Writing the Prescription to Fix Broken Nurse Practitioner (NP) Education (Pt. I)

  1. 13

    There are over 230,000 licensed nurse practitioners (NP) in the United States and I am proud to say that I will soon be one of them. NPs have achieved great advances in practice since the first education program began at the University of Colorado (UC) in 1965. NPs provide essential care for millions of Americans and now have full, independent practice authority in 22 states. However, despite these advances, our educational preparation is inconsistent, flawed and needs restructuring.

    Writing the Prescription to Fix Broken Nurse Practitioner (NP) Education (Pt. I)

    NURSE PRACTITIONER HISTORY

    When Drs. Loretta Ford, RN and Henry Silver, MD developed the first NP certificate program in 1965 it provided experienced registered nurses (RN) with the additional training to work in pediatric primary care settings collaboratively with physicians to manage acute and chronic illness (American Academy of Nurse Practitioners, n.d.). Drs. Ford and Silver believed that majority of the healthcare needs presenting in pediatric primary care settings could safety be overseen by nurses with advanced training in physical assessment, pathophysiology, pharmacology, and disease management. After creating the program at UC, Dr. Ford continued to work to develop the NP role and advocate for its implementation throughout the country. Since the NP role began, education has evolved from certificate to graduate degree programs and now includes acute and primary care specialties serving patients across the lifespan. NPs work in clinics, community settings, hospitals and private offices; some work completely independently while others work collaboratively in multidisciplinary treatment teams.

    Even with all of the progress achieved in advancing the NP role, debate continues regarding the necessary education and training required for NPs. Some of the biggest points of dispute include minimum number of clinical practice hours, degree for entry to practice, prerequisite RN experience, and necessity of post-graduate residency/fellowship training. In this two-part series I will discuss each of these topics and offer my take on what is broken within the current system and then suggestions on how we can improve it for future practitioners. Please keep in mind that these are my opinions and do not reflect the views of any college/university or professional organization. This is not a critique of any specific education program but rather a general commentary about NP education in the United States with the hope of starting an open and productive dialog between members of this forum.

    EDUCATION SYSTEM PROBLEMS

    The first NP programs were designed to build upon the practice of experienced nurses but as time has marched on we have seen the emergence of new educational formats including online and accelerated programs. Students can now complete NP programs in online classrooms from anywhere in the world and non-nursing professionals from a variety of backgrounds can join our field through accelerated degree programs. Utilizing new educational tools and alternative paths to entry are important to remaining current but these methods present challenges for maintaining quality standards and the “nurse” identity of nurse practitioner. Studies have found that having previous clinical experience as an RN was not associated with improved academic success or stronger clinical skills as a new NP (El-Banna et al., 2015; Rich, 2005, Rich & Rodriguez, 2002). While I won’t debate that non-nursing professionals can effectively complete accelerated programs and become successful NPs, I believe that these NPs miss out on critical socialization aspects of being an RN and are less likely to identify with the “nurse” aspect of being a nurse practitioner.

    Another issue that comes under frequent discussion is the variation of clinical practicum hours that NP students have to complete depending on their program. The Commission on Collegiate Nursing Education (CCNE) mandates that programs have a minimum of 500 direct patient care hours but offer few other specific guidelines (2016). A review of programs from around the country, the average number of clinical practicum hours range from 500 – 1000 hours when a masters degree or post-graduate certificate is conferred and 750 – 1250 when a doctoral degree is awarded. At first glance, one might assume that the higher clinical hours associated with completing a doctoral program would mean more direct patient care hours but in most circumstances the additional hours are for the completion of a capstone quality improvement or research project. This has come under serious discussion as it has been suggested that the entry degree to practice be changed from the Master of Science in Nursing (MSN) to the Doctor of Nursing Practice (DNP). The idea of raising education requirements and improving scholarship is good in theory but many question the “value add” of the DNP degree for NP when the additional clinical hours required for the degree are not typically related to direct patient care but are instead focused on a quality improvement or research project. The purpose of this article is not to debate the merits of a particular degree but to consider its value specifically as it relates to improving the ability of a NP to provide direct patient care as a clinician.

    Another major hurdle for many programs is securing appropriate clinical sites and preceptors. Many prospective NP students and healthcare professionals outside of nursing are unaware that in a number of programs it is the responsibility for students to find their own preceptors and clinical sites, which is challenging and results in unnecessary delays for program completion. For the more programs that take the responsibility of matching students with preceptors it can still be difficulty because most nursing programs do not pay experienced practitioners a stipend for having a student work with them and instead rely on volunteering and offers of continuing education credits or course credit at the affiliated college/university. In this writer’s opinion, forcing students to find their own preceptors is inappropriate and contributes to a lack of standardization in quality education. Also, by not offering some form of financial compensation or stipend to preceptors it sends the message that the preceptor’s time is not valuable and the education of NPs is less valuable than physicians or physician assistants (many PA and medical school programs provide financial compensation to preceptors for their time working with students).

    In the next segment I will discuss some problems seen with the modern graduate student and then provide a “prescription” for how fix a broken system. My question for the readers is, do you think that any major change is needed to this system at all? Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape? Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)?

