I talk to a fair amount of nurse practitioners who are in a space of indecision. My goal is to help them sort out what will best serve their {whole} life goals. It’s always about balancing work-life factors with career goals. Some of them are considering leaving the profession and going back to the bedside or doing something else altogether. Some are coming to me seeking interview/job acquisition help and what we discover is that their confidence has been wrecked by a unhealthy work environment. I’d be willing to bet many of you have experienced this in the past or are stuck in this situation currently. It’s truly a sad state of affairs these days particularly for nurse practitioners. In this article I wanted to talk about this phenomenon and what some options may be for you.

“That show was trash,” says the teenager in my house. Apparently this is how one describes bad things. How many of you are or have been the subject of a trash workplace? I have, sort-of. I think all teams have a spectrum of trashiness (probably not an approved version of the sentiment). It’s sort of a “is the grass really greener elsewhere” assessment. Weighing the balance of positives and negatives is a topic of conversation that I have often enough with nurse practitioners that it’s impossible to deny that there’s a culture issue within our profession. I see it across the country. I can’t tell you how disheartening it is to hear. In the end, I still love this profession and I think there are wonderful teams to work with but it may be a little harder to find.

What I find interesting is that sometimes clients either don’t realize the source of their issues is the environment or they underplay the severity. While these may seem obvious, I have to take a minute and list out red flags of an unhealthy nurse practitioner work team.

• Over criticism.

• Lack of feedback.

• Micro-managing.

• Unreasonable work flow expectations (high census, not enough time for FTF visits, not enough dedicated charting/admin time, assigning difficult cases before you are capable of handling them).

• Unreasonable work-life expectations (more call, holidays, contracted days, overtime than agreed to in your contract).

• Unreasonable pay or lack of raises/reimbursement for increased productivity or experience level.

• Abbreviated or ineffective orientation.

• Scope limitations (not allowing you to practice to your scope, may feel like you are a note jockey or just enter orders without participating in key components of plan development or implementation)

• Not enough support (they leave early, they aren’t available for questions/assistance, not receptive to questions or ongoing training)

• Passive-aggressive statements or actions.

• Sexual or demeaning behavior.

This is by no means comprehensive but these are the commonly encountered issues. I think many NP’s are scared to leave, worried there aren’t other jobs out there, or are too insecure to recognize how bad things have gotten. They are so skilled at adapting to the problems they may be blind to toxic the situation really is. Listening in as the consultant I can recognize it clearly, but just like when you’re kids are growing up - it happens so gradually and progressively that you may not see it until others point it out. Here are some signs that you are in the wrong workplace.

• Dreading going in to work (checking the schedule to see who your workmates are the next day and then perseverating on your strategy for dealing with them).

• Emotional or physical signs of anxiety. For me this was completely physical. Sure, I have stress, not denying that, but it didn’t seem more than the usual amount. Sometimes the usual amount has been growing gradually and you’ve been adjusting slowly as well but not always in a healthy manner. Mine looked like less time for hiking (my healthy coping skill), more irritation with my family, and (late stage) development of severe heartburn. I’m talking dysfunctional, can’t eat, vomiting, no meds work type of heartburn. I was convinced I had a hernia. Once I addressed the anxiety/stress it resolved 100%.

• Emotional or physical signs of depression. Sleeping too much or too little. Lack of interest in things that used to make you happy. This may even look like lack of interest in a profession you once loved. No desire to expand your education/practice any further.

Why? Why is this not an uncommon problem for nurse practitioners? I won’t make broad generalizations about the personality types that go into certain fields (we all know them). I also won't elaborate on the obvious - as NP’s we are working much closer with physicians. There is a definite power play and a “scope-creep” fear that aggravates some team interactions and limits our job opportunities.

Beyond that, I am sure many physicians and APP teams have had bad experiences with poorly prepared nurse practitioners which taint their opinion of the profession as a whole. If you watch any of my stuff you’re aware of my less-than-subtle opinions about this ;) It doesn’t reflect well on our profession when new nurse practitioners start practicing with too little training, too much hubris, and demanding too much independence. We have to crawl before we can run, and I feel that the AACN and our educational institutions push too hard for the inappropriate practice of medicine by non-physicians who are not ready. We are brain-washed to believe we can and should do anything we want in keeping with our physician colleagues. I’m all for full scope practice and I value being able to do what I do. But again, it has to be done in a safe way for our patients.

