Early Lessons for New Nurse Practitioners (Part 1)

Regardless of your specialty or setting, there is a mountain of knowledge to take in during your first year of practice that goes far beyond medicine. Whether you work in-patient or clinic, ICU or dermatology, there is a unique culture that you are stepping into. Hopefully, it is a culture of teamwork, grace, and growth. But wherever you find yourself, there are a few universal lessons that all NP’s need to learn during this crucial period.

Know where you want to be, but don’t forget where you came from

Many years ago, I was working a busy day shift in the emergency department as an RN. We weren’t terribly understaffed, the census wasn’t horrific, but there was still plenty of work to be done. In our ED, there is a central station in each pod, with one half occupied by attendings, residents, and medical students. The other half is where the nurses and techs sit. We are all within earshot of each other to promote availability and communication. Our nurses and physicians have a long history of camaraderie and great team dynamics, and many of our attendings are more than happy to jump in and help with even the most mundane of tasks when needed.

If by this point you are guessing that I am setting the stage for a bad encounter, you are correct. A medical student who already had developed a reputation for interrupting or ignoring the nursing staff while interacting with patients had just come out of a patient's room and walked straight by the ice machine to the closest nurse. “Can you take a cup of ice to room 6?”

Now, on top of walking by the ice machine and across the pod instead of getting it herself, she was also asking a nurse who wasn’t even assigned to the patient. As the nurse stared at her incredulously, the attending stood, picked up a cup of ice, and took it to the patient without saying a word. This simple act by our attending was more than just a silent lesson for the medical student; it was a moment of acknowledgment and respect to the nurses in the pod.

When you are starting as a new provider, you will have an opportunity to set the tone for how your coworkers will view you. Be mindful of the little things that help build leadership capital with your new team. And as a career nurse, I can tell you with confidence that word travels fast, whether it's good or bad.

Be the new hire who's known for going to find the warm blanket or the cup of ice chips for the patient. These few seconds of your time might also mean offloading a task from a nurse or tech who desperately wants to go eat lunch. Remember that if you are having a great day, that probably means someone else on the unit is having a rough one.

You are responsible for knowing your scope of practice

I had recently started working at a large level 1 trauma center after leaving a job at a much smaller community ED. I was helping to get my new patient, who had just been dropped off by EMS from a nursing home, situated. While I was getting the patient into a gown and onto the monitor, I noticed two large IV catheters protruding from their chest, one red and one blue. Since the patient was altered and confused, I knew IV access was going to be an issue, but I also had a mountain of labs that had been ordered.

I turned to ask the intern if I could just get the blood out of the blue port on the patient's “chest IV,” to which he responded in the affirmative. I was shocked at how easy it was to draw blood from the massive catheter, and when I was done, I flushed and clamped it back like a good nurse. While taking the tubes of blood with me back to the nurses' station, the team lead in my pod remarked about how quickly I was able to get my line and labs done. I told her about the patient's “chest IV”, and her face slowly turned from confusion to a look of disbelief. She briefly went into the patient's room to assess the situation before returning to the desk and telling me to grab a heparin flush.

Using the colorful but loving language of a seasoned ED nurse, she informed me that I had just pulled labs from a dialysis catheter. I told her that I had checked with the resident first, and her response still sticks with me to this day. “He’s a doctor; they don’t know what you can do. YOU are responsible for knowing your own scope of practice.”

As an NP, you have a national certification, a state license, and institutional privileges. There may very well be a myriad of things that you can do according to your state license, but it is up to you to know exactly what your hospital has credentialled you to do, and more importantly, what you can’t. The physicians you work with may have a limited understanding of what your scope of practice is, and may ask you to perform a procedure or task, assuming that you are covered to do so.

During onboarding, you should have clear documentation of your clinical privileges, and you need to know how to access them. If you aren’t provided one, you need to ask, and it needs to be in writing. On this same note, do not under any circumstances perform a task given to you by a physician that you are not credentialed to perform. Should you do something that is outside your scope of practice, it is likely that your malpractice insurance will not be there to cover you.

Much more to come

There is so much to learn in your first year of practice, so let's stop here for now. Next month, we are going to get into how to set professional boundaries with your co-workers, and what to do when things aren’t going well, or if you find yourself in a serious ethical dilemma.

As always, I would love to hear your stories, suggestions, or pearls of wisdom learned during your first year of practice. Shoot me an email at NP@hippoeducation.com

See you next month!