Welcome to Becoming a Stress-Free Nurse Practitioner, a show for new NPs and students that want to pass their board exam the first time and make that transition from RN to NP as seamless as possible. I’m your host Sarah Michelle. Now, let’s dive into today’s episode.

Hey friends, this is the end of my little three-part series on your first year as a nurse practitioner. Today, I’m bringing a guest on the show to discuss the reality of being a nurse practitioner, because Cassandra has now been an NP for an entire year. And Cassandra actually works closely with the DNP Molly B, who I chatted with in that previous episode about contract negotiations.

Cassandra, I’m super excited to have you here on the show today to dissect your experience a little bit over this last year, and your personal growth and evolution in that time as well. Why don’t you just give everyone a little introduction to you and where are you’ve been working out for the last year?

Cassandra: All right. So, hey Sarah. Like she mentioned, my name is Cassandra Justice. I actually work with Dr. Molly Bradshaw over at First Choice Immediate Care, and that is in Columbia, Kentucky. I grew up just about 15 minutes away from there. So it’s a little small town close to Lake Cumberland. I don’t know if anyone knows where that is.

But I’ve been married to my husband, Adam, for about five years now. We’ve got a little 19-month-old girl named Hadley Ren. So she’s consuming most of my time now.

So I got my BSN from the University of Louisville. And then I worked for about a year or so and then joined the MSN program at Northern Kentucky University. And so I graduated in May of 2019. And then had Hadley in July of 2019 and started my new job in October of 2019. So that was a really big year for me. And I’ve been with Cumberland Family Medical for a while, but in a different role. So this was my first time at the urgent care as an NP.

Sarah: You’re such a brave soul to be a new NP and a new mama all at one time, because I cannot imagine. So a big kudos to you just for that alone. Especially to do it all back-to-back. To graduate, to have a baby, I mean, whew. You know, when you got out of school, how did you end up in this job that you have today? Was it a tough process finding that job? Or did you kind of already have it lined up a little bit?

Cassandra: So thankfully, it wasn’t as hard as I thought it would be. I’d actually worked in an ER for a couple years. And I decided, you know, for schedule purposes, for school, it would be better to get more on a like eight to four type job. So I actually started like as a pediatric nurse with Cumberland Family Medical. And in the back of my mind I kind of had hopes that maybe when I graduated with my NP that that company would want to keep me around. And maybe I could stay working for them.

And that actually worked out. It’s a really great company to work for. And they just, they really encouraged me to finish school. And then, you know, they really looked for me to have a place to be when I graduated. You know, we looked at a couple options and discussed for me being a new grad, you know, where the best place would be. And this is where I ended up.

Sarah: It sounds like it was a pretty smooth transition for you over to urgent care with that experience you already had and that background. And especially with them supporting you behind the way too. Because not everybody has that literal easy transition over, to be like, “Oh, I already worked here, I’ll just move over here. I’ll just transition into this new role within the same company.”

You know, even with all that urgent style experience, what was it like truly being a brand-new nurse practitioner in those first couple of months?

Cassandra: It was definitely scary. I can remember being a new nurse on the floor working, and I’m sure everybody has felt the same way. Like you literally feel like you don’t know a thing. I’d shake when I’m going to start an IV, stuff like that.

But this time it was scary in the sense that I knew I was responsible. Like before I was so conditioned to having the ER doctors or whoever right there. And whatever was going on I got to just run and talk to them and ask them. I never actually had to make a decision. And now I’m having to make these decisions for people.

So I think the pressure was just a little higher for me. Obviously, I had to learn the first couple weeks that I was not going to know everything and that that was okay. You know, me and my preceptor kind of would go in the rooms, kind of like you did in your clinicals and stuff, and then discuss things when we came out of the room.

I ended up knowing most of what I should have known, but I just didn’t know how to express it in the room. Like I couldn’t get my wheels turning and thinking in the right way as fast as she could. You know, she had been doing it for so much longer and had her system of how she examined the patients. And like you could tell she was turning these wheels in her head that like I just wasn’t ready to turn my wheels that fast, you know.

But after a couple of months, I mean, it was getting much easier the more that I saw the same kind of things to kind of go in order of my priorities and what I needed to do with those patients.

