Ep #159: First Year as an NP: Transitioning from Student to Practitioner

Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hey, hey everyone and welcome back to another episode of the Real Deal Nurse Practitioner Club podcast. It’s Anna here as usual, and I’ve got Courtney here again with me today.

Now, today we’re going to build off the last main episode that we did, and I really want to dive into what that first year as a nurse practitioner actually looks and feels like. And I love this one because the transition from being an expert RN to a student, to a new NP is a really big deal. And I don’t think I have ever heard one new NP say that their first year was easy or say that they never had a moment of doubt when starting.

Courtney: Yes, we all had that defining, “Oh, this is real now” moment. It’s exciting, it’s humbling, and it definitely comes with a few, “Wait, so what do I do now?” moments. This is one of the biggest professional identity shifts you’ll ever experience. And honestly, it’s not talked about enough. I remember being so surprised by how new I felt again.

Anna: Yeah, it’s so different from even thinking back to when I first started as a nurse. Like it is so different from nursing school and starting out as a registered nurse at the bedside. Not every visit is going to go perfect, even once you’re experienced, right? And so we’re going to really walk through what that first year is like. It is not a highlight reel, but it’s also not horror stories, right? 

We’re just talking about the real experience here. I want to talk about that mindset shift from student to clinician and some tips and tricks that you can use to just help boost your confidence and your self-assurance a little bit as a new NP, right? Whether you have just passed your boards or maybe you’re a few months into practice and you’re starting to wonder if you’ve made a huge mistake. Those feelings are okay. They are very normal, and this episode is for you.

Now, let’s start with what is probably one of the biggest shocks for most people, and that’s the moment when you realize like you are the clinician. You are the provider. There is no more presenting to a preceptor. There’s no more waiting for approval. There’s no calling, you know, the physician for orders like you’re used to at the hospital. There’s no more of that, “What do you think we should do?” Right? Like patients are looking at you for answers. And not only that, but with all of that comes being a novice again.

Courtney: Yeah, I remember like sending my very first prescription and I will never forget it was for an acid reflux medication. And I went to send it in the EMR and I just like froze because I was thinking, “Wait, like so I do this? Like I can do it? I just do it? I just hit send? Like we’re doing this?” But, you know, that can feel very terrifying at first. And so one thing I wish I understood earlier is the goal of the first year is not, you know, being confident all of a sudden. 

It’s safety and it’s structure. So that confidence builds and it comes later. And it can take at least six months, but to be honest, it’s usually a solid year to really start finding your groove. So what you’re building early on is a solid assessment process, a safe decision-making framework, and the ability to recognize when something is outside of your comfort zone.

Anna: Absolutely. Remember in school, the focus is so often like, “What is the right answer?” And in practice, there’s not always one right answer, right? The focus is really shifting onto, okay, what is the safest next step? And that shift alone takes time. It’s okay. It’s not going to happen overnight.

And one thing I feel like just hear constantly when I talk to learners is that it’s like, “Hey, I passed my exam. I graduated NP school. But why don’t I feel ready?” And, I mean, here’s the truth,right? The exams, they’re not designed to make you feel ready. They are designed to confirm that you have the baseline knowledge to practice safely as a novice NP. Focus on the word novice there, right?

We are testing the recognition of red flags and first-line management and when to refer or escalate care. But they’re not testing your efficiency. They’re not testing your confidence. They’re not testing the real-world nuance that exists, right? Exams are very very textbook, and real life is not. And those things are just going to come with experience and with repetition and with mentorship, not with just studying for an exam.

Courtney: And if you’re constantly looking things up in your first year, and honestly, even beyond that, congratulations. You’re practicing safely. So we talked about this last episode, but experienced clinicians still look things up every single day. I still look things up every single day. Medicine constantly evolves and you can and you should always check up-to-date guidelines and ask questions.

Anna: Yes, we always joke about how humbled we are very very quickly, even now being on the content side of things. We’re writing a practice question or a review course, and we’ll write out a draft of what we think is the right answer, and then we go double-check ourselves and realize, “Oh, you know what? A month ago, new guidelines updated.” And so there is just always things changing and there is always learning to be had.

All right. Let’s talk about orientation because I feel like this truly can make or break your first year and ultimately your whole career as an NP. And unfortunately, it’s not something that’s standard across the board. A good orientation should include a very gradual increase in patient load. And I’m talking like several month increase. Like you should not have a full patient load by yourself day one. That is not setting yourself up for success. 