    REFERENCES

    American Academy of Nurse Practitioners. (n.d.). Historical timeline. Retrieved from AANP - Historical Timeline

    Commission on Collegiate Nursing Education. (2016). Frequently asked questions: Clinical practice experiences. Retrieved from American Association of Colleges of Nursing (AACN) > Home

    El-Banna, M., Briggs, L. A., Leslie, M. S., Athey, E. K., Pericak, A., Falk, N. L., & Greene, J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5), 276-280. doi: 10.3928/01484834-20150417-05

    Rich, E. (2005). Does RN experience relate to NP clinical skills?. Nurse Practitioner, 30(12), 53-56.

    Rich, E., & Rodriguez, L. (2002). A qualitative study of perceptions regarding the non-nurse college graduate nurse practitioner. Journal of the New York State Nurses Association, 33(2), 31-35.
    Last edit by Joe V on Oct 20
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  3. by   shibaowner
    Thank you for starting this discussion thread. I agree with much, but not all, of your post. We all want high standards for nurse practitioner education and practice. But how best to determine what the standards should be? Our approach must focus on what is good for patients. Personally, I don’t care about the “prestige of the profession” line of argument. So, again, how to determine what is best for patients? We take the evidence-based medicine approach to determine the best solution. We don’t make important decisions affecting patients based on the personal biases of some practitioners. Even sadder, I have found MDs to be much more open to hiring new grad NPs without RN experience than many NPs.

    All available evidence indicates that NPs without RN experience are as likely, or more likely, to succeed in MSN programs. In addition, some studies indicate NPs without RN experience have superior clinical skills as evaluated by NPs and MDs. Not one single study has demonstrated that NPs without RN experience have worse patient outcomes. In addition, I fail to see how RN experience in an acute care setting helps in the primary care arena. Many primary care and outpatient specialists have told me they have no interest in hiring an NP or PA who only has acute care experience. Finally, ironically, this is similar to the MD vs NP debate. We all get frustrated with MDs arguing against full practice authority for NPs even though over 100 studies have shown NPs provide the same, or better, quality of patient care.

    I will carry this argument a step further. The U.S. has an acute shortage of primary care and mental health care providers, especially in smaller cities and rural areas. While medical schools are beginning to address this issue, it will be difficult and take a long time to produce enough primary care MDs and psychiatrists. NPs are most likely to go into primary care and are also more likely to practice in more rural areas. Therefore, we need to provide the optimum training program to produce competent providers. More does not necessarily mean better. For example, in the UK, doctors complete a 3 year bachelor’s degree. Med schools in the U.S. are now experimenting with 3 years of med school. Simply piling on more hours of education and training is not necessarily going to result in better practitioners and creates an unnecessary barrier to entry.

    With regard to the DNP, there is no evidence that DNPs provide better care. Many DNP programs do not provide additional clinical education and training, but focus on administrivia. Since the current NPs (mostly with MSNs) provide the same or better quality of care as MDs, what is the point of requiring more education and training? And if DNP is the new requirement, then might as well go to med school! If I had to get a DNP in order to be an NP, I honestly would have just gone to med school.

    I do agree we need to improve consistency and quality in NP schools. The MDs have been very strict about med school and do not allow for-profit medical schools in the U.S. NPs have more responsibility than RNs and the standards for getting into NP school should be stringent. I am dismayed at how many RNs seem to think they are automatically entitled to be an NP and who only want to become an NP because they can make more money and they think it is an easier job. Another way to crack down on subpar for-profit schools is to simply not hire their graduates. That would certainly be effective. That said, I have no issue with for-profit schools that have rigorous admissions and provide a high-quality education.

    I also agree that NP schools should provide preceptors. In some states, like Maryland, preceptors get a substantial tax break. It would be great to see more states, and the federal govnement, adopt this approach. However, preceptors shouldn’t be motivated only by money – every preceptor I had did it to give back to the profession. Perhaps a social marketing campaign to encourage more NPs to adopt this mindset would be helpful. In addition, NPs can also agree to precept only students from high quality schools, which would drive the subpar schools out of business.

    I believe we should have NP residency programs for new grads and the AANP, ANNC, and state level NP organizations should lead the way in helping us with policy, legislation, and funding to support this. It would be great if there was funding for residencies in underserved areas and NPs choosing this route could get tax breaks or some student loan forgiveness.

    With regard to online courses – if it is just lecture, then who cares? In fact, the advantage of an online lecture is you can listen to it as many times as you need, whenever you want. The only value to an in-person class is if there is substantial class participation and Q&A. Only a few of my MSN classes had that, and I went to a top school. There are online learning platforms that do provide for real-time student participation and allow the instructor to call on individual students. Here is a link to a fascinating article on Minerva University, a highly selective online college:
    The Future of College? - The Atlantic


    References

    El-Banna MM, Briggs LA, Leslie MS, Athey EK, Pericak A, Falk NL, & Greene J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5):276-80. doi: 10.3928/01484834-20150417-05.

    Rich, E. R. (2005). Does RN experience relate to NP clinical skills? The Nurse Practitioner, 30(12), 53-56.

    Rich, E. R., Jorden, M. E., & Taylor, C.J. (2001). Assessing successful entry into nurse practitioner practice: A literature review. Journal of the New York State Nurses Association, 32(2).
  4. by   WestCoastSunRN
    Great article and discussion! I love the brainstorming feel of discussions like these.

