Unsure about your skills as a NP

Editorial Team / Admin · Oct 6, 2008

I think that uncertainty is unique (if all would be honest) in every career path dealing with individual's lives.

Bear in mind many come here not only to share information, but to vent, receive support, etc. Some of this may include those who feel unprepared for the real world.

But, do not take this as meaning, "I don't know what I'm doing".

Sure, some enter into this career with no idea of what they are getting in to. Some cannot handle the pressures of providing daily health care, making decisions that affect the lives of others. BUT, that isn't exclusive to the NP. MD's feel that same pressure.

Nurses need a safe haven to which to come and voice their concerns.

allnurses.com is that safe haven.

core0 · Oct 6, 2008

I get the impression that a fairly common sentiment amongst NPs (on this site) is they're very uncertain about their skills or abilities. It's actually concerning to read. I understand a NP is not a MD however, a FNP should be able to treat 80% of all illnesses and do it with confidence. Studies have shown the ability of NP to provide comparable family care as FMD yet I read that some NP are unsure or feel unprepared on complex treatments and/or diagnosis that they will encounter as a FNP or other NP.
Scary...

This is a pretty common issue. Here are some articles about the problem:

http://www.medscape.com/viewarticle/533648

http://www3.interscience.wiley.com/journal/119989481/abstract?CRETRY=1&SRETRY=0

http://www.nursingresearchonline.com/pt/re/nnr/abstract.00006199-199701000-00008.htm;jsessionid=LqgQfThpwZZ2DyXP5x2lTf1hplQMLHPr1cqnXq8YFLSRNh21L2KR!-2060166207!181195629!8091!-1

Here is a nice article on coping with it:

http://include.nurse.com/apps/pbcs.dll/article?AID=/20080519/NATIONAL02/80516012/-1/frontpage

Lest you think that this is solely a nursing problem:

http://www.stfm.org/fmhub/fm2004/April/Kathy248.pdf

Imposter Phenomenon in PA Education. J. Prata and J. Geitzen, Pacific University School of PA Studies, Hillsboro, Oregon (Poster at the 2007 AAPA conference).

The secret to this, if there is one is the initial position out of school. Remember that in medicine it is rare to work in a vacuum. Most NPs are part of practice and will have multiple mentors and resources. The key is to find a good practice (which may be difficult depending on your situation). This will allow you to develop your skills in an environment that acknowledges this. Graduation from a program just means you have the basic skills to do the job. Those skills get refined on the job and you learn any position specific skills. A supportive position will recognize this and provide an adequate orientation and good backup. Even physicians will develop a support network of other physicians that they can discuss cases with and get advice on management.

When we developed the Colorado PA practice act one of the concepts that we used was graduated practice. This requires on-site physician prescence for the first six months with new grad PAs.

Along those lines there are a number of jobs that are probably not the best for new grads:

Minute clinic type jobs (for a number of reasons)

Night positions

Solo clinic positions

All of these will have difficulties with face to face mentoring (which I think is the key). Bottom line your worries are common. The key is to find a position that will allow you to overcome the fears and build your clinical skills.

David Carpenter, PA-C

allnurses Guide · Oct 6, 2008

Revolution, you do post the oddest assortment of statements/questions!

jrprthd96 · Oct 7, 2008

I think its worth saying that nurse practitioners generally care about their patients and take their patients health care personally. This is easily seen as you consider the motivation for us to return to school and go after this degree and work. Many positions that do what be do will go for financial reasons when a little care and concern for others would be beneficial. As a nurse, I became frustrated that there were obvious things not done for patients and many times I was looked down upon for suggesting changes in the POC for my patients. I have been yelled at for questioning an order, written up for not carrying out a dangerous order, and unable to effect the care plan for a patients who were under-served for various reasons. One thing I have not been is arrogant enough to assume I know everything. What should scare you is the number of times an arrogant MD has made a statement full of absolutes and been so wrong, and then, when the truth was clear, all they could say was how it was not their fault. I take comfort in knowing that we will be smart enough to know our limits (experience, knowledge, or scope of practice) and that we would be humble enough to ask advice. Anyone not governed by those principles, NP or otherwise, scares me.... But I may be strange.

Trauma Columnist · Oct 7, 2008

And...as with everything, there is a learning curve. I have now been an APN for 2.5 years. I have learned a lot, but need to learn a lot more. Does that make me incompentent? I don't think so. It makes me totally aware that my medical decisions can have far-reaching consequences and thus; for my patients' sake, I need to be cautious.

I do say "I don't know to my patients" and make appropriate referrals - that's the sign of an APN who wants to provide excellent patient care, cont to have a good relationship with the patient and one who wants to keep their license.

Good question.

emtneel · Oct 7, 2008

i don't know if you are meaning new grads, which i would think then you are stating the obvious. But not sure what that means if you mean in general...

I do know that my nurse manager always said she was more confident in a nurse that admitted that they didn't know everything than a nurse that thought they knew everything.

I would think that would transfer to the position of a midlevel as well.

We didn't go to med school, we didn't do 3-7 years of residency, so yeah, we don't know everything. That's pretty obvious isn't it?

Being a new grad I feel like I would need to look most things up just because I am not confident in my judgement yet.

christvs, DNP, RN, NP · Oct 7, 2008

I get the impression that a fairly common sentiment amongst NPs (on this site) is they're very uncertain about their skills or abilities. It's actually concerning to read. I understand a NP is not a MD however, a FNP should be able to treat 80% of all illnesses and do it with confidence. Studies have shown the ability of NP to provide comparable family care as FMD yet I read that some NP are unsure or feel unprepared on complex treatments and/or diagnosis that they will encounter as a FNP or other NP.
Scary...

