Transcript: What I Wish I Knew as a New Nurse Practitioner

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple. The weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients.

In this video, I want to talk about what I wish I knew as a new grad and things that I sort of knew, but I didn't really give enough credit to. And then the trends that I've seen with the new grads that I'm in community with. In the hopes that this will help what to expect or normalize what you're already experiencing if you are in there. And I think the reason I want to talk about it is because it comes up a lot with the mentees that I work with. So I do some one-on-one work with mentoring new grads as an experienced NP. And a lot of the questions we talk about are clinical questions that have some gray areas to them. But a lot of what I'm going to talk about in this video is actually a lot of what we talk about in the calls together. So I felt like it would be helpful to share as well.

So a couple things I want to start with. So one, I wrote this paper in my last quarter of school. I was in a quarter system, not a semester system, but the last class. And I kind of blew it off as a fluffy assignment. And I read the paper maybe a year after I became an NP. I was going through my Google Drive and I was like, oh, I wish I had listened to myself. Because this is nursing... I don't know if it's nursing theory, but it's based on a book and I can link to it down below. It's one of the assignments I did in grad school. And basically it's talking about the transition to practice that has been studied for new nurse practitioners. And I'm not going to necessarily cite, I believe it's her direct stuff, but I'll give a general highlight of the things that are in her kind of theory. But the thing that I also see, and then some other things that I have to add that hopefully will be helpful.

But basically in the first three months of practice, it is extremely frustrating to be a new nurse practitioner. And these are the things that I read about, but it didn't get embedded for some reason. Or maybe, I don't know, who knows? But anyway, it's when new grad start there is a lot of optimism, there's a lot of energy, there's excitement, there's feelings of accomplishment, getting to the end of your program and feeling like, you know what? I got this. This is going really well. And then I think what happens is that we go into clinical practice and we have to translate school into the real world. So there's a couple of different things that happen.

One is that things in the real world almost never look like textbooks. The textbook cases are textbook for a reason, but with each situation that you have, there's a lot of gray areas where it's not exactly matching up with the things that you've learned about and they don't look the same way and there's a lot of ambiguity. And so one of the ways that I approach my practice still to this day is through a red flag approach. What are the worst case scenarios for this potential symptom? And there are a lot of ways to figure that out. And that's an ongoing learning thing in addition to what you've learned in school. But continuing to learn as we're clinicians, because it never stops honestly.

Symptom To Diagnosis is a book that I really love. I have a UpToDate subscription that's really helpful. There's a number of resources, but just acknowledging that when you graduate there is going to be frustration, like it's guaranteed. And that's just the nature of the transition of practice no matter how much you loved your program and how adequately it prepared you, that's just a fact. So the first three months, people feel like they're drowning, they question their decisions, they feel like an imposter. And then nothing looks like it did in school. Well, unless you were in clinical, but maybe it did. But that's really frustrating. And then over the course of the next three to six months, there's more. So this is kind of based on this person's theory, but I'm also adding a bunch of stuff in. So anyway, I'll link down below.

I'm just going off based on what I've seen. But anyway, the first three months are really, really hard. Really hard. And so it's really important to get mentorship if you can. It's important to have peer support if you can, at your workplace with your former student colleagues in grad school. It's just really important to get some sort of support. What are your self care things? And these are all the things that maybe you're listening to and you're like, yeah, yeah, yeah, I'll do that, same way that I did. But it is actually really, really important. And I kind of wish I took my own advice a little bit more.

So in the next three to six months, there tends to be a little bit more of a return of optimism, but still with frustration as you're getting to feel more competent in what you're doing. I think one of the things, and I'll kind of like stop there, that's as much as I'll talk about that kind of theory with my little things thrown in. But the two other things I wanted to talk about that I talk about a lot with my mentees as it relates to the transition of practice and how it influences all of our conversations about clinical topics.

So the next one is about one right way. And I've talked about this a little bit both on Instagram and here. So follow on Instagram if you're not already, but I've talked about this a little bit already where it's kind of like when new grads graduate, they want to know the one right answer and it just does not exist. And I think that, I just want to share a little story. I was working with a mentee one-on-one, new nurse practitioner, and one of our first meetings, we actually just concluded our time together and she's like, oh, I'd love to give you some feedback. And I was like, yes, please. I want it to be amazing. I want it to be helpful. And she told me when we first started working together that she was really frustrated. I really frustrated her. And the reason was is because she came in thinking that there was one right way to do one right thing.

