and will not cover, plus all the XRs are read and reported by radiology, so while the ER providers may read them themselves, an official read is mere minutes away.

Yes. This is exactly what I'm talking about. I know what I need to do as far as care, but it's knowing how to specifically go about it. Like, how do I arrange the PT, how do I go about getting prior authorizations from insurance companies for medications and rehab, etc. What labs are going to be covered for today's visit, what do I need to document to ensure proper billing/coding? When does the patient require a specialist as opposed to managing their problem in office, what specialists do I refer to- is based on insurance or provider preference?

I have been an emergency department bubble where providers have any and all resources at their disposal and there is no need to worry about what insurance companies will and will not cover, plus all the XRs are read and reported by radiology, so while the ER providers may read them themselves, an official read is mere minutes away.

Are you really responsible for arranging PT and getting all prior auths? Generally there should be nurses or MAs who take care of most of that, only involving the provider if a peer to peer review is needed. And all images should have a formal read by radiology. Depending on the situation you might be in a position to make treatment decisions before radiology can complete the read, but there's nothing wrong with saying, "nothing immediately pops out to me on this xray, but we need to wait for the radiologist to formally review your xrays." There's a reason radiology is its own specialty.

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