What was your first AGACNP job?

[kdawnz]

Hey all, curious what your first ACNP job was out of school? I am job hunting (which isn't great during this pandemic I realize), and have been told by 2 recruiters that I will almost certainly need to work in a clinic setting for my first job. This is a bit confusing to me since I did acute care as my specialty, spent my entire career inpatient, and did all of my training inpatient. When I have told them I am looking for an inpatient position they literally all say "you and everyone else". All of the inpatient positions I have applied for require prior experience, which is difficult to get when no one will hire you. AGACNP's seem to be somewhat of a rarety in the 5 state area I'm primarily looking and FNP's are working inpatient so that makes it tough for me without prior experience.

If I need to bide my time in a clinic for a bit I will for sure, but I feel a bit backed in to a corner: I did Adult/Gero Acute Care which means I can't get any clinic job that cares for all ages. That pretty much leaves the specialties. Again, this is fine, but if my interest is to be a hospitalist or intensivist at some point, will clinic experience in a specialty be considered applicable?

[Guest1144461]

On 4/21/2020 at 4:32 AM, KatieMI said:

I do not know... I started from running hospital floor with FNP, it was nothing "terrifying" except for number of nursing calls, out of which at least 70% were pure nonsense. Was working for two years (still FNP) doing everything within the same practice except Urgent, which I hated from the day#1. Hospital floor census was rarely below 20 patients a day. After two years of doing everything and anything there, I found a sweet and reasonable hospitalist job, again started running floor from the day #1.

I am still going for acute care certificate, but I only need it in case we will move or if I'd like to try ER or ICU one day.

Did it all without any "residency" and with minimal orientation. It is not that complicated if one had a couple of years of hospital experience and did not spend those years mastering bedpan placement and "policy application" skills and hanging on the phone all the time for "updates".

Honestly, I do not know what kind of hospital you work at, but in my hospitalist position there is no way a new grad could just waltz in and succeed without putting in extremely long days and or getting "wrecked" in every sense of the word. I am at a metro academic medical center where we are a transfer hub with very sick patients that even the internal medicine board certified docs have a hard time with 13-16 patients on most days. I really would love to meet all the NPs (regardless of specialty) who could come in and feel comfortable on day #1. If 600-700 hours of clinicals preps you for that and all the nuances that come with being a hospitalist I would be truly impressed.

You must be a savant of some sort, since most of the NPs that came before me either quit or were let go because they couldn't hack it.

[KatieMI, BSN, MSN, RN]

30 minutes ago, Numenor said:

You must be a savant of some sort

So... I am one, anything wrong with it?

[OhioCCRN, MSN, NP]

New Grad NP here- My first job is a Critical Care NP- I also did AG-ACNP- and I've never heard of clinic work being an option (unless you're working with a specialty service). Take heart, there are jobs out there- especially for acute care- Maybe its your area?

[Guest1144461]

1 hour ago, KatieMI said:

So... I am one, anything wrong with it?

No? But your experience does fit the situation for the majority of new NPs.

[KatieMI, BSN, MSN, RN]

2 hours ago, Numenor said:

No? But your experience does fit the situation for the majority of new NPs.

3 to 4 of years of bedside in a well-run diverse unit (or widely diversified experience, at least two specialties avoiding ones with set routines such as elective Ortho surgery;

Within these years, reading Big 4's for medical school (biochem, micro, pharma, physiology normal and patho);

NP school can be online or brickstone, picking up one which is harsh and demanding; continuing to work at least part time while there;

Doing whatever to avoid group work while in school; if it is not avoidable, re-doing all assignment alone in free time;

Harrison's Internal Medicine (or any other such book according to specialty) as a favorite pasttime reading;

Not telling anybody in school, offering to "help" preceptors to get more clinical hours;

Most importantly, from the very beginning, spending the majority of the time for assessment and analysis of every patient and every order; mastering physical assessment ideally before entering NP school; If there is a provider who likes to teach, treating him as the God;

Within 3 months before hitting the first job, reading and memorizing quick specialty review book for residents ("Secrets" is a good option);

After all this done, pretty much everyone should be ready for running routine rounds on any hospital floor (with exception of highly specialized) within a couple of weeks. There is nothing new or genious about it, just good old combination of time and concentrated effort.