So what are your options?

1. The first step is recognition. Knowing your situation and the severity of it helps drive your decisions. My recommendations for this are to talk to people. If you are seeing red flags, if you are experiencing some of those signs above, or if your family keeps pointing out those signs - talk to people. Talk to people in your micro-universe. Other NP’s in your practice, former NP’s from this practice, NP’s who work for other specialties within your health system, former classmates. Then broaden the range by talking to NP’s in your state groups; FB forums (there are so many NP forums - regional ones, specialty ones, stage of training, etc). You would be surprised how many people will reach out if you put up a post requesting feedback about a specific problem. As them about their experiences. Is your issue unique? Does it seem more severe than most? How is the market in your region and specialty, do you have other options? You can always reach out to me about scheduling a consultation, I love to help with your unique situation.

2. The second step is outlining the issues. I’m very visual so I like to literally write out a list of pros and cons and rank them by importance. Make an abstract problem concrete and as objective as possible. Then I suggest you write out your goals and rank them as well. The last step is to match up your goals with the issues at your current job. For example, if your primary goal is money and you are making a great income at your current place you may pull out the old calculator to back into a time frame for when you can afford to take a pay change/cut. If your primary goal is training/education and you aren’t receiving this you may explore other positions that are more established or even look into fellowships where the training is standard at the expense of a pay cut or longer commute. You can always explore the option of setting up a consultation with me and I am happy to help you evaluate your situation and make career decisions.

3. If the balance weighs in favor of leaving you can start the job acquisition stage and all that entails.

4. If the balance weighs in favor of staying you can drill down to the major issues and focus on coping strategies.

   • If it’s a co-worker personality issue: I love the book “The Five Love Languages” by Gary Chapman. There is a workplace version more specific to understanding how colleagues receive and give love/appreciation. https://amzn.to/3Xm8IdQ. If you know how people tick - the things they appreciate and value - you can adapt your behavior/communication to their style. You would be amazed how a difference in what the two of you consider important can jeopardize a relationship. Adaptability is the name of the game here. A little sacrifice on your part will have downstream change in how they treat you.

   • If it’s a request for more money, I find the old adage doctors like data applies here. Administrators also like data. If you can obtain a market analysis and present how this compares to your pay you will get more attention. If you follow this up with your specific performance data you can make an argument for how you financially benefit the team. Do this by asking friends, people in your area for salary/call pay/bonus/PTO etc info. The more confirmed the better - meaning if you can get copies or pictures of contracts it will hold more weight. Gather your case logs, average census and associated income generation (most commonly used billing codes, procedures or other higher income generating tasks). Create a power point or some other presentation and this is your talking points. It comes across as professional, organized and is far more impactful than the tear filled assertions that you are just worth it and they have no idea how much value you bring to the team.

   • If it’s unreasonable expectations (or any of the other concerns above) you can, and should, consider a one on one discussion. Tread gently here though. I would not just willy nilly bring it up on a day when you are annoyed with something. I would ask for a dedicated time you can have a meeting. If it’s a really toxic relationship I may even ask for a mediated discussion. Have objective, limited emotional, points of discussion. Have clear asks and be specific on when and how you will receive or offer feedback about how it’s going.

5. And ultimately, as with most things in life, this will come down to you. Changing/adapting your expectations and learning to just let things go will help with your mental health. There are plenty of workplace issues that you have zero power to change. Finding things outside of work or other small things within your job that bring joy help mitigate. Knowing your goals also helps you deal with the issues.

Final words: Please, please know that even if all you’ve known are unhealthy; unhappy work environments, this is not the bee all end all. Your first job won’t be your last job. There are many wonderful, supportive, collegial work teams out there for nurse practitioners. You are valuable. And even in a time of nurse practitioner “saturation” there is potential for career satisfaction. I’m living proof of that.