You also want to make sure that you have training and time to learn the EMR. And then also inquire more about like your preceptor, what access you have to a mentor or a collaborating provider. And make sure you’re going to have space to ask all of the questions without judgment.

Sometimes I hear new NPs being the only provider in the office, especially if they’re in a rural setting or a retail clinic. And that might work for some. But for a lot of people, that’s not enough, especially being brand new. So what kinds of questions can people ask in their interviews in your experience, Courtney?

Courtney: Yeah, asking questions like, “How long is the orientation process?” or, “Who do I go to when I have questions?” or, “What does my schedule look like in month one versus month three versus month six?” You want to make sure the job you are interviewing for is as much of a fit for you as you are a fit for them. If a job expects you to function independently with a full patient load on day one, especially as a new grad, that is a big red flag. That is not a compliment.

Anna: Yeah, I think NPs get so excited about landing that first job. Like they just want to get started. They just want to find a job where they can work, and they get worried about asking these types of questions. They get worried that they’re not going to get offered a job if they’re asking for support. But that support is truly going to set you up for success for this first year. If a job is not offering it to you because you are asking for an orientation or you are asking for more support, that is only doing you a favor in the long run.

And let’s just be honest, like the learning curve in the first year is steep. Even after school, even after boards, you have a lot to learn. And most NPs are going to go through a few like main phases. And the first is that transition phase, and it takes the longest, right? Everything just seems like it takes forever. 

I mean, first, before you are even an NP, you have the credentialing process, and that takes months before you start that first job. And then seeing each patient, documenting, finding the right tests or the right treatment, it all goes slower at first and it can feel really really overwhelming.

But eventually, I promise you are going to get into a groove, and you’re going to move into like a pattern recognition. You’ll start seeing some of the same concerns over and over again, and you’re going to get more comfortable with those treatment algorithms and how to individualize your care from there. And eventually, I’m telling you, it takes time. It takes a lot of time. I wish someone had told me that. 

But eventually, you will move into being more efficient. You’re going to know what matters and what doesn’t. Your documentation is going to speed up. You can pre-chart. You can use smart phrases that are all built out finally. And you can really focus your assessments more and get deeper into what’s really driving that visit.

Courtney: Yeah, one of the biggest mindset shifts that helps is focusing on patterns, not being perfect, especially when you’re starting out. Review the patient chart for the visit, and instead of thinking, “I don’t know enough,” or, “I know nothing about this,” start thinking, “What are my go-to questions for this particular concern? What red flags can’t I miss? So what is my default plan if everything is uncomplicated?” 

And having that framework really just helps build that confidence because if you have a general plan, even if there’s an A, B, and C to that plan, you know, if you have that going in, you can refresh on the content beforehand.

Anna: But let’s also be real here. Sometimes you walk in, you have this whole plan A, plan B, plan C, you’ve got everything pre-charted, you have it ready, and you think the visit is for something simple, and then the patient takes you in a very different direction. Like let’s say you have a patient here and they’re here for a follow-up and you are ready. And you walk in, and now they are asking you about a brand new concern that they have.

Don’t panic. Use your thorough history and assessment skills. Remember, you can always step out of the room. You can say things like, “Hey, I just actually need to go check the supply closet for something,” or, “Let me see if I have a sample for you.” Or, “Hey, let me double-check something real fast. I’ll be right back.” Whenever you need to give yourself a moment, whatever you need to say is fine. If you need to look something up, come back in with a safe plan, that is allowed.

Courtney: Yeah, my go-to and the way that my support team knew that I needed backup was I would say, “I’m going to grab something off the printer,” and then I would beeline straight to my supervising physician’s office door. Now, keep in mind, there’s also nothing wrong with telling the patient, like “Hey, I just want to get a second opinion here. I’m going to go grab my supervising physician,” or colleague or whoever that might be if you’re able to, and say, “I’m going to grab them if that’s okay and bring them in here and make sure that you know we’re aligned here.”

Anna: Yeah, patients would always rather you be upfront and honest. They understand that people are learning. And they would way rather that you’re being thoughtful and you’re being careful and you are using all of your resources and someone more experienced is there to help you when you’re unsure. But I know that internal panic where you want to be that expert. And so if you have to use an excuse like grabbing something off the printer, go for it.