Sarah: And I think you kind of mentioned, we were talking earlier a little bit about school teaches you everything in boxes. Do you want to kind of expand a little bit more on that?

Cassandra: Absolutely. So of course, in school you learn you’ll have stuff about hypertension one week, diabetes one week. And I guess I always knew that patients didn’t fit in a box. But it was just very different to be approached with those patients that had high blood pressure, cholesterol issues, diabetes, all at the same time. And then you would have that same patient who also had chronic pain issues, depression. They just had everything on one visit. And so I think that was overwhelming at first.

And so you really had to realize, and it’s taken me this whole year to kind of calm down and realize that you’re not going to fix all of those things in one visit. And so you shouldn’t put that pressure on yourself. Because I feel like as new grads, we just want to get out there and like tackle these patients, and we want to change the world. And we’re going to, you know, make people feel better.

But you know, in reality, they have a lot of things going on, most of the time it didn’t get that way overnight so you’re not going to fix it overnight. So you kind of have to just break it down in your head, think what’s the most important thing? Or as my preceptor said, what’s going to kill them first. You know, get that kind of figured out and then have them come back for follow-up visits, make referrals as you need to.

In my case I need to get them back to their primary care because they’re here in the urgent care. And so a lot of these things are not stuff that I typically need to be fixing. They need to kind of have that managed by their primary care.

But then you’ve got patients that I see all the time that doesn’t have a primary care. And they come here because they like us, and they don’t want to have somebody else. So then you kind of have to treat them like a primary care patient.

But I think just realizing all those overwhelming things didn’t have to be that overwhelming made it better, and it helped build up your confidence too. Because confidence is a huge thing that you’ve got to overcome in that first year.

Sarah: Yeah, I like your little priority system there, what’s going to kill them first. It’s perfect, though. I mean, it’s perfect for urgent care. Like what are we going to handle right here so they can make it to the next appointment, hopefully, with primary care? Unless they’re obviously using urgent care as primary care.

And I think school kind of puts us in a bind sometimes because it really teaches us those rules instead of those exceptions to the rules. So we get really lost in that thinking. And so it can be kind of a tough mental shift to figure out how we’re going to think outside of the box and be able to critically think about those patients with all those different comorbidities and things going on.

But you’re obviously living proof that that can be done. And I think one of the best ways to kind of shore yourself up when you’re first getting into practice is utilizing those resources. And so what kind of resources have you been able to utilize along the way to kind of build up those confidence levels?

Cassandra: So, obviously, I didn’t keep every textbook I’ve ever used in nursing school. But I definitely kept my primary care textbook and my basic pediatric primary care books. I’ve referred to them several times for just basic things that you don’t even think about.

I do have access to another textbook, of course I don’t have it sitting here with me. But some type of like an emergency room, like skin textbook, that has been really helpful to find like graphics of rashes, I hate rashes, but stuff to reference back and look at besides just Google. Because sometimes I’m kind of eerie about typing that into Google. So I’ve got that, and then I use Epocrates every single day, like multiple times a day. And Medscape.

But I’ll tell you what’s helped me the most, I made myself a little journal. And kind of that first little bit that I was kind of shadowing and getting started I would just make lists of the diagnoses of the patients I would see and kind of write out what we did for them, like what treatments and everything.

So like someone that came in with a migraine, someone that came in with just basic belly pain, what we did for them, fungal infections, otitis media externa. You know, just medications that I could go back to without having to flip through a bunch of things and just say, “Okay, this is kind of first line for this, and I have that written down for that.”

So it’s kind of my own little reference book I’ve made myself from a variety of sources though. So it’s become my little reference book that Molly has even borrowed and said, “Let me see your little book and see what you wrote down for this.” So it’s really come in handy. And I keep adding to it every day. So I would recommend that highly.

Sarah: I love that you basically made like a little guide for yourself in your journal. Because I think the biggest thing when people are new is there are all these resources that you can use. So you can use Epocrates, or Google, or Medscape, but how do you condense that down to what you’re going to use in actual day to day practice? And so having that little guide can only help a new nurse practitioner along. And just remind yourself, like, “Hey, I made this decision on this day, this was a good decision. So I should do this again for my next patient that shows up like this.” Right?

