What I Wish I Knew as a New Nurse Practitioner
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Show notes:
When I work with new grad nurse practitioners one on one, we usually talk about the cases keeping them up at night, the lab results they’re struggling with, but there’s a sneaky under-layer that we don’t really talk about much in school.
Actually scratch that-- we absolutely do, but it’s one thing to read about (and write papers on!) and another to experience in real life.
What I Wish I Knew As A New Nurse Practitioner
In this video I’m talking about the core struggles new grad NPs have-- so you can be better prepared with what I wish I knew as a new grad, or to normalize what you’re already going through. And of course, the tools and resources to help.
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Liz Rohr (they/she) | Real World NP (00:09.038)
Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational company for nurse practitioners in primary care. I'm on a mission to equip and guide new nurse practitioners so that they can feel confident, capable, and take the best care of their patients.
If you're looking for clinical pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and leave a review so you won't miss an episode. Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com slash podcast.
Liz Rohr (they/she) | Real World NP (00:55.426)
Well hey there, it's Liz Rohr from RealWorldNP 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 like 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 and in the hopes that this
will help you know what to expect or normalize what you're already experiencing if you're 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 MP. 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 of things I wanna start with. So one, I wrote this paper in my last quarter of school. I was on 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 like 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.
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 gonna necessarily cite, I believe it's her direct stuff, but I'll give like a general highlight of the things that are in her kind of like 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, when new grads start, there is a lot of optimism. There's a lot of energy, there's excitement, there's feelings of accomplishment, right? 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.
Liz Rohr (they/she) | Real World NP (03:16.226)
One is that things in the real world almost never look like textbooks. Like 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. Like 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 learned in school, but like continuing to learn as we're clinicians, because it never stops, honestly. Symptom to Diagnosis is a book that I really love. I have an up-to-date 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, right?
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 like 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 students, former student colleagues in grad school. It's just really important to get some sort of support. What are your self-care things, right? And these are all the things that maybe you're listening to and you're like, yeah, yeah, yeah, I'll do that. The 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 confident in what you're doing. 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 like 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.
Liz Rohr (they/she) | Real World NP (05:30.06)
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, a new nurse practitioner.
And one of our first meetings, we actually just concluded our time together and she's like, I'd 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 questions that we, cases that we talked about was a woman with hirsutism. She was in her 50s, I believe, the patient.
and she came in to ask for treatment for hirsutism. And I'm not really getting into the hirsutism 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 as new nurse practitioners is actually also to be skeptics in the way of like, well, where is that coming from? Like, why does she have it in the first place? Like that's like another kind of like separate.
role transition thing. But I was like, the other thing that we can talk about, you the first line treatments in which she had come prepared with, was like, you know what, I'm trying to decide between oral contraceptives and a topical treatment. And again, this is not advice about ersuchism, so please do your own research when looking at that, depends on the comorbidities and all that stuff and the underlying reasons. 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 wanna 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, like I absolutely agree with you. There's a couple of things to think about and there are a couple of options. And so we talked about, you know, insurance availability and what the patient wants to do and all of these different things. And she was really frustrated. I think I felt it at the time in our call, but it's, there is no one right answer. And I think that that ties into my next point.
Liz Rohr (they/she) | Real World NP (07:42.382)
which is like, is not an actual nursing theory, but it's like kind of this thing I feel like, this theme that keeps coming up all the time, that there is the must know, which is in the middle, like the information that you have to know, which is bread and butter stuff of primary care. And then here on the outside, if we're doing a couple of big concentric circles, on the outside, that belongs in the hospital, that belongs to a specialist, like 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've both been in practice for I think about 10 years each. So one of them is like he and I, if there are archetypes of like 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 like 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 this example of those two physicians. One physician loves complicated cases.
is literally a walking textbook and I tell him this all the time and knows everything and he's like, oh I don't know 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 like...
next level translated into patients' lives and normalizes all the medical things we're doing and like retranslates it back into like layperson, quote unquote, layperson, kind of like 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. And she's not as interested in the other kind of like end-stage liver disease with...
Liz Rohr (they/she) | Real World NP (09:58.873)
Hepatorenal syndrome and cardio renal syndrome at the same time with all like all this crazy stuff, right? Which is more like 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 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, right? And 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 wanna do, right? There's a must know. And then there's the optional, right? So for example, the person who is more interested in the bread and butter of 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, right? But I think that's another conversation that we frequently have is
is like 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, right? 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 you will, 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 or maybe you'll ignore me the way I ignored myself.
But anyway, if you haven't, but that's all for this video. If you haven't grabbed the ultimate resource guide for the new NP yet, head over to realworldnp.com slash guide. You'll get these videos and 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.
Liz Rohr (they/she) | Real World NP (12:09.95)
If you feel like you figured out your archetype of medicine, like I would love to have names for that. Maybe I'll work on that. Who knows? Maybe I have a couple of people I can think of to potentially help with developing those, but welcome all that input. But hopefully this video was helpful.
Liz Rohr (they/she) | Real World NP (12:26.68)
That's our episode for today. Thank you so much for listening. Make sure you subscribe, leave a review, and tell all your NP friends so together we can help as many nurse practitioners as possible give the best care to their patients. If you haven't gotten your copy of the Ultimate Resource Guide for the new NP, head over to realworldnp.com slash guide. You'll get these episodes sent straight to your inbox every week with notes from me.
patient stories and extra bonuses I really just don't share anywhere else. Thank you so much again for listening. Take care and talk soon.
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