    Shibaowner, you say you have found MDs wanting to hire NP's with no RN experience over those WITH RN experience? Hmmmm. If that's the case in your area, I have to wonder if is more of a money issue. Experienced RN's make good money compared to a new grad NP when you are talking about the level of responsibility, liability and hourly wage. -- These nurses are more likely, I would think, to need a higher wage to do the work of an NP. This is an interesting aspect when discussing RN experience that I don't think gets enough air time in discussions like this. But also, in my experience (I am not an NP yet, haven't even started school, but I know and work with physicians and other employers...), employers favor an NP with RN experience. I can see why. You say that acute care experience would have no effect on primary practice? But how can that be? I have spent years at the bedside assessing patients and having their treatment plan change and flex based on those assessments. It's true I don't prescribe the treatments, but I certainly can anticipate what should be ordered and am often (teaching hospital) in a position to recommend specific orders. There's no doubt I have a ton to learn about primary care and advanced assessment and pharmacology, but I have NO doubt I will be a better NP BECAUSE of my RN experience and not in spite of it.
    I see the same El Banna and Briggs article over and over used here as some kind of proof that RN experience doesn't matter. I think we need a LOT more statistically relevant studies to prove such an assertion. In the meantime it's certainly something to think about. If we want NPs with no RN experience then lets give them a pathway similar to the PA to get there (my .02).

    I know mine is not a popular stance on the subject, and I imagine such an opinion can be hard to swallow from NPs without the RN experience. I mean no disrespect and truly there are very competent NPs without RN experience. But I think that phenomena begs for more investigation ... as does the idea of standardizing NP education.
    I think one thing we all agree on is that the pathway to NP should not be "easy" or "quick".
  5. by   ghillbert
    We need more clinical across the board throughout NP education. More hard science - patho, pharm etc.

    Less letters after our name - not so much super specializing... it really limits our careers having to go back to school get a new certificate for everything if we change specialty. It's so much easier work-wise to be a PA and move from whatever speciality to another.

    More structured transition to practice programs for new grad NPs.
  6. by   popopopo
    How about start with a better barrier for entry into NP school? Imagine making the curriculum harder only to have a hypothetical 70% graduation rate- schools will never allow that. The crop of students entering will be elevated. Can we add another method other than GPA? More stringent undergrad requirements maybe?

    Another thing that bothers me is that part-time schooling really reduces the difficulty level of NP education. Medical concepts isn't necessary difficult to absorb, but the volume of information thrown at an average PA or medical student is enormous. The adage goes that it's like drinking from a firehose. If we add more "hard science" like ghillbert suggested, we should discriminate against the ability to take courses part-time.

    The above are my opinion and I understand incorporating them will cause a slew of other problems too .
    Last edit by popopopo on Jul 29
  7. by   BCgradnurse
    Quote from shibaowner
    Thank you for starting this discussion thread. I agree with much, but not all, of your post. We all want high standards for nurse practitioner education and practice. But how best to determine what the standards should be? Our approach must focus on what is good for patients. Personally, I don’t care about the “prestige of the profession” line of argument. So, again, how to determine what is best for patients? We take the evidence-based medicine approach to determine the best solution. We don’t make important decisions affecting patients based on the personal biases of some practitioners. Even sadder, I have found MDs to be much more open to hiring new grad NPs without RN experience than many NPs.

    All available evidence indicates that NPs without RN experience are as likely, or more likely, to succeed in MSN programs. In addition, some studies indicate NPs without RN experience have superior clinical skills as evaluated by NPs and MDs. Not one single study has demonstrated that NPs without RN experience have worse patient outcomes. In addition, I fail to see how RN experience in an acute care setting helps in the primary care arena. Many primary care and outpatient specialists have told me they have no interest in hiring an NP or PA who only has acute care experience. Finally, ironically, this is similar to the MD vs NP debate. We all get frustrated with MDs arguing against full practice authority for NPs even though over 100 studies have shown NPs provide the same, or better, quality of patient care.

    I will carry this argument a step further. The U.S. has an acute shortage of primary care and mental health care providers, especially in smaller cities and rural areas. While medical schools are beginning to address this issue, it will be difficult and take a long time to produce enough primary care MDs and psychiatrists. NPs are most likely to go into primary care and are also more likely to practice in more rural areas. Therefore, we need to provide the optimum training program to produce competent providers. More does not necessarily mean better. For example, in the UK, doctors complete a 3 year bachelor’s degree. Med schools in the U.S. are now experimenting with 3 years of med school. Simply piling on more hours of education and training is not necessarily going to result in better practitioners and creates an unnecessary barrier to entry.

    With regard to the DNP, there is no evidence that DNPs provide better care. Many DNP programs do not provide additional clinical education and training, but focus on administrivia. Since the current NPs (mostly with MSNs) provide the same or better quality of care as MDs, what is the point of requiring more education and training? And if DNP is the new requirement, then might as well go to med school! If I had to get a DNP in order to be an NP, I honestly would have just gone to med school.