Cassandra: Exactly.

Sarah: And skin too, skin is tough. I don’t super love rashes either. And so if you could have a resource on hand where you could look at a literal picture, and kind of match it up in your brain to your patient. I mean, you don’t have to show your patient your textbook that you’re going to be looking at. But I think that’s a really great way to shore up your knowledge base too.

So kind of looking back on your experience in this last year, what is something that you feel has made all the difference in your ability to care for patients on your own? Because I think one of the biggest fears of our listeners is when they do come off orientation, and they are finally expected to be the real deal and make these decisions.

Cassandra: Yeah, so definitely I would say working on my confidence was the biggest thing, because we know this information. Like you’ve been taught this stuff, you know it. It’s just a matter of putting it together and applying it to the patient. And just being sure of yourself.

Honestly, I don’t recommend following a preceptor a lot in the actual place you’re working, because you don’t want patients to see you shadowing somebody. Because that kind of drops their confidence in you, because they think, “Oh, they’re not very sure of themselves. I saw them shadowing somebody else.” So, you know, if you can do all that somewhere else, maybe not in your workplace, or do it as small amount as possible I do think that would help too. Just because you want them to have more confidence in you than you might even have in yourself.

But I remember you just really have to walk in there, even if you don’t have the best answer for them you have to sound confident. You have to work on not just hemming and hawing around and just kind of circling the drain. Because they’re going to slowly sink in their chair and they’re not going to listen to anything that you’re telling them.

But I think too, we have to remember talking about like having all the pressure on our shoulders that we have to fix this person today. And we’re going to solve all these problems. We kind of have to let some of that go and know that we can only handle what we can handle.

And, you know, you’ve heard before you can lead a horse to water, but you can’t make them drink. I dealt with that a lot, even in the ER, but you know, here especially we can coach them about what they need to do. But it’s ultimately up to the patient. They have to have a little responsibility too. So don’t put all of that on yourself.

And then also, Molly told me this, I don’t know if she’ll care that I’m telling you. But, you know, some things to think about, only about 75% of the medicines we send actually gets filled by these patients. And also the majority of things, at least in the urgent care, that they come in for sick visits, a lot of them would get better on their own within a week, even if we didn’t do anything.

So you know, when I was sitting there fiddling around with someone that I thought had like a cold and I’m like, “Oh my gosh, what antihistamine should I give them or whatever?” You know, just kind of calm down and think number one, majority of that’s over the counter. Number two, it’ll probably work itself out because it’s probably viral anyway. And really, the medicine is not going to do much for them. Or they may not even go get it.

So, you just kind of have to have that in the back of your mind. And I think that really did help me once I’ve learned all that stuff, though. I know it sounds silly but just to kind of take that pressure off of me some.

Sarah: Well, I think people come in in this like panic level anxiety, where it’s like every decision matters so much. But like you just said, like antihistamine versus antihistamine, like it’s going to be okay no matter which way you go.

And I was really lucky that my last preceptor in school, she kind of harped that fact over and over and over again, you’re not going to fix everything in a day. You might not even be able to fix a slew of comorbidities at all. You’re only kind of prolonging and trying to help them along the way. But if they’ve had chronic kidney disease for the last 20 years, we’re not fixing that we’re just treating that along the way to improve their quality of life essentially.

But as nurses, we’re so used to being fixers, it’s like ingrained in ourselves. It’s so hard to be anything but a fixer. Especially in primary care and especially, especially in urgent care, you’re not always going to be able to be that fixer.

Now, kind of looking back, is there anything that you wish you would have known on day one of your job?

Cassandra: Not necessarily. I think for the most part, once we get into nurse practitioner school, we know kind of what the job is supposed to be like. We know what we’re going to be doing, for the most part. I think, if anything, I just wish I would have just trusted myself more.

And realized too that, you know, you could ask three providers that you work with about a certain situation, and all three of them are probably going to tell you a different answer. They all are going to give different medicines, treat different ways. But that doesn’t mean that any of them are wrong.

