NP bridge programs, regarding ADVANCE article...

Tim-GNP · Mar 17, 2001

Research... no, I have none. Non-RN to NP programs.... I am against them 100%. But please don't take it personally-- I have a great deal against a LOT of things with NP education. I am glad that you flourished and did well in your NP program, and I am also pleased that you have a good working relationship with your physician. Autonomy is a good thing.

As for me, I was an LPN, then an RN/BSN. The MSN/NP program that I attended required at least 18 month of RN experience before admission.

I have taught students from a non-BSN to RN/MSN program [however, it was not an NP program, it was a clin. spec. program]. I can immediately tell that they do not have same level of competency as the RN/BSN who is going through an MSN program. I would not call them 'sub-par' [that is actually quite an ignorant way to refer to another human being] but I can safely say that they are in need of an expanded clinical experience.

The knowledge base and skills that you are referring to are closer to that of a Physician's assistant. The NP's claim to fame is the nursing background WITH the knowledge of the medical model. You will notice that 'Nurse' preceeds the 'practitioner.' Without a thorough knowledge of the nursing process and 'nursing intervention' to augment health- then you are practing the medical model only.

Your point is also a good one about years of RN experience not preparing you to understand in-depth pathophysiology. But in depth knowledge does not always mean that a person will have good judgment- that is what the experienced RN brings to the table. I have seen some NP's go NUTS with a prescription pad.

I also have concerns over other things in NP education- and, I don't mean to offend, either, but I am against the FNP. In my NP program, I spent 2 years of my life studing under an experienced, board certified Geriatrician to learn how to handle the complex problems involving multi-system deterioration in older adults [both normal aging and pathological processes]. In that SAME amount of time, the FNP's in my program were supposed to have learned, pediatrics, obstetrics, adult health, mental health, AND Geriatrics. I would love to know how.

Well... I have gone on enough. These are just my humble opinions [bearing in mind my opinion and $.74 wouldn't get you a soda]. But, the post was here, and I responded.

I wish you much luck & success.

Tim GNP

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Tis with our judgements as our watches, none go just alike, yet, each believes his own.

-Alexander Pope

Chris-FNP · Mar 17, 2001

Tim,

Thank you for your reply and I obviously disagree with you to some extent, but that's ok.

As an FNP, I do agree that there is a lot to learn in a short time. However, we must remember an important thing here...

Medical students graduate, get their MD, and are put in charge of a lot of people with very little back-up, which is a recipe for danger. But, they do have back-up in their internship. I think that an NP's first years are just like an internship. We have a good base of knowledge, but we need that MD support for back-up and to continue learning.

Also, I do agree that rapid NP programs are almost like PA programs in a sence...but we have to think about this, what is the harm? So we may not have a huge grasp of nursing theory, but personally, I dislike nursing theory. People will gasp at that and I don't really care. Nursing theory is out-dated and seldom remembered...let alone used. My buddy is getting his Ph.D. in nursing theory right now and will demonstrate how very few NPs actually use a particular theory. Yes, this will be very controversial when published...but its true of a large percentage of all nurses.

Are we "mini-docs?" The reality is yes. If nurses choose to think otherwise, they are hopelessly holding on to dated thoughts and beliefs. Today, the bottom line is that NPs are cost-efficient and provide good care. We know our limits and when to hand off the ball to the MD.

The future of healthcare is just going to show that more Docs will specialize and NPs will be the major PCPs. Why would Docs today go into family practice with $200,000 of debt and make $110,000 a year? We have to be realists.

The reality is that Bridge NP programs do produce quality NPs. Maybe they don't produce the "ideal" nurse in many's eyes, but oh well, that's just the old breed's opinion in a rapidly changing healthcare system.

The bottom line is that all NPs are taught to provide care in a safe manner and to know their limits. Floor nursing is a whole different ballgame that cannot be logically compared to the actions of an NP. Like it or not, that's the reality that most people are just either afraid to say or admit to themselves.

Chris-FNP

Tim-GNP · Mar 17, 2001

My hats off to your buddy doing the Ph.D. in nursing theory. I am going for my Ph.D. but it is in Health Science Education. I just couldn't cope with a Ph.D. in nursing. I use nursing theory all the time. Even though I hated OB/GYN, I use the mid-range theory of Ernestine Wiedenbach a nurse midwife who developed the 'need for help' theory in the 1950's-1960's. The quick and the dead of it is that a nurse [or, in this case, NP] could only intervene where the patient allows them to intervene [once certain prerequisite conditions are met].

For the most part, though--- you are right. Most nurses see no use in nursing theory. I must also agree [even though I hate to admit it], but NP's really have been removed from nursing, per se. I mean-- I still have my basic nursing skills [i do staff relief part time at an area nursing home to keep those up], but there is very little use in that capacity for my NP skills, and in my Monday-Friday NP job, there is little use for my RN skills.