    I do agree we need to improve consistency and quality in NP schools. The MDs have been very strict about med school and do not allow for-profit medical schools in the U.S. NPs have more responsibility than RNs and the standards for getting into NP school should be stringent. I am dismayed at how many RNs seem to think they are automatically entitled to be an NP and who only want to become an NP because they can make more money and they think it is an easier job. Another way to crack down on subpar for-profit schools is to simply not hire their graduates. That would certainly be effective. That said, I have no issue with for-profit schools that have rigorous admissions and provide a high-quality education.

    I also agree that NP schools should provide preceptors. In some states, like Maryland, preceptors get a substantial tax break. It would be great to see more states, and the federal govnement, adopt this approach. However, preceptors shouldn’t be motivated only by money – every preceptor I had did it to give back to the profession. Perhaps a social marketing campaign to encourage more NPs to adopt this mindset would be helpful. In addition, NPs can also agree to precept only students from high quality schools, which would drive the subpar schools out of business.

    I believe we should have NP residency programs for new grads and the AANP, ANNC, and state level NP organizations should lead the way in helping us with policy, legislation, and funding to support this. It would be great if there was funding for residencies in underserved areas and NPs choosing this route could get tax breaks or some student loan forgiveness.

    With regard to online courses – if it is just lecture, then who cares? In fact, the advantage of an online lecture is you can listen to it as many times as you need, whenever you want. The only value to an in-person class is if there is substantial class participation and Q&A. Only a few of my MSN classes had that, and I went to a top school. There are online learning platforms that do provide for real-time student participation and allow the instructor to call on individual students. Here is a link to a fascinating article on Minerva University, a highly selective online college:
    The Future of College? - The Atlantic


    References

    El-Banna MM, Briggs LA, Leslie MS, Athey EK, Pericak A, Falk NL, & Greene J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5):276-80. doi: 10.3928/01484834-20150417-05.

    Rich, E. R. (2005). Does RN experience relate to NP clinical skills? The Nurse Practitioner, 30(12), 53-56.

    Rich, E. R., Jorden, M. E., & Taylor, C.J. (2001). Assessing successful entry into nurse practitioner practice: A literature review. Journal of the New York State Nurses Association, 32(2).
    ^^^^ This
  8. by   dmittman
    Let me start off by saying I am a PA for many years with many NP friends and colleagues. Almost all (but not all) have echoed that they would have loved to have had the initial education PAs have had. Not trying to say PAs are better or worse, just talking about education. In fact, I think we all wind up on the same roof, doing much of the same thing. Still, I will throw in my two cents putting in some questions you may want to consider about education moving forward.

    -PA education is standardized, at least 27 months long and full time. There are no part time programs. Most programs are modeled after one another. My program was 50 hours a week in class and clinical first year and second year 80 hours a week of rotations through all of the major medical specialties functioning as an "intern". We learned all procedures physicians learn and were ready to function fairly well upon graduation. We were in the best sense medical generalists and were expected to find our specialty later in our rotations or after graduation. Again generalists, not specialists upon graduation.

    -NP education seems to be less standardized (on line, two years full time, 2 programs integrated fully with PA programs) and generally shorter programs in hours. I have heard the argument that is because most applicants have RN experience. Again, my friends tell me this prior RN experience is sharply decreasing these days and also what is being asked of the new NP knowledge wise has increased significantly. Both professions are being asked to step into positions which were unheard of 15-20 years ago.

    Another large difference between NPs and PAs is that all NPs specialize in their initial education. Again, PAs do not and are less restricted because of this. Pediatric, women's health, acute care, etc. Do you want to continue this or expand this should be another question to consider?

    -What is interesting is that PA education, IMHO, will be taking a serious look at itself in view of PAs now looking for full practice authority/responsibility (we call it optimal team practice-as it comes with more), and also we are at the beginning of the formation of add-on clinical doctorates at PA educational programs. I think we have 5 programs now. We also have over 140 postgraduate specialty residencies where one can learn a specialty after graduation. Traditionally, PAs learned their specialty while working in a clinical position, many at teaching hospitals.

    -My belief is that we will see many more residencies where both NPs and PAs will join together learning a medical specialty and associated skills.

    Thanks for allowing me to share some thoughts. Whatever comes of this, I wish you luck in the future. I know that in both professions change will be a constant and we will have to learn from one another.
    Dave
    Last edit by dmittman on Jul 29 : Reason: adding thoughts.
  9. by   cjcsoon2bnp
    Quote from dmittman
    Let me start off by saying I am a PA for many years with many NP friends and colleagues. Almost all (but not all) have echoed that they would have loved to have had the initial education PAs have had. Not trying to say PAs are better or worse, just talking about education. In fact, I think we all wind up on the same roof, doing much of the same thing. Still, I will throw in my two cents putting in some questions you may want to consider about education moving forward.

    -PA education is standardized, at least 27 months long and full time. There are no part time programs. Most programs are modeled after one another. My program was 50 hours a week in class and clinical first year and second year 80 hours a week of rotations through all of the major medical specialties functioning as an "intern". We learned all procedures physicians learn and were ready to function fairly well upon graduation. We were in the best sense medical generalists and were expected to find our specialty later in our rotations or after graduation. Again generalists, not specialists upon graduation.