So I think that kind of thought, you just have to pick a treatment, you know, you’ve looked it up in your Epocrates, you’ve looked it up in Medscape or whatever, and it is one of the options. So that means, you know, it has been done. You know, just pick something, try it with the patient. If you’re really worried about them, schedule a follow-up visit, check on them see how they’re doing, call them later in the day or something and see how they’re doing. But just know that it’s not necessarily wrong if you do something different than your coworker.

Sarah: And I think it’s hard being new too because you’re like, “Oh, well this co-worker said this, but this colleague over here said this. Like, which is the right answer?” and I’m like, “Well, technically everybody’s right here.” You know? Like, we could all treat this differently and it would all still be okay for this patient.

So overall, how are you feeling about your decision to become a nurse practitioner and kind of take on this role of provider instead of being like the person who follows the orders, like you were in the ER? You know, is it kind of what you hoped it would be when you went to nurse practitioner school?

Cassandra: I love my job, I really do. Like, I’m so glad that I decided to do this. I’m such a people person. And I really have loved getting to know my patients, because even being in an urgent care I still do have a lot of frequent fliers that I see commonly. Or, you know, even people that will call and ask if I’m working because they’re going to come in if I’m working. And that makes me feel so good that I’ve established some sort of a relationship with them.

But, you know, realizing too that I don’t have to make this huge decision or put them on this crazy medicine and trial thing to change their life. Like some of these people just want you to go in there and educate them and talk to them. Some of them have never even been explained what the medicine is they’ve been taking for 20 years is. So sometimes they appreciate so much you just going in and talking to them.

I have had so many little old people thank me for everything I’ve done, and I have not done a thing but talk to them. But, you know, stuff like that is what I enjoy doing. And that’s why, you know, I went into this field was to kind of talk to people and at least give them the sense that I have helped them in a way.

Sarah: I think education and not making assumptions can go a long way. And I even learned that in my nursing career because I worked with bone marrow transplant patients. And so these transplant patients, they would be on these medications for years. And then I would go when they were discharged and like, “Hey, do you remember this, this, and this?” And they’re like, “Well, nobody told me that.” And I’m like, “Oh my gosh, well let’s stop right here.”

Education can make all the difference in them following up too and making sure that they’re doing the things that they’re supposed to be doing for their health. Like if you’re on this hypertensive medication but you don’t know about diet and exercise and all those other things, you’re really kind of missing the ball.

Cassandra: Mm-hmm, exactly. And sometimes that’s all they need, is somebody to show them how to track their food, you know. Like, Molly showed me, you know, we found a couple apps and I’ve literally taken my patient’s phone, and I’m like, “Here honey.” And we download an app, and we’ll teach them how to track their food. Like I didn’t do anything crazy, you know, most teenagers probably could do that. But some of these people need some help and a little guidance to do that. But that can make all the difference for some of these people.

Sarah: Yeah, just kind of give them a little boost along the way to be like, “Here’s an app where you can do it all in one place. So that way you’re not overwhelmed by it so you can actually follow the medical advice that I’m trying to give you today.”

Well, Cassandra, thank you so much for coming on the show today and kind of sharing your guidance with everyone because there’s so many new NPs out there hoping in just a little wall that they can feel ready to do all the things that you’re doing right now and kind of boost up those confidence levels.

And I think it’s so important to hear from a nurse practitioner that’s really kind of hit their stride too, and actually loves their job. Because in the scary Facebook world it can seem like nurse practitioners don’t like their jobs. But there are plenty of people out there that actually do, that love it every second of every day and I feel like you’re one of those people.

Cassandra: Yes, I am.

Sarah: That’s it for this week guys. Tune in for another episode next week.

Now, to celebrate the launch of the show, I’m going to be giving away a Medelita gift card which will allow you to go buy a gorgeous white coat when you’re ready. Now, I’m going to be giving away a gift card to two lucky listeners who subscribe, rate, and review the show on iTunes. It doesn’t have to be a five-star review, although I really do hope you love the show. I want your honest feedback so I can continue creating a show that provides tons of value for you guys as nurse practitioners.

Visit stressfreenp.com/podcastlaunch to learn more about the contest and how to enter. And I’ll be announcing the winners on the show in an upcoming episode.

Thanks for listening to Becoming a Stress-Free Nurse Practitioner. If you want more information about the different types of support we offer to students and new NPs, visit stressfreenp.com. See you next week.