And we really can’t talk about the first year without talking about charting. We’ve mentioned it in our last main episode, but I know, Courtney, you are very passionate about this and you have some excellent tips.

Courtney: Oh yes. So charting is where many new NPs lose their evenings, their weekends, and truly their sanity. And here’s the good news. You will get faster. You will stop over-documenting, and you will learn what actually matters in the chart. But early on, it’s normal for notes to take longer than the visit. It really does. And again, just circling back to that new mentorship or new orientation or whatever that might look like, like make sure there’s time allotted for you to chart or have that time to catch up on your charts for that admin time.

A few more survival tips here: pre-chart when you can, look at your visits ahead of time if you can, enter those templates or smart phrases. And then try your best to close those charts before moving on to the next patient. Remember, your note does not need to be a novel to be a good medical record. This is going to sound contradictory, but you will learn how to be thorough and concise at the same time. I have precepted many, many students over the years, and when they start writing notes, I would remind them to look at their notes big picture. 

Ask yourself, does your documentation support your plan of care? Remember that in the treatment section, you can include your actual train of thought. I know we are all very nervous about, you know, notes because, you know, we would submit these, we would get graded on them. But like you are allowed to think through your clinical decision-making process in your note as long as it justifies your plan of care.

And so remember, you aren’t expected to know everything. And so you have a patient who comes in with elbow pain, right? And you suspect some sort of tendinopathy and you’re recommending conservative measures. Okay, great. Does your note clearly state that there were no signs of infection? Do you have no swelling, no redness or erythema, no open wound? And that note should support that there’s no reason to suspect, you know, a septic joint, right?

And you can look at your notes that way. Look at the diagnosis that you’re suspecting and make sure every ounce of that assessment, you know, the review of systems, the treatment plan, supports what you’re actually thinking. 

And there’s nothing wrong in the note to say, “Hey, this is the most likely diagnosis, right? These are the tests that I’m ordering. This is the medication that I’m ordering. But if this were to happen, this would be my next course of action.” And so really just again, leaning on that train of thought.

Anna: Yeah, and you can put that patient education in here. Patient instructed to follow up if symptoms don’t resolve. Patient instructed X, Y, and Z and very specific things that you talked about in case maybe it was something else that is not the most likely differential. And so just use that documentation and ask yourself, like am I covered here? Like is this everything that supports what I’m billing and what I am prescribing? Those are like the main things.

And again, I can’t not mention imposter syndrome and those feelings in the first year where you feel like you are barely keeping afloat and you feel you are just trying to survive. And trust us, like if you are feeling this, you are not alone. Nearly every new NP thinks, “What if I miss something? What if I hurt someone on accident? Everyone else is more confident than me. When is this going to get easier?”

And really what matters is how you respond to that, right? Do you double-check something when you’re unsure? Do you ask the questions? Do you use your resources? Do you use your support system? Do you follow guidelines? And do you document clearly to back up your plan? That is safe practice. That’s how you’re going to get through your first year.

So here’s really what I want you to take away from this episode. Your first year as an NP is going to be a major transition. That is okay. The goal is not being perfect. The goal is being safe and building your systems and learning to think like a provider and then eventually developing that confidence through repetition and through experience, right? Your orientation matters. Your support system matters. Advocate for your support and your structure because this learning curve is so real. 

And feeling overwhelmed at first, it is normal and it is expected, but it doesn’t mean that you’re failing. It just means you’re normal in that first transition phase,right? Like charting is going to get easier, boundaries are going to protect you, asking for help is just part of being a strong clinician and it is always going to be needed.

And to everyone listening, whether you’re deep in board prep or you’re signing your first NP contract, I want you to know that you are ready to do this. You’re going to make mistakes. You are going to learn from them. You’re going to encounter feelings of doubt, and you will slowly but surely grow into the role that you have studied so hard for. It’s going to feel like you’re in a midlife crisis at times, and you have no idea why you went to NP school in the first place. Like we have all been there. 

But we are here to support you. And if you need extra support through that journey from passing your boards to thriving in year one, go ahead, check out our NP courses, our communities, our resources. Like we are here to walk alongside you every step of the way. Like you have got this. We are always cheering for you, and thank you for listening. We’ll see you in our next big episode.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.