    -NP education seems to be less standardized (on line, two years full time, 2 programs integrated fully with PA programs) and generally shorter programs in hours. I have heard the argument that is because most applicants have RN experience. Again, my friends tell me this prior RN experience is sharply decreasing these days and also what is being asked of the new NP knowledge wise has increased significantly. Both professions are being asked to step into positions which were unheard of 15-20 years ago.

    Another large difference between NPs and PAs is that all NPs specialize in their initial education. Again, PAs do not and are less restricted because of this. Pediatric, women's health, acute care, etc. Do you want to continue this or expand this should be another question to consider?

    -What is interesting is that PA education, IMHO, will be taking a serious look at itself in view of PAs now looking for full practice authority/responsibility (we call it optimal team practice-as it comes with more), and also we are at the beginning of the formation of add-on clinical doctorates at PA educational programs. I think we have 5 programs now. We also have over 140 postgraduate specialty residencies where one can learn a specialty after graduation. Traditionally, PAs learned their specialty while working in a clinical position, many at teaching hospitals.

    -My belief is that we will see many more residencies where both NPs and PAs will join together learning a medical specialty and associated skills.

    Thanks for allowing me to share some thoughts. Whatever comes of this, I wish you luck in the future. I know that in both professions change will be a constant and we will have to learn from one another.
    Dave
    I really like the idea of post-graduate residency programs that combine NPs and PAs, I think it brings together the strengths of both disciplines and will advance the combined education. I am lucky to work side by side with quite a few PAs, many of them are great advanced practice providers. You mention the fact that PA education is primarily 24+ month full-time intensive programs which provide a solid didactic and clinical preparation for new providers but by not providing any part-time options you limit the ability for older students, students who have families, or students who need to work full-time from returning to become a PA (and thus why you see most PA students are in their early 20's and people who very recently completed their undergraduate degee). I think that a plus of having part-time NP programs are the ability to have a more diverse student group but they could stand to borrow a bit of the rigor of PA programs (in my opinion).

    On a side note, one thing that I have found to be more common with PAs is that these programs tend to attract a lot of young, eager and gifted students but when they graduate they have a hard time working with some of the other disciplines in a cooperative and team-oriented way because they have limited work experience in healthcare settings. It seems like PA programs (and MD/DO programs for that matter) are taught that they are the leaders of the healthcare team and they write or give orders, while nurses, technicians and other therapists exist to carry out orders. In my experience, this mindset makes new PAs come across eager to prove themselves which means they may be hesitant to accept differing opinions or suggestions to change patient care from non-physician providers. This is certainly not the case for every PA and it depends largely on the person's personality, confidence level, precious work/life experience and the culture of the healthcare setting where they are employed. I think that as any new provider (DO/MD, NP, PA) gains more experience in their role and working as part of a team then they will develop a more cooperative approach and be more open to suggestions and constructive criticism. I feel that NPs who were experienced RNs are a bit less likely to do this but on the other hand they may have to deal with tensions with RNs who resent the NP role (but that is an entirely different discussion).

    Its funny that this discussion came up because just last week one of my PA colleagues asked if I would come and teach skills lab at the PA program where he is an adjunct faculty member. He asked me because he believes the students need to learn how to do the hands-on technical skills that nurses know (NG tube/foley cath and IV insertion, basic wound care dressings etc.) and he said that the teaching style he has seen me use with my nursing students would be supportive to new PAs and help them to develop a better respect for nurses.

    My takeaway point is, I think any program that brings together NPs and PAs and advances their education and professional cooperation is a good thing and that NP and PA education programs could learn a lot from each other.

    !Chris
    Last edit by cjcsoon2bnp on Jul 29
  10. by   JellyDonut
    Quote from shibaowner
    So, again, how to determine what is best for patients? We take the evidence-based medicine approach to determine the best solution. We don’t make important decisions affecting patients based on the personal biases of some practitioners. Even sadder, I have found MDs to be much more open to hiring new grad NPs without RN experience than many NPs.

    All available evidence indicates that NPs without RN experience are as likely, or more likely, to succeed in MSN programs. In addition, some studies indicate NPs without RN experience have superior clinical skills as evaluated by NPs and MDs. Not one single study has demonstrated that NPs without RN experience have worse patient outcomes. In addition, I fail to see how RN experience in an acute care setting helps in the primary care arena. Many primary care and outpatient specialists have told me they have no interest in hiring an NP or PA who only has acute care experience. Finally, ironically, this is similar to the MD vs NP debate. We all get frustrated with MDs arguing against full practice authority for NPs even though over 100 studies have shown NPs provide the same, or better, quality of patient care.

    I will carry this argument a step further. The U.S. has an acute shortage of primary care and mental health care providers, especially in smaller cities and rural areas. While medical schools are beginning to address this issue, it will be difficult and take a long time to produce enough primary care MDs and psychiatrists. NPs are most likely to go into primary care and are also more likely to practice in more rural areas. Therefore, we need to provide the optimum training program to produce competent providers. More does not necessarily mean better. For example, in the UK, doctors complete a 3 year bachelor’s degree. Med schools in the U.S. are now experimenting with 3 years of med school. Simply piling on more hours of education and training is not necessarily going to result in better practitioners and creates an unnecessary barrier to entry.