You also said something else interesting-- about medical residents. We have a large medical residency program where I work. The residents rotate through approximately 12 different experiences, spending a month in each spot. Over the course of 4 years, they get approximately 4 months in each specialty. Granted, some specialties permeate others--but on the whole, it's not a lot. Want to guess how much of their rotation is Gerontology??? An occasional month in the nursing home with my Doc's-- who usually send them with me to show them 'comprehensive geriatric assessment.' They are usually never intersted, anyway.

My collaborating physicians always give the 'difficult' old people to me [who I never seem to find difficult], but by the same token, I give the unstable cardiology cases to them. It is a very mutually reciporcal relationship. So, your comments about NP's being the major PCP's is right on the money. My MD's are interested in the 'specialized' sorts of problems.

This is definitely an interesting discussion. The other NP's who work where I work are not as, shall we say, 'fun' as I am. They are all FNP's and very aggressively involved in advancing the NP role. Like I said in my previous posts about some NP's going nuts with prescription pads. I work with one other GNP, and she is of the same mind-set as I am. Prescriptive authority--- 'big deal.' We are more into the holistic approaches to aging, patient teaching, wellness promotion, assessments of medication compliance, etc. Don't get me wrong, we don't hesitate to treat anyone for a second, but we are not as 'aggressive' as some of the other NP's.

Just curious... do you work with GNP's?

Chris-FNP · Mar 17, 2001

Tim,

This is a great discussion. I usually tend to "irritate" other nurses with my unconventional views. I appreciate your honesty and for listening with an open mind. I do agree with you on some points as well.

Personally, I don't work with any GNPs directly...although my friend who is getting his Ph.D. is a GNP. But he is a full-time student.

Also, I have to admit that I tend to (against my own wishes sometimes) use my script pad a lot. Mostly because I am in a family practice and if a mother does not leave with an abx for her child, she will complain and argue until I give in. Again, the reality of the situation is that trying to explain abx-resistence in a 15 minute visit with 20 patients in the waiting room is VERY hard. So, you end up giving in. Some nurses may say that "Oh, you did not explain it well enough." Some might say that they "never" give in. The reality is that if you tick off enough parents by not giving the patient (or should I say consumer nowadays) what they want...the practice suffers financially. Thus, our (me and the MD) hands are tied in a sence. I think that this issue is very common and one that I personally am trying to change through education...but in baby steps.

I've been thinking about this discussion a great deal tonight and its made me think about how so many nurses just fight each other. NOT YOU AND I, but on the whole. MDs stick together. PAs stick together. Nurses pick each other apart constantly...it really irritates me.

I remember when I was in an ER once (while in my non-RN to NP program). I was a patient and was being triaged. Now, I was obviously not well and when the nurse made small talk and asked me what I do...she stopped taking my vitals to argue with me. "How can you become an NP without being an RN first?" she said. I was like, "Hello, this is not the time!!!" That bothered me.

RNs who became NPs have to just get over it and move on with their lives. MDs, PAs, Marines, etc. They all share a common bond. Nurses of all levels should to.

Example...A person can become an officer in the armed services by going to Annapolis, West Point, etc. Or they can have a BS/BA and go to a 3 month OCS program then be commissioned. All officers stick together!!! And the ones that went to OCS learned about the millitary in 90 days as opposed to 4 years.

Let's accept the fact that there are all types of nurses...good and bad.

My long 2 cents again,

Chris-FNP

Home Health Columnist / Guide · Mar 17, 2001

Quote form Chris:

"Also, I do agree that rapid NP programs are almost like PA programs in a sence...but we have to think about this, what is the harm?

So we may not have a huge grasp of nursing theory, but personally, I dislike nursing theory. People will gasp at that and I don't really care. Nursing theory is out-dated and seldom remembered...let alone used."

I totaly disagree with these quotes. The essence of Nurse Practitioner education is that you are a NURSE first, practitioner second...Your lack of experience in this profession shows here, as this 20 yr veteran, MSN/FNP student sees it.

The essence of medical school and PA training is the medical model: diagnosis, treatment and cure.

Nursing is about CARING: helping persons understand their health,illnesses, or disabilities; wellness + preventive care; and helping ease dying persons final momemts and provide comfort to their loved ones---allowing people to make informed choices and help them to deal with and maximize their daily lives.

After 1 month into my Nursing Theory Course, I see more clearly the differences between each model.

Examples:

HTN Mmgt

Doctor: Review BP readings taken by nurse/assistant over 1 or more visits, perform physical exam, diagnose problem, prescribe medication, diet, exercise, begin teaching re HTN mgmt. Schedule re visit.

RE visit: check BP readings, BP still high, more