So just as an example, I think one of the first cases that we talked about was a woman with her. She was in her 50s, I believe, the patient. And she came in to ask for treatment for her sutism. And I'm not really getting into her sutism part of this video, but generally speaking, there's a couple of different things to think about. So one, I was like, yeah, we can definitely talk about the treatment but I also have a couple of other questions for you because our job is, as new nurse practitioners is actually also to be skeptics in the way of like, well, where is that coming from? Why does she have it in the first place? That's another separate role transition thing. But I was, the other thing that we can talk about, the first line treatments in which she had come prepared with, she was like, you know what I'm trying to decide between oral contraceptives and a topical treatment. And again, this is not advice about her sutism, so please do your own research. But looking at that depends on the comorbidities and all that stuff and the underlying reasons.

But if you figured out your diagnostic clarity and it's safe to treat them, the first two things to think about are those two things. And so she was saying, you know what? I really want to do the topical because I'm afraid of giving someone a systemic treatment and I'd rather prefer topical over systemic in general. And I said, of course, I absolutely agree with you. There's a couple things to think about and there are a couple of options. And so we talked about insurance availability and what the patient wants to do and all of these different things. She was really frustrated. And I think I felt it at the time in our call. But there is no one right answer. I think that that ties into my next point, which is not an actual nursing theory, but it's kind of this thing I feel like this theme, that kinks coming up all the time that there is the must know, which is in the middle, the information that you have to know, which is bread and butter stuff of primary care.

And then, if we're doing a big couple big concentric circles on the outside that belongs in the hospital, that belongs to a specialist, do not touch that. That is not appropriate. Do not go further. Do not pass go, whatever. And then in between there is your choice of philosophy of scope of practice. And so the example I have for that is that I have two clinicians I work with at my in-person job at the clinic. And they are both phenomenal providers. They're both physicians. They both been in practice for I think about 10 years each. So one of them, he and I... If there are archetypes of medical providers that you have seen, please send it to me. I love consuming that kind of stuff and I'm not as good at generating those types of creative drawings of whatever. But anyway, if you see something like that, please let me know.

But anyway, there are archetypes. It seems like there are archetypes of philosophy of practice. And I think that's one thing that new grads don't realize until they're on the job in the context of that right decision. Clearly there's a wrong decision that is harmful, but there are many right decisions. And I'm going back to those example of those two physicians. One physician loves complicated cases, is literally a walking textbook. I tell him this all the time and he knows everything and he is like, ah, I've done everything. He's very sweet too. He's good with his patients, but he's more interested in the complex medical stuff. That is what I perceive.

However, my other physician with the same amount of experience is really all about holistic care, that is very next level translated into patients lives and normalizes all the medical things we're doing and re-translates it back into lay person, "Lay person," kind of worldview and what works for them and explains things to them like that is her thing. And she loves the bread and butter of primary care. She's not as interested in the other kind of end stage liver disease with hepatorenal syndrome and cardiorenal syndrome at the same time with blah, blah, blah, all this crazy stuff. Which is more up his alley. It's more up my alley too because I love that weird stuff. But it's not weird, but it's more complicated medical stuff. And I'm not as good at the things that my other colleague with the holistic, very patient-centered, translation, bread and butter, stuff like that, that is clearly her strength.

I say those two kind of archetypes because I see that pretty frequently. And it comes back to that conversation of safe practice and philosophy of practice and what you want to do. There's a must know and then there's the optional. So for example, the person who is more interested in the bread and butter primary care may be more apt to refer sooner, whereas the other provider may be more apt to manage whatever he can in house because he wants to do that stuff. But I think that's another conversation that we frequently have is the realization that there are choices and then understanding their own personal choice. And then the other part of it is just over time, understanding where those circles end. What is the must know and what is the optional. And I wish I had a hack for that and if I do come up with it, I will certainly share it. But I think unfortunately, it comes down to case by case management, reading specialist notes, looking at how things go, looking at how other providers are practicing, of course, following guidelines, utilizing resources and asking a ton of questions.

But hopefully this is reassuring for you if you're in practice currently or helps you prepare potentially to expect things, if you're a student maybe you'll ignore me the way I ignored myself. But anyway, that's all for this video. If you haven't grabbed the ultimate resource guide for the new NP yet, head over to at realworldNP.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories and bonus content that I just don't share anywhere else.

I hope this video was helpful and I would love to hear where you're at in your practice. If you feel like you're in the frustration drowning stage. If you're in the, okay, I think I got this stage, if you feel like you figured out your archetype of medicine, I would love to have names for that, maybe I'll work on that. Who knows? Maybe I have a couple people I can think of to potentially help with developing those. But welcome all that input, but hopefully this video was helpful. Thank you so much for watching. I'll see you soon.