    With regard to the DNP, there is no evidence that DNPs provide better care. Many DNP programs do not provide additional clinical education and training, but focus on administrivia. Since the current NPs (mostly with MSNs) provide the same or better quality of care as MDs, what is the point of requiring more education and training? And if DNP is the new requirement, then might as well go to med school! If I had to get a DNP in order to be an NP, I honestly would have just gone to med school.

    I do agree we need to improve consistency and quality in NP schools. The MDs have been very strict about med school and do not allow for-profit medical schools in the U.S. NPs have more responsibility than RNs and the standards for getting into NP school should be stringent. I am dismayed at how many RNs seem to think they are automatically entitled to be an NP and who only want to become an NP because they can make more money and they think it is an easier job. Another way to crack down on subpar for-profit schools is to simply not hire their graduates. That would certainly be effective. That said, I have no issue with for-profit schools that have rigorous admissions and provide a high-quality education.

    I also agree that NP schools should provide preceptors. In some states, like Maryland, preceptors get a substantial tax break. It would be great to see more states, and the federal govnement, adopt this approach. However, preceptors shouldn’t be motivated only by money – every preceptor I had did it to give back to the profession. Perhaps a social marketing campaign to encourage more NPs to adopt this mindset would be helpful. In addition, NPs can also agree to precept only students from high quality schools, which would drive the subpar schools out of business.

    I believe we should have NP residency programs for new grads and the AANP, ANNC, and state level NP organizations should lead the way in helping us with policy, legislation, and funding to support this. It would be great if there was funding for residencies in underserved areas and NPs choosing this route could get tax breaks or some student loan forgiveness.

    With regard to online courses – if it is just lecture, then who cares? In fact, the advantage of an online lecture is you can listen to it as many times as you need, whenever you want. The only value to an in-person class is if there is substantial class participation and Q&A. Only a few of my MSN classes had that, and I went to a top school. There are online learning platforms that do provide for real-time student participation and allow the instructor to call on individual students. Here is a link to a fascinating article on Minerva University, a highly selective online college:
    The Future of College? - The Atlantic


    References

    El-Banna MM, Briggs LA, Leslie MS, Athey EK, Pericak A, Falk NL, & Greene J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5):276-80. doi: 10.3928/01484834-20150417-05.

    Rich, E. R. (2005). Does RN experience relate to NP clinical skills? The Nurse Practitioner, 30(12), 53-56.

    Rich, E. R., Jorden, M. E., & Taylor, C.J. (2001). Assessing successful entry into nurse practitioner practice: A literature review. Journal of the New York State Nurses Association, 32(2).
    As someone who has worked with NPs from all different backgrounds I can see a difference in the backgrounds when it comes to practice. A nurse with 10 years experience who becomes an NP is a safer practitioner than someone with zero experience. She is easier to train, catches on quicker and I do not get a phone call form a staff nurse at 1800 asking me what the heck she is doing. The ones without experience take longer to spin up and wow some of the obvious things escape them. I am not saying this applies to all, but I have experienced it way too often to just be a coincidence.

    I refuse to even interview a for profit online NP without any experience. If one does drop a CV with 10 years background I may be moved to speak to them especially if someone I know can vouch for them, otherwise they will no be hired for my group.

    I do agree that a BSN who moves straight to the MSN program will do better in school than a nurse who has been away from the classroom for 10 years. However, if they both pass it is a moot point. The experienced RN has been exposed to more disease processes than the novice as NP school covers only a few, maybe a handful of conditions. The experienced nurse if gonna have way more background to fall back on.

    Just because there is not a current study to prove something does not discount the fact. I do not need a study to tell me it will hurt to shoot myself in the leg.
  11. by   shibaowner
    Quote from JellyDonut
    As someone who has worked with NPs from all different backgrounds I can see a difference in the backgrounds when it comes to practice. A nurse with 10 years experience who becomes an NP is a safer practitioner than someone with zero experience. She is easier to train, catches on quicker and I do not get a phone call form a staff nurse at 1800 asking me what the heck she is doing. The ones without experience take longer to spin up and wow some of the obvious things escape them. I am not saying this applies to all, but I have experienced it way too often to just be a coincidence.

    I refuse to even interview a for profit online NP without any experience. If one does drop a CV with 10 years background I may be moved to speak to them especially if someone I know can vouch for them, otherwise they will no be hired for my group.

    I do agree that a BSN who moves straight to the MSN program will do better in school than a nurse who has been away from the classroom for 10 years. However, if they both pass it is a moot point. The experienced RN has been exposed to more disease processes than the novice as NP school covers only a few, maybe a handful of conditions. The experienced nurse if gonna have way more background to fall back on.

    Just because there is not a current study to prove something does not discount the fact. I do not need a study to tell me it will hurt to shoot myself in the leg.
    One does not make policy decisions based on anecdotal evidence and personal biases. Period. NPs who think that is good practice demonstrate a poor education and lack of understanding of evidence based medicine. Things change all the time in medicine, based on new evidence. For example, the JNC 8 changed treatment guidelines for HTN based on health outcomes. These decisions are not based on the personal biases of practitioners. And a practitioner that does not adjust their practice based on new evidence is a poor practitioner indeed. So, I would hire a new grad NP w/o RN experience who understands this over a new grad NP with 20 years' RN experience who practices based on personal biases and anecdotal evidence.

