New Job, New Nurse Practitioner Challenges

As I drove in to the emergency department yesterday, my route differed from the norm. I’m maintaining my employment at the hospital where I’ve worked for years now, but I also recently accepted a new PRN position in another emergency department. During my 8:30pm commute, my thoughts bounced between the dread that came with knowing I’d be up all night to “why did I do this again?”. Suddenly, faced with my first day in a new position, feelings of anxiety about my skills as a nurse practitioner crept in.

Not only was I worried that in this new ER providers would practice differently and my efforts would somehow miss the mark, I was acutely aware of the need to prove myself to a whole new set of coworkers. In my current position where I’ve been employed as a nurse practitioner for nearly five years, I’m generally regarded as a hard worker and one who’s good at my job (at least that’s what they tell me). When I have an off day, am feeling tired, or admittedly a bit lazy, my reputation preceds me and a shift that’s not quite as productive as others doesn’t raise any red flags. Now, in my new job, I needed to be energetic and my decisions spot on to gain the confidence of my new coworkers. So. Much. Pressure.

I arrived at the emergency department, to ER beds chock-full of patients waiting to be seen. For the first part of my shift, I was in charge of manning rooms designated as a lower acuity zone. I jumped right in to my role of suturing lacerations, draining abscesses, and ordering nebulizer treatments for asthmatics. To my benefit, both emergency departments where I now work use the same electronic medical records system which made documentation at this new facility a breeze. When my low acuity section cleared out around midnight, I entered the main ER ‘rotation’ I had been dreading.

In my longstanding ER position, charts for patients waiting to be seen are placed in a rack and are fair game for whichever NP, PA, or MD can take on an additional patient. Each provider is responsible for maintaining his/her own manageable workload and picks up new patients at their own pace. This also allows for selective chart selection. While picking through charts is generally regarded as inconsiderate (someone has to see patients requiring rectal exams) this does allows providers to treat patients of a comfortable level of acuity. When a 90-year-old sent by her PCP for a hemoglobin of 6.1 and a 6-year-old with pharyngitis are seated in the waiting room, generally the nurse practitioner on duty treats the lower acuity patient. After my years of working as a nurse practitioner in the emergency department, this system gives my job a high degree of comfort.

My new ER position goes about things differently. Patients are assigned to a provider as they walk through the doors of the hospital on a rotating basis. Regardless of acuity level, last night patients were assigned to physician 1, physician 2, then to me, without considering the differential diagnoses at play. So, I received a patient requiring two units of blood for a GI bleed and an elderly woman with metastatic lung cancer presenting for chest pain while the physician before me in the rotation treated a case of otitis. This system probably doesn’t make sense to most working in the emergency department, but I do appreciate the vote of confidence for NPs!

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Another challenge I faced last night was admissions. The hospital where I have worked for years doesn’t allow nurse practitioners to admit their own patients, Yes, the hospitalist service and most specialists employed by the system use nurse practitioners, but negative experiences with NPs in years past tarnished our reputation. This means more work for physicians. If I treat a patient in the emergency department requiring admission, the ER physician must consult with the admitting doctor and put admission orders into the system on the my behalf.

The emergency department where I’m now picking up a few shifts a month does things differently. With more confidence in nurse practitioners, NPs are expected to admit their own patients. As I’m not usually the one consulting specialists and putting in admission orders in my primary place of employment, this was an anxiety-provoking experience for me. Consulting specialists went much more smoothly than expected. All were kind despite my 3am wake-up calls. I still have some learning to do when it comes to putting on orders for patients once they leave the emergency department, but primarily due to the complexities of the electronic medical records system.

Overall, my ‘first day on the job’ experience was a positive one. I made it through the night shift without falling asleep and drooling all over my desk. I believe I left a good impression on my coworkers. Most of all, people were helpful and understanding as I asked my many questions of the evening.

How was your first day on the job?


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