It's Been A Time
Becoming a new provider has its own set of trials and tribulations. Add on the wrinkle of being new to critical care. Fellowships exist to help grow new APPs into competent novice providers. However these programs are few and far between. I was fortunate enough to start as an APP in the hospital where I started as a nurse resident, and then a new grad RN nearly a decade ago. In the ensuing years I precepted many new grad nurses. I became a supervisor and had direct reports and a whole lot of members on my team both formal and informal who helped me along the way, and I was always agreeable to repay the favor.
If you read forum posts on social for APPs - the vast majority of posts are from people searching for preceptors. The shortage of preceptors for midlevel providers is to blame for the rise in pay to play preceptors utilized in graduate level education. If you're paying for someone to mentor you, what is their motivation?
This is the same person who would be qualified to teach and help grow new providers in a clinical setting, but they won't do it for the benefit of the thing itself. Good for goodness sake. Antiquated concept perhaps. I was fortunate enough - after asking two years in advance I was able to secure my final semester of clinicals as an APP in the critical care unit. My other two prior semesters I was able to arrange through networking at my hospital, and because of my prior good will - people were amenable to repaying the favor. No one has to do this. But there are thankfully some people, but certainly not enough, that believe that having the ability to pay it forward and to impart what they have learned to someone else is reward enough. And then there is everybody else.
That 280 hours in the ICU with my preceptor led to my being encouraged to pursue critical care when I graduated, despite my lack of prior critical care experience. I finished my clinicals. I completed my DNP project. I turned in all necessary paperwork. Filled out the numerous forms and showed my due diligence for the many hours spent. Gave presentations. Passed exam after exam after exam. I demonstrated clinical proficiency with standardized patients while being filmed. I wrote paper after paper. Gave presentation after presentation. I graduated with my doctorate. I wore the robe and the hat. I studied and passed boards soon after and applied for the job they were kind of enough to offer to me. I jumped through the hoops to be credentialed. And then I started orientation - again with a preceptor. So as a new grad APP entering critical care I had every understanding of the gravity of the situation. My dayshift months with my day shift preceptor were dreamy. I felt anxiously comfortable, but was reassured that I was doing well and I would be off orientation early. Night shift orientation began and I experienced whiplash unlike anything I've known.
Nocturnists do things differently. I knew this. I worked night shift for five years. I did my last clinical on night shift. I saw the culture and the pace. I saw how night was when people deteriorated and resources were more scarce - so nocturnists have to dig in. My preceptor was new to my hospital but an experienced APP who was used to running their own show, their way. My supervisor had been burned before by new grads. Therefore - a full six months of learning was what I would get. And the way I needed to adjust and do things completely opposite from how they were for the last two months shook me to the ground.
I wanted to quit. Almost every shift. Being tested shows you what are capable of. It shows others where you are deficient. I didn't do this because it was easy. I didn't do this blindly. But I didn't sign up for how this went. I can talk about it now because it is nearly over.
The phrase about nurses eating their young is cliche. I feel it sets a tone that nurses are the mean "girls". And I think that is a fallacy. I think when we talk about "theory" - that part of padding of a 4 year BSN nursing degree and the padding of a 3 year DNP degree, what it means is that once you achieve a degree of competence, you block out what it was like to be a novice.
Because being a novice is terrifying. You work hard to get better to be competent because feeling like you know nothing is the worst. You can fail forever and feel like shit forever and not succeed or be the one people cannot depend on - which is its own type of hell. Or you can work your ass off and do all you can to learn and get as good as you can get.
The ability to succeed is limited by your capacity to drink through a fire hose that is spitting actual fire. Once you get on the other side of it - you block out the trauma. And when you are in proximity to someone who is novice again, you have forgotten. You have intentionally, subconsciously, forgotten what it is like to be them. Because its awful. I see APPs talking about nurses they work with either as stars or saints or stupid. Seems to be a lot of the latter. And its unfair.
What is worse is to know that the people who are doing it about others in front of your face, are doing it about you behind your back. No one is exempt. Then there is the APP vs nurse zeitgeist because, as my first preceptor back when I was in school explained to be - it's "church and state". Once you're a provider you are no longer a nurse. I tried not to do this. I will always be a helper. I understand what I ask you to do for a patient may have consequences on your mental and physical health. While the patient comes first, I will consider the consequences of what I order on the person carrying out my order. I will consider you. We are a team. Or at least I thought we could be. The nurses I have worked with seem to appreciate me sitting beside them on a hard night. I trust you to do your job. Until you make it hard for me to trust you. My preceptor made it clear it was her way and her way only. No room for interpretation now. No room for another idea. It's not the way to learn and grow, in my opinion. However. I bent the knee. For six months. With all stick and very little carrot. On one vulnerable occasion where I was stressed but successful during a procedure I said I needed a minute because my confidence was low. And I got reprimanded. So I will never be vulnerable again. That's not how to be a team with someone. Everyone will have a moment where they are not their best.
In healthcare that can affect if someone lives or dies so we take it seriously. But the thing to do is step up and help in those moments.
This goes to say I think someday I will be glad I did this. I will be proud of what I have accomplished so far - but I have no clue if in fact the people I work with secretly feel I am a worthy part of the team. And I wish that weren't the case.
Oh and I have had to stop being "helpful" and bend more to the separation of Church and State. The Church told my attending physician that in morning rounds of nursing leadership I should not talk to them. The only things I mentioned were helpful in terms of ..I honestly don't remember what it was. I think it was about a transfer. Nursing leadership likes to ask APPs about patients coming in because of availability of staff, or where they are putting patients - or what they can and can't do. And that's not really our business.
A sick patient needs to come to the critical care unit - they need a bed. I'm sorry if they can't get a sitter, or have enough staff, or what they need. It's their job to figure that out. It's my job to care for patients. But as my attending has said - we operate parallel to that. I thought it was a team sport. But apparently there are new teams. Which likely contributes to the misery of the commons. So for better or worse, this noble crusade I embarked upon has been my labor for a year. A year a graduated APP. Six months of precepted shifts. The next campaign begins. I am not fresh or ready. I am demoralized and changed and humbled. I am crushed beneath the steadily turning wheel. Grist for the mill of our healthcare calamity.