    That said, I do believe more studies should be done on NPs w/o RN experience vs NPs with RN experience. However, the studies that have been done (and these date back to the 1990s) indicate that RN experience is not needed to be a good NP. (I did not cite older studies.)

    In addition, there is a big difference between an NP in primary care vs acute care. I am in primary care and outpatient mental health care. I fail to see how RN hospital experience is such a big help in the outpatient environment. We are not administering medications, running IVs, or providing personal care to patients. RNs do not take extensive histories, perform diagnostic PEs, diagnose, or write medical orders. In addition, few RNs work in the outpatient environment - VS and basic intake is generally performed by medical assistants.

    So, here is my anecdotal experience. I attended Johns Hopkins - certainly no "diploma mill." About half the class had worked as RNs (I did not have RN experience). The first semester of MSN NP program, we had a semester course in physical exam skills. I went into this PE course thinking the RNs would have a real advantage. Much to my surprise, they did not. I performed better than most of the students with RN experience with regard to PE skills.

    Fast forward to my geriatric clinical in a SNF. My preceptor was a wonderful NP, but she was a bit miffed I did not have RN experience. So when my clinical faculty instructor from Hopkins visited for the mid term clinical check up, my preceptor voiced her concern. The JHUSON instructor asked for an example of how this had impacted my actual performance. The preceptor could not think of anything except I didn't know some acronyms. She also spoke privately with my JHUSON instructor. Afterwards, my instructor, who has been an NP for over 30 years, told me that she didn't know those acronyms, either! Well, they were institution-specific terms, so why would the preceptor expect everyone to know those terms? My JHUSON instructor, let's call her Betty, was very highly regarded and respected by the students and faculty. She was also a preceptor, in addition to being an instructor. She told me the studies supported NPs w/o RN experience, which is why JHUSON made the change to admit these students. She also said that she personally had never seen that RN experience was of much benefit in working with outpatient populations (although the RN experience would be an advantage in working with inpatients).

    In addition, throughout my clinicals and in my courses, all my preceptors and professors praised me for my ability to take a thorough H&P and produce excellent documentation. They complained that few students, including those with RN experience, had these skills. My write ups were a pleasure to read. And the H&P is a core fundamental skill for an NP, PA, or MD, the foundation for successful diagnoses and treatment.

    My last clinical rotation was in a specialty outpatient private practice. The physical exam skills were not taught in the BSN, MSN, or even in medical school. My preceptors were 2 MDs and they told me that even the residents they precepted did not know these techniques - these had to be acquired through OJT. Nor would these techniques be known by an RN unless she had worked in a similar practice, but these practices don't employ RNs - they use medical assistants. The MDs wanted to hire me, but I had to return home to California, plus I had a public service requirement, or I would have gladly taken the job. So they asked me to help them hire an NP or PA. They were adamant they did not want to hire anyone who had only worked inpatient. The only RN experience that mattered to them was if the RN had worked in outpatient/primary care. In fact, based on previous hires, individuals who only had acute care inpatient experience performed poorly in their practice. We did not have IVs, administer medications, or provide personal patient care. The only 2 pieces of equipment were the VS machine and a machine to perform specialized procedures. So they were happy to consider a new grad NP (AGPC or FNP PC) w/o RN experience. What did give a candidate an edge was NP or PA experience relevant to the job at hand, but those candidates were in very short supply.

    RNs are not all created equal. Some are crummy, most are average, and some are outstanding. I see no advantage to NP practice from crummy or mediocre RNs - a motivated, intelligent, capable non RN would make a better NP.

    And for all the naysayers out there who don't like NPs like me and also for the NPs moaning and groaning about an inability to find a good job: I returned to SoCal and have had numerous recruiters contacting me about jobs in San Diego and OC. I chose to take a job in Redding because that job had the equivalent of a residency program (rigorous OJT) and this position fulfills my public service obligation and also pays top $. All the jobs I've been considered for pay A LOT of $. So lots and lots of people and organizations want to hire people like me. One of my school mates, w/o RN experience, graduated as an FNP in May, and just got hired for a very competitive NP residency program in the SF Bay Area. All of my JHUSON classmates w/o RN experience were hired within 3 months of graduation for top $ and by very prestigious and reputable organizations. So, naysay all you want, I have a great job, I'm doing well, my supervisors are happy, my patients love me, and I'm laughing all the way to the bank!
  12. by   KurtDNP
    I am a DNP-prepared nurse practitioner, having completed both brick and mortar as well as online programs at state universities. I saw no innate advantage in one format over the other, although I prefer online as I think my time is typically utilized more efficiently when not locked into real-time live lectures. I've also matriculated through both full-time and part-time programs. There were no appreciable quality differences. I started with an Associate RN degree, got my BSN, then my MSN, followed by a Post-Masters Certificate and finally the DNP.

    Admittedly biased by the skewed sample of my personal experience, I tend to think nursing education should continue to offer family-oriented, nontraditional, step-wise entrance/advancement options that cater to people at all stages of life. I hope we continue to offer part-time and distance/online options. I know of no studies providing reasonable evidence to support the one-size-fits-all approach to disciplinary entrance and advancement academically that mark other health-related disciplines. I see no evidence of correlation between nursing's flexibility and lack of consistent quality. I hope, therefore, nursing maintains this flexibility.