[Guest1144461]

1 hour ago, KatieMI said:

3 to 4 of years of bedside in a well-run diverse unit (or widely diversified experience, at least two specialties avoiding ones with set routines such as elective Ortho surgery;

Within these years, reading Big 4's for medical school (biochem, micro, pharma, physiology normal and patho);

NP school can be online or brickstone, picking up one which is harsh and demanding; continuing to work at least part time while there;

Doing whatever to avoid group work while in school; if it is not avoidable, re-doing all assignment alone in free time;

Harrison's Internal Medicine (or any other such book according to specialty) as a favorite pasttime reading;

Not telling anybody in school, offering to "help" preceptors to get more clinical hours;

Most importantly, from the very beginning, spending the majority of the time for assessment and analysis of every patient and every order; mastering physical assessment ideally before entering NP school; If there is a provider who likes to teach, treating him as the God;

Within 3 months before hitting the first job, reading and memorizing quick specialty review book for residents ("Secrets" is a good option);

After all this done, pretty much everyone should be ready for running routine rounds on any hospital floor (with exception of highly specialized) within a couple of weeks. There is nothing new or genious about it, just good old combination of time and concentrated effort.

I think you are grossly over simplifying it. NP school in general is a non factor, at all echelons regardless of brick and mortar vs online the training is substandard. NPs are graduating expecting to be ready and they aren't

Harrison's? No one reads that, not even residents (med students barely skim it, its not readable). Way too bulky and cumbersome. The MKSAP review, frameworks of internal med and "Current Medicine" books are much more high yield.

Everything you are saying is fine and dandy but you need to reps in a supervised role to get the hang of it. None of this can be done without guidance and mentorship in a structured fashion. Hitting the ground running with 15-20 patients independently is not conducive for learning. A provider that like to teach? Umm they expect you to be competent right when you walk in to work. An independent attending is not going to be there to hand hold you or "teach" when they have their own list and you are supposed to be flying solo.

RN experience is fine for patient interactions but largely pointless for the provider role. The good ole OJT and reading in your free time (in order to actually learn your job) while having the burden of taking care the livelihood of very sick patients is a recipe for disaster.

Why do you think residents are supervised with forced didactics, patient presentations and grand rounds in a structured program for at least 3 years? For fun?

[ghillbert, MSN, NP]

My first NP job was CT surgical/transplant step-down floor with ICU cross coverage then critical care. I had offers for ICU jobs as a new grad with the system I did all my critical care clinicals with, but it was straight nights and it was a generic surgical ICU. My interest was cardiac, and I knew the nurses and docs I was working with on the floor. I did have to learn/practice invasive ICU procedures when I moved to critical care after 3 years, but my attendings were all good at and happy to do teaching.

In my area (NE OH, SW PA, NW WV) there are many ACNP positions although FNPs are also utilized in hospitals a lot. I personally don't hire FNPs for critical care, even with ICU nurse experience; the gap in knowledge is too much.

Physicians don't care about FNP vs ACNP because many don't know the difference, or even (I think) understand that NPs are not trained as generalists; they are much more familiar with PA training model. Being able to get hired into an acute job as FNP or vice versa doesn't mean it's appropriate to work in an area that you don't have the education/training for - I can open a chest or place ECMO, but I wouldn't know one rash or arthritis med from another.

[Tegridy]

9 hours ago, ghillbert said:

My first NP job was CT surgical/transplant step-down floor with ICU cross coverage then critical care. I had offers for ICU jobs as a new grad with the system I did all my critical care clinicals with, but it was straight nights and it was a generic surgical ICU. My interest was cardiac, and I knew the nurses and docs I was working with on the floor. I did have to learn/practice invasive ICU procedures when I moved to critical care after 3 years, but my attendings were all good at and happy to do teaching.

