It’s funny looking back to myself as a brand-new nurse practitioner (NP). There was so much I would learn over the next several years by trial and error and trial by fire. At the time, I wish I had been able to ask a group of experienced nurse practitioners what they wish they knew as new grads that they know now as experienced NPs. Questions on topics like contract negotiation, educational resources, and confidence in prescribing.
While I can’t return to my new grad self, I can share sage advice from the 40 experienced NPs that I surveyed in an online forum. Here’s what they have to say about a range of topics from advice they have, to challenges they struggled with upon entering practice.
I posed the following question to the group:
What do you wish you knew then, as a new NP grad, that you know now as a more experienced NP?”
Contract Negotiation
“I would spend at least some amount of time shadowing various areas of practice…I do not recommend jumping into the first position offered. You spent the time getting through school. Take a couple of months or so to get your mind thinking about what really interests you. Don’t be afraid to ask about turn-over rate (red flag if this is high), expected amount of patients to be seen daily, how long to get your feet wet before you’re expected to be at that goal and DON’T EVER get chummy with your patients. Keep it professional and not personal.”
“Salary negotiation including things beyond pay (CME, travel, PTO, etc). Giving ourselves permission to ask these questions is a huge hurdle (especially for women) and the best time to get what you want is when you’re offered the job!”
“Getting the pay that is reasonable and the experience/training that is necessary for success!”
“Negotiations! Never under sell yourself.”
“Fair scheduling of patients, don’t sign contracts with promise of bonus for year 1 maybe 2 as a new provider, you have built your patient base.”
“…knowledge as to the kinds of things to include in your contract would have been very helpful. I had no idea you could stipulate things like the number of new patients daily, or the length of intakes versus follow-ups.”
Prescribing Confidence
“Best advice that I heard is to not take [medication] side effects personally.”
“…If a medication doesn’t work, change it. Never say “I’ll never prescribe this or that (benzo or stimulant) you really never know what kind of pts walks in the door. Be flexible.”
Role Confidence
“Please LISTEN, to your patient!”
“…overcoming “imposter syndrome”. It is a real transition from RN to NP.”
“That it’s ok to not be sure of the diagnosis at the first visit. A provisional dx is ok until you can get more understanding.”
Collaborating Physician (state-dependent)
“I find a lot of new NP grads who say they’re looking to find a physician who is like-minded and practices similar to them. I’ve also heard this while I was in school to find a physician who you have the same values. This is true to an extent. The majority of your work is independent. It’s more important to have a physician who is approachable and wants to teach.”
“Where to get SCA [Standard Care Arrangement] if employer didn’t provide. And FREE CEs at OAAPN and AANP, to keep up with needs and education.”
“I started out with a less-than-stellar supervising psychiatrist and didn’t even realize what I was missing until I changed jobs and was assigned a terrific mentor!”
Certification and Licensure
“The time that lags between graduation, licensure, passing boards, getting DEA, obtaining a collaborative doctor if required by your state and having this prior to getting your state licensure and CSR. Then when you get a job the time lag on Credentialing. Most don’t know all of this can take up to 6 months or more.”
“Still wish I knew when to renew and how many CEUs are need? Does opioid waver training hours count? Do we need hours if it is the first renewal after graduation? Do we need separate RN hours?”
Educational Resources
“Having a binder or a book handy with family practice guidelines. And get an UpToDate membership”
“I had UTD (uptodate) and like Epocrates better and it has up to date guidelines. But the point being using a reliable resource for looking up information is a must.”
“Information on Medicare and Medicaid, what they are, who they serve, where people from each program can go to get care.”
“I worked in Urgent Care as a new grad and use 3 great resources, 2 of which are books. Not everything’s on an app. I use a derm book with pics and a procedure book with pics. These have helped me since derm is so broad and so much to learn and often seen in urgent care as well as procedures we never learned in nursing school.”
“So knowing what your resources are for clinical and contract questions is very important. Uptodate is worth every single penny. Contract/job questions are best asked within a group like this as everyone has such varied experiences.”
“Knowledge about getting an NP license. When to apply, how it differs from an RN license. Also pharmacology cheat sheets would be great, ones you can print out and put on your clip board or on your bulletin board if you’re WFH.”
Steps after graduation
“Definitely steps to take after graduation. Such as how to apply for boards, and once you pass what to do after. I didn’t know that I had to apply for an endorsement, have my ANCC results and my transcripts sent to the board of nursing, I also had to take an Ohio certified pharmacology class because my school was out of state, things like that.”
“I wish I knew more that I would be practicing medicine pretty much independently. My first job I was thrown out to swim on my own unfortunately, but I learned a lot from there.”
Interviews
“What to ask in an interview.”
“Big thing I teach students that I precept, when they interview in primary peds, ask for a working shadow day. Follow each provider, ask how they treat colds, viral illness, ear infections, asthma, etc. Do they follow AAP guidelines and all on the same page of do their own things? That’s a red flag for inconsistent in practice.”
“For all the no’s you get there will be one yes don’t get discouraged.”
Co-workers/Team
“My challenge is having to deal with inexperienced RNs that go directly into SOME NP program. And create horrible messes for experienced providers to fix.”
“Dealing with defiant MAs [medical assistants] when your boss didn’t help the situation.”
Lab interpretation
“…Just learning you don’t always have to have all the answers in one visit.”
“I remember this big emphasis in nursing school about memorizing the normal limits for a whole slew of labs, but never learning what to do if a value was outside of normal limits. Totally impractical.”
“Resources on when and how to order for tests/labs and when to refer.”
General Advice/Role Confidence
“You’ll never know everything and things will be alright. First 6-12 months are tough.”
“My rights as a practitioner. For example, my right to deny to treat certain conditions or prescribe certain medications… and how to practice in a way that feels ethical while also avoiding litigation.”
“Learning to chart during sessions while still being empathetic so I don’t take work home.”
“To simply just breathe and listen.”
“Make sure you get a copy of your malpractice insurance face sheet. You will need this for future positions.”
“One of the most important things is establishing relationships with specialists so you have people to refer out to for specific things. Physical Therapy, Orthopedics/Orthopedic Surgery, Cardiology, GI, Dermatology, Neurology, Sleep Medicine/Pulmonology, and perhaps most importantly Behavioral Health.”
“My biggest challenge was “starting over” with benefits, pto, bosses not leaders who focus on revenue and not patient care and burn out…”
“No clinician knows everything. Critical thinking and knowing how to use your resources are the best!”
“Hi. PMHNP for 21 years. “Know what you don’t know”. “Be Humble”. “Always have an experienced Psy NP or Psychiatrist that you have in your back pocket to ask questions.. We are not MDs. Any good NP or MD, knows what they don’t know…. best advice from my mentor back in 1998.”
