I waited five years for this day: my first day as a psychiatric-mental health nurse practitioner. Mental health is a specialty with the highest demand and lowest supply in the United States. I filled one of seven vacancies, so the staff welcome was warm and inviting to say the least. The outpatient setting was grandeur. It was a far cry from what I am accustomed to. The air was fresh, the bathrooms were clean, and I even scored a corner office! It is a shared space, but who cares? The office has a large window showcasing the mountains and orange trees. The desks are height-adjustable, giving the option to sit or stand. I was excited and prepared for whatever came my way. There was just one problem: It does not seem like they were prepared for me.
After a week and a half of hospital orientation, a nursing mental health supervisor invited me on a tour of my work area. It was my first day actually seeing the clinic and meeting my coworkers. After copious introductions, he invited me to his office. He began the conversation with an oh-so-familiar precursor in nursing: “I have to be honest with you.” I knew I was in for some hardcore truth. Here are the highlights of his honesty about orientation: (a) This is not the nursing you know; (b) there are no checklists or competency fairs for you; (c) you will shadow people who do not have your experience; (d) be a skeptical sponge; and (e) you will only get out of it what you put in to it.
I want to assure you everything the mental health supervisor said rings true. The following weeks were an emotional rollercoaster. There were times I would feel challenged, confused, frustrated, bored, excited, and disappointed all before lunch hour. If you feel this way, this is normal. Experiencing a barrage of emotions is not unusual in your quest to function at the advanced practice level, learn the workflow and learn the system, all while maintaining your nurse identity. Work through it. Do not give up.
Here are some tips that will help you transition successfully from the RN to NP role.
Find a Mentor
Many new graduate nurse practitioners identify mentorship and structured orientations (i.e., residencies and fellowships) as most important in considering job prospects. If your employer is one-in-a-million and offers a nurse practitioner residency/fellowship program, I encourage you to apply. However, the truth is many employers do not offer nurse practitioner training programs. Do not be discouraged. Consider investing your time in a mentorship instead. Mentorship is a powerful tool to ease your transition. Mentors are reliable resources, safety nets, so to speak. They will assist in developing your knowledge base, clinical skills, and overall confidence. If you do not feel comfortable searching for a mentor. Do not worry. It is likely your supervisor will assign a mentor to you being that you are a new graduate. Be advised: Mentorship is a partnership in which both you and the mentor are responsible for your professional growth. Remember, you get out of it what you put into it.
Mentoring is a skill not everyone is able or willing to do. Poor mentorship is detrimental to your professional growth and work environment. It often results in disappointment, isolation, and poor job satisfaction. To avoid a bad experience, try to find a mentor whose experience resembles your own. If there is discord between you and an assigned mentor, or if you feel the mentorship hit a glass ceiling, request another mentor. There is no rule against it, and you do not want to stifle your growth.
Don’t Have a Plan? Develop One
If your employer does not have a program or plan for you, create your own. It is important to set deadlines and expectations for yourself and communicate those with your mentor and supervisor. If you fail to do so, you may find yourself practicing independently too soon. Orient yourself by reading standard operating procedures of your work area and shadowing different providers. Pay attention to the workflow, the workload, and interdisciplinary interactions. Once you are familiar with the system and feel comfortable, I recommend the sink or swim approach. It builds confidence from the start, and you will gradually become more independent.
Ease into first-time assessments and interviews by seeing patients with a clinician shadowing you. Invite constructive criticism and feedback. It can only benefit you. Invest in an updated prescriber’s guide, and search online for local and national organizations relative to your specialty. If you do not want to go bankrupt joining organizations, look at their event calendar. From there, you can attend meetings that would be most beneficial to you for a nominal fee.
As the mental health supervisor mentioned, your training and experience may differ from that of your mentor. You will find a surprising number of nurse practitioners are oriented to their role by physicians. In addition, consider the variation of training and clinical experience within our own profession. There are nurse practitioner programs that require years of experience working as a registered nurse. Conversely, there are other programs that require little to no experience at all. You will see these variations in your workplace. Research suggests that RN experience neither promotes nor inhibits transitioning to the nurse practitioner role. Avoid the trap of drawing baseless conclusions. One graduate is not better than the other; however, experience shapes perspective. You will notice differences in perspective.
My background includes five years in a medical-stepdown unit and the emergency department as a registered nurse, so, naturally, not getting a set of vital signs because “they need to do that” is strange and disconcerting. I remember hearing a nurse practitioner say, “You are doing well. Do you see the difference? You are a nurse practitioner now. Nurses do not critically think. Nurses just take orders. Real thinking is not involved in that. Now, you have to think critically.”
Now, I have to be honest with you. You may hear similar comments in the office, the breakroom, or a meeting. Remember, some nurse practitioner programs are a fast-track to terminal degrees with little to no experience working as a registered nurse. Furthermore, physicians orient nurse practitioners to their role, not the other way around. These comments are not personal affronts. They are knowledge deficits. People do not know what they do not know, so know yourself. You critically think in your sleep. Be self-aware.
Know Your Place
Find your job description and read it thoroughly. Inquire about your role in your area. By role, I am not talking about the mechanics of advanced practice. I am talking about your position on your team. Nurse practitioners are utilized so many different ways. For instance, psychiatric mental-health nurse practitioners in my facility can admit and discharge patients, round on inpatient units, treat patients in the psych holding area of the emergency department, and see patients in an ambulatory care setting. It is important to know what role you play in your area.
Discuss performance measures and standards of care with your supervisor. “What are your expectations? How are you evaluating my performance? What is the standard of care?” Add their expectations to the list of expectation you should have for yourself. Use them to set your short and long term professional goals.
Knowing your place also has to do with knowing the culture. Every work environment has a culture. For me, transitioning from bedside nursing to an office setting was like waking up in the twilight zone. I went from sharing everything (i.e., computers, lunch, dreams, scrubs, pens) to boundaries and territories. Once, I was politely and abruptly escorted out of my office, a shared space, for taking a call while the other provider was charting on one patient. The first and only patient seen all day. This was yet another ride on the emotional roller coaster. Again, I am accustomed to sharing everything. I have seen three nurse practitioners share one office. I could not fathom the “No Talk While Typing” rule going over so well. Again, I did not consider it a personal affront. It was another opportunity for me to learn. Office culture is not at all like bedside culture. Read about office etiquette in shared spaces and be prepared. I most certainly was not.
I do not embarrass easily, so I am comfortable sharing my experiences. I hope my sharing will help make your transition smoother and less intimidating. The nurse practitioner role is indebted to the art of caring and compassion that is nursing. You are a member of the most ethical profession in the world, and nursing is at the heart of everything you accomplished. It is what distinguishes nurse practitioners from other clinicians. Remember, role change does not imply change of character or professional identity. You are a nurse, so this is not your first role transition. You have done this before, and you can do it again.
health nurse practitioner at VA Loma Linda Healthcare System. She is an ad hoc member on the Mental Health Field Advisory Committee in Washington, DC and a doctoral candidate attending the University of South Alabama.