In my area (NE OH, SW PA, NW WV) there are many ACNP positions although FNPs are also utilized in hospitals a lot. I personally don't hire FNPs for critical care, even with ICU nurse experience; the gap in knowledge is too much.

Physicians don't care about FNP vs ACNP because many don't know the difference, or even (I think) understand that NPs are not trained as generalists; they are much more familiar with PA training model. Being able to get hired into an acute job as FNP or vice versa doesn't mean it's appropriate to work in an area that you don't have the education/training for - I can open a chest or place ECMO, but I wouldn't know one rash or arthritis med from another.

Yeah I think it is falling out of favor to have fnp.L in the hospital which is a good thing. I was an fnp in an inpatient role. But I was very rural so they could not recruit acnp for the job. Learning curve was tough. I think they Still use them where I was just since no acnp in area. I know even in established places they don’t want FM docs in hospitalist roles much preferring I'm since they are on wards much more. Everything is getting pickier around the board.

[Tegridy]

On 4/25/2020 at 9:01 PM, Numenor said:

I think you are grossly over simplifying it. NP school in general is a non factor, at all echelons regardless of brick and mortar vs online the training is substandard. NPs are graduating expecting to be ready and they aren't

Harrison's? No one reads that, not even residents (med students barely skim it, its not readable). Way too bulky and cumbersome. The MKSAP review, frameworks of internal med and "Current Medicine" books are much more high yield.

Everything you are saying is fine and dandy but you need to reps in a supervised role to get the hang of it. None of this can be done without guidance and mentorship in a structured fashion. Hitting the ground running with 15-20 patients independently is not conducive for learning. A provider that like to teach? Umm they expect you to be competent right when you walk in to work. An independent attending is not going to be there to hand hold you or "teach" when they have their own list and you are supposed to be flying solo.

RN experience is fine for patient interactions but largely pointless for the provider role. The good ole OJT and reading in your free time (in order to actually learn your job) while having the burden of taking care the livelihood of very sick patients is a recipe for disaster.

Why do you think residents are supervised with forced didactics, patient presentations and grand rounds in a structured program for at least 3 years? For fun?

Lawl Harrison’s too much for anyone to remember practically. I liked frameworks as a base. Secrets series was good. Mksap nice. NEJM 360 is good for cases and stuff. Everything else more point of care reference. Or just too much Info.

[kdawnz, MSN, NP]

On 4/25/2020 at 7:01 PM, Numenor said:

I think you are grossly over simplifying it. NP school in general is a non factor, at all echelons regardless of brick and mortar vs online the training is substandard. NPs are graduating expecting to be ready and they aren't

Harrison's? No one reads that, not even residents (med students barely skim it, its not readable). Way too bulky and cumbersome. The MKSAP review, frameworks of internal med and "Current Medicine" books are much more high yield.

Everything you are saying is fine and dandy but you need to reps in a supervised role to get the hang of it. None of this can be done without guidance and mentorship in a structured fashion. Hitting the ground running with 15-20 patients independently is not conducive for learning. A provider that like to teach? Umm they expect you to be competent right when you walk in to work. An independent attending is not going to be there to hand hold you or "teach" when they have their own list and you are supposed to be flying solo.

RN experience is fine for patient interactions but largely pointless for the provider role. The good ole OJT and reading in your free time (in order to actually learn your job) while having the burden of taking care the livelihood of very sick patients is a recipe for disaster.

Why do you think residents are supervised with forced didactics, patient presentations and grand rounds in a structured program for at least 3 years? For fun?