I agree with Siri: we need to have a place to come to ask for advice and support, and to just vent. What is so wrong with that? Who doesn't do that-ask their peers for help? I think if an NP or MD or anyone went around thinking they knew it all and were right about everything, then THAT to me is what is scary.

christvs, DNP, RN, NP · Oct 7, 2008

This is a pretty common issue. Here are some articles about the problem:
http://www.medscape.com/viewarticle/533648
http://www3.interscience.wiley.com/journal/119989481/abstract?CRETRY=1&SRETRY=0
http://www.nursingresearchonline.com/pt/re/nnr/abstract.00006199-199701000-00008.htm;jsessionid=LqgQfThpwZZ2DyXP5x2lTf1hplQMLHPr1cqnXq8YFLSRNh21L2KR!-2060166207!181195629!8091!-1
Here is a nice article on coping with it:
http://include.nurse.com/apps/pbcs.dll/article?AID=/20080519/NATIONAL02/80516012/-1/frontpage
Lest you think that this is solely a nursing problem:
http://www.stfm.org/fmhub/fm2004/April/Kathy248.pdf
Imposter Phenomenon in PA Education. J. Prata and J. Geitzen, Pacific University School of PA Studies, Hillsboro, Oregon (Poster at the 2007 AAPA conference).
The secret to this, if there is one is the initial position out of school. Remember that in medicine it is rare to work in a vacuum. Most NPs are part of practice and will have multiple mentors and resources. The key is to find a good practice (which may be difficult depending on your situation). This will allow you to develop your skills in an environment that acknowledges this. Graduation from a program just means you have the basic skills to do the job. Those skills get refined on the job and you learn any position specific skills. A supportive position will recognize this and provide an adequate orientation and good backup. Even physicians will develop a support network of other physicians that they can discuss cases with and get advice on management.
When we developed the Colorado PA practice act one of the concepts that we used was graduated practice. This requires on-site physician prescence for the first six months with new grad PAs.
Along those lines there are a number of jobs that are probably not the best for new grads:
Minute clinic type jobs (for a number of reasons)
Night positions
Solo clinic positions
All of these will have difficulties with face to face mentoring (which I think is the key). Bottom line your worries are common. The key is to find a position that will allow you to overcome the fears and build your clinical skills.
David Carpenter, PA-C

David, you are so right. I am a new NP and I am in my first NP position as a Hospitalist NP. I am working nights, and that is exactly why I am looking for another position. It's scary to have so few MDs on at night when I am so new, and also scary is the fact that I am covering 50 patients, some of which are urology and neurosurgery patients, in addition to hospital medicine patients...and the urologists here are famous for never calling back when there is an emergency with their patients. Now that is scary. I have total confidence in myself that I am doing the best I can do and am a safe practitioner, but given the circumstances I feel that I would be more supported and feel better in a less stressful environment-such as a Cardiology NP job that I am interviewing for this week-which is a day shift position, working with numerous MDs, PAs, and NPs. It is very tough to be in this kind of job (nights and covering so many patients) as a new NP.

Joan Z · Oct 7, 2008

I think confidence comes with time, but perhaps it is the nursing training that makes us want to double-check ourselves. I know as a new NP that there are some things I haven't seen, some stuff I want someone else to verify. It's not me personally, it is me making sure.

Yesterday I saw a pt with the worst psoriasis of his scalp I'd ever seen. I was pretty confident of my diagnosis BUT I'd never seen someone whose scalp looked so bad but had NO involvement of the elbows or knees or anywhere else. So yeah, I had someone else look at it. I even told him (the doc) that I just hadn't seen anything like this, but the lesions looked pretty obvious. He didn't mind, the pt didn't mind either. And I learned something.

ANPFNPGNP · Oct 7, 2008

I get the impression that a fairly common sentiment amongst NPs (on this site) is they're very uncertain about their skills or abilities. It's actually concerning to read. I understand a NP is not a MD however, a FNP should be able to treat 80% of all illnesses and do it with confidence. Studies have shown the ability of NP to provide comparable family care as FMD yet I read that some NP are unsure or feel unprepared on complex treatments and/or diagnosis that they will encounter as a FNP or other NP.
Scary...

I'll tell you what's scary...how about a doctor who treats diverticulitis with Keflex monotherapy and a patient ends up with a perforated bowel and a colostomy b/c of it. How about a doctor who thinks that an A1C of "9" is "good" and doesn't make a change in the patient's medication regimen. How about a doctor who doesn't treat an LDL of 170, even though the patient has already had a MI and stroke. How about a doctor who has patients walking around with average BP's >160/90 and never bothers to treat them. How about a doctor who never tests for H-Pylori b/c he thinks it's a harmless bacteria (it can lead to stomach cancer about 2% of the time if untreated). How about a doctor who hasn't even done an anemia "workup" on a patient with a hemoglobin of 7.7. I can fill up pages with all the things I've seen done and NOT done by DOCTOR'S.

If I were you I wouldn't get too concerned about what the NP's on this forum are saying...AT LEAST THEY RECOGNIZE THEIR SHORTCOMINGS! You need to be far more concerned about some of those physicians out there who have plenty of shortcomings, but don't even recognize them!

Spacklehead, MSN, NP · Oct 9, 2008

I do say "I don't know to my patients" and make appropriate referrals - that's the sign of an APN who wants to provide excellent patient care, cont to have a good relationship with the patient and one who wants to keep their license.

Exactly. This was also told to me by my preceptor yesterday who has been a practicing MD in internal medicine for over 20 years. Admitting when you don't know something to your patients but reassuring them that you will find out the answers for them or will refer them out to the appropriate resources who do know the answers will only help you and the relationship you have with your patient. They will have much more respect and trust for the practitioner who is humble enough to admit they don't know it all, but will help them find the answers than for the practitioner who pretends to know it all and then causes the patient harm.