    Notwithstanding, there is indeed a need for quality standardization in terms of clinical hours, documentation of clinical experience and the like across academic programs nationally. I appreciate the unique purpose of the practice doctorate in nursing (DNP), for example, but wish more CLINICAL experiences were included for those in clinical tracks (like NPs, CRNAs, CNMs and CNSs). I wish NP programs required extra courses like gross anatomy, medical biochemistry and procedure workshops relevant to basic clinical skills every advanced clinician should know well.

    Perhaps the MSN could lead to a generalist advanced practice nurse with primary and acute care training across the lifespan. Then the specialty aspect can be added during the doctoral leg (along with the quality improvement and translational evidence-based practice skills the DNP degree was designed to offer). Finally, some sort of optional post-graduate clinical internship, fellowship or clerkship (preferably with other advanced practitioners) could be available (with some government-funded sponsorship IMO) for those wanting to achieve practice autonomy faster or for sub-specialization.

    Anyway, that's kind of how I see things right now. If nothing else, it is clear that most of us believe there is room for improvement in NP education. Hopefully by continuing these sort of discussions, real changes that are substantive and impactful will follow.

    Blessings...
    Kurt
    Last edit by KurtDNP on Jul 30 : Reason: misspelling, flow
  13. by   Baviary
    I believe that there are major problems that nursing will never (?) solve - and some of these are the infighting and 'digging in heels' when discussing change. RN's who have been practicing for many years believe that THEIR way is the ONLY way and that anyone who says different is WRONG. Change 'for many years' to 'just a few' and you have the SAME ARGUMENT!!! We look at other RN's with different training and say he/she can NOT be as good as WE are. WE know what is best and NO ONE will change that. 'WE' can be ANY RN with ANY background, training, experience, etc. As a profession - we need to get OVER ourselves and stop behaving like a bunch of high school children. Change is needed. Period. What should the change be? Standardization of education across ALL schools. Since the research - yes, the research, indicates better mortality and morbidity rates from bachelor's prepared RN's, then the entry level should be bachelor's prepared. Now here's when people want to lynch me....I NEVER SAID that I BELIEVE that RN's with ANY OTHER DEGREE are LESS THAN or WORSE, etc. It is the RESEARCH. Again, let's get over ourselves and move on, shall we? As far as APNs are concerned, I only have personal opinion to go on as I have not read any research on this. People who want to be APN's should be held at a higher level academically - be able to write well, etc. There should be rigorous training in the sciences and prepare the NP for a generalized role (kind of like the PA). There should be clincal work - just like when getting one's RN with rotation in various specialties. When the NP chooses a specialty, there should be additional training and clincial work. I believe we should have a residency program as well. Maybe 2 years working in your field of choice with either an NP with 5 - 10 years experience or an MD. Similar to PAs and MDs this would be a paid position where you would basically do the job but with close supervision. DNP's? Not useful in the clinical world and created because the ivory tower people want to advance the prestige of the profession. I started a DNP program and dropped out after 1 semester. Why? the classes and the project that we were to do were EXACTLY what I did in grad school. Waste of my time. AND we had to write a 1 page paper 'to see if we could write'. Sorry but while this was quite a prestigious program, it is obviously not very discriminating if they'll take people who can't even write a decent paper...and they DON'T KNOW IT already! Makes me crazy. Anyway. None of what I or anyone here says, believes, etc. will do anything to assure that changes will be made. The people in charge don't want to hear it as THEY fit into the same catagory as what I said earlier in my little diatribe. Sad but true. Everyone wants it their way and refuses to change. Everyone wants the power. Sounds like our government right now. Again, sad but true.
  14. by   ivanh3
    No offense to the OP, but I think "broken" is a strong term. I do not feel that NP education is broken. Any program can be improved, and most quality programs (of any kind) constantly self evaluate to improve their product. I have to agree with the responder who stresses the importance of research and the avoidance of anecdotal experiences that may erroneously guide decision making. I have seen new grad NPs with plentiful nursing experience fail, and I have seen new grads with limited RN experiences excel. I have also seen the opposite occur. I have not stepped out of my fishbowl to research which is the norm. Instead I judge each NP by their actions. I learn from both. I "steal" techniques and knowledge from those I think are sharp and use this to develop my own style, and I learn what not to do from others. New NPs often bring new and fresh approaches and they keep me on my toes.

    In terms of NP vs PA education I can say this. I didn't want to go to PA school. I may admire the rigor of their programs, but I don't see a better or worse final product. In my region all job postings are "NP/PA" or "PA/NP" but never one or the other alone. I work with PAs and man are they sharp, but so are the NPs where I work. We have to be. It is a high acuity, high volume setting, and we all turn to each for help. I was full time in school, but I was able to work. I was able to be part of my newborn son's life. My wife went part time to NP school which was a bonus for our family. BTW she totally kicks ass in her "nurse practishery" skills.

    Let's continue to improve our programs and our practice, but strong language like "broken" is not helpful or accurate.
    My .02

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