I would say you are oversimplifying a tad as well... not all work places are built alike nor is RN experience. New grads such as myself certainly need a lot of support and I understand that is hard to come by depending on the setting and location, but even interns just out of med school come in and are expected to hit the ground running though they seem to be woefully unprepared. I routinely have 4th year medical students walk in to an ICU room and ask what the tube in their mouth is and what's that big machine next to the bed. 3 months later they are on call for a 15 bed ICU by themselves at night with an attending at home 10 miles away. It's hard and it's a steep learning curve, but it seems to be what medicine demands. Do I have more to offer right at this moment than the average intern I've worked with and probably even an R2? Yes, I would say that I do. I have familiarity, instinct, and a decade spent hand holding said interns and residents followed by 2.5 years of education and time actually doing the job. I worked in a somewhat unique setting that was insanely under covered with 1 attending running an OR 40+ hours a week in addition to the 15 bed ICU, so an awful lot was expected of nurses. However, I don't think this is necessarily unique to those of us that worked long enough as an RN to have really started to grasp the medicine and gotten well past the point of just checking off the task list. That being said, school and clinical was very humbling and I worked my butt off to try and fill the gaping holes in my knowledge. I did get a lot out of school and was given a lot of autonomy in clinical, but maybe this is somewhat unique?

I am wondering what you recommend for a new ACNP graduate? It sounds like you don't believe starting in a hospital is feasible. Hospitalist internships are not a thing anywhere near me.. I've looked in the 20 states that surround me. I have found several CT surgery NP internships but as I ultimately do not want to live in a metropolitan area that has this service specializing doesn't seem wise. Should every ACNP in the country head back east and try to get in to one of the highly competitive hospital internships there? It doesn't seem terribly reasonable or feasible for a nation of ACNP's to do this.

[Guest1144461]

25 minutes ago, kdawnz said:

I would say you are oversimplifying a tad as well... not all work places are built alike nor is RN experience. New grads such as myself certainly need a lot of support and I understand that is hard to come by depending on the setting and location, but even interns just out of med school come in and are expected to hit the ground running though they seem to be woefully unprepared. I routinely have 4th year medical students walk in to an ICU room and ask what the tube in their mouth is and what's that big machine next to the bed. 3 months later they are on call for a 15 bed ICU by themselves at night with an attending at home 10 miles away. It's hard and it's a steep learning curve, but it seems to be what medicine demands. Do I have more to offer right at this moment than the average intern I've worked with and probably even an R2? Yes, I would say that I do. I have familiarity, instinct, and a decade spent hand holding said interns and residents followed by 2.5 years of education and time actually doing the job. I worked in a somewhat unique setting that was insanely under covered with 1 attending running an OR 40+ hours a week in addition to the 15 bed ICU, so an awful lot was expected of nurses. However, I don't think this is necessarily unique to those of us that worked long enough as an RN to have really started to grasp the medicine and gotten well past the point of just checking off the task list. That being said, school and clinical was very humbling and I worked my butt off to try and fill the gaping holes in my knowledge. I did get a lot out of school and was given a lot of autonomy in clinical, but maybe this is somewhat unique?

I am wondering what you recommend for a new ACNP graduate? It sounds like you don't believe starting in a hospital is feasible. Hospitalist internships are not a thing anywhere near me.. I've looked in the 20 states that surround me. I have found several CT surgery NP internships but as I ultimately do not want to live in a metropolitan area that has this service specializing doesn't seem wise. Should every ACNP in the country head back east and try to get in to one of the highly competitive hospital internships there? It doesn't seem terribly reasonable or feasible for a nation of ACNP's to do this.

A few things. When I did my inpatient rotations I worked with MS4 students and other interns on a daily basis. While they lack practical experience, they can run circles around the average NP when it comes to the foundations of medicine. NP school is very superficial when it comes to learning the tools of the trade, woefully so. Even basic anatomy is lacking in NP school (and no pathophysiology does not count). I am talking basic anatomy far beyond the scope of a simple BSN program. This is just one point. You are right, interns hit the ground running, BUT they are also heavily supervised for 3 years and gain confidence VERY quickly. I saw this first hand in one year working alongside them. They become confident and in my opinion rather proficient, fast.

Sorry, I worked as an ICU nurse for years and while it helped me with pattern recognition and basic concepts, the complexity just does not mirror the provider role. It just doesn't. The best NPs I have met were never RNs, they were just smart.

Yes, I believe residencies and fellowships should be standard if one wants to be independent as a novice NP. I did over 4000 hours in one year and the value added was 10x greater than my NP program (a large state school which was brick and mortar btw). There are more programs popping up every year because the value is there. The NP accreditation bodies need to get their act together STAT and actually do their job by forcing more hours and required preceptor placements. There is ZERO barrier to entry to become an NP and that is a problem. A glut will eventually happen. I work as a hospitalist and literally half the nurses on the floor have 1-2 years of exp and are already vacating the beside for NP school because there is nothing stopping them.

To put it plainly, would I want a new NP or even novice NP treating me independently in the inpatient setting vs an internal med board trained MD? Absolutely not....that is telling and sad at the same time

[kdawnz, MSN, NP]

2 minutes ago, Numenor said:

A few things. When I did my inpatient rotations I worked with MS4 students and other interns on a daily basis. While they lack practical experience, they can run circles around the average NP when it comes to the foundations of medicine. NP school is very superficial when it comes to learning the tools of the trade, woefully so. Even basic anatomy is lacking in NP school (and no pathophysiology does not count). I am talking basic anatomy far beyond the scope of a simple BSN program. This is just one point. You are right, interns hit the ground running, BUT they are also heavily supervised for 3 years and gain confidence VERY quickly. I saw this first hand in one year working alongside them. They become confident and in my opinion rather proficiency, fast.

Sorry, I worked as an ICU nurse for years and while it helped me with patterns recognition and basic concepts, the complexity just does not mirror the provider role. It just doesn't. The best NP I have met were never RNs, they were just smart.

Yes, I believe residencies and fellowships should be standard if one wants to be independent as a novice NP. I did over 4000 hours in one year and the value added was 10x greater than my NP program (a large state school which was brick and mortar btw). There are more programs popping up every year because the value is there. The NP accreditation bodies need to get their act together STAT and actually do their job by forcing more hours and required preceptor placements. There is ZERO barrier to entry to become an NP and that is a problem. A glut will eventually happen. I work as a hospitalist and literally half the nurses on the floor have 1-2 years of exp and are already vacating the beside for NP school because there is nothing stopping them.

To put it plainly, would I want a new NP or even novice NP treating me independently in the inpatient setting vs an internal med board trained MD? Absolutely not....that is telling and sad at the same time

Of course I agree... being an RN in general doesn't necessarily prepare you to be an NP. I know many many RN's who would be abysmal providers no matter how much time they spent the role. It's just a personality type, but I do feel that if you have the personality type and the experience you are less likely to be deemed utterly worthless as a new provider.

The reality is that at this moment there are not sufficient internship/fellowship programs for all ACNP's to go through. It's not feasible or possible for us all to do with the lack of programs. So what do you recommend living in this current time? Are we all screwed? I would say not... I did most of my clinical in an ICU that relied heavily on their ACNP's, and nearly all were hired as new grads. Most already worked on the unit or in the facility, but were fresh out of school. They do most all procedures and manage around 8 ICU patients at any given time and seem to do just fine (several were about 8 months in when I started). In fact some of the weakest team members were the ones that had prior experience in a different setting.

My frustration is the huge influx of NP's that seems to have happened in the last year. Jobs that had 7 applicants 15 months ago now have 30 in my area. Maybe just lots of these online programs saturating the market? I don't know. Everyone seems suprised. When I started school this was not the situation at all... so no, I didn't really sign up for a scenario where moving across the country and working 80 hours a week for $60,000/yr was the plan or expectation for myself and my family. Since my RN time is meaningless I guess I should have just gone to school 6 years ago instead of wasting my time becoming a leader and "mastering" the role before going on. Figuring out how to navigate this and contemplating working in a setting/specialty (clinic) that I am entirely unfamiliar with feels a bit odd since the learning curve there will be much steeper than the learning curve inpatient where I have spent my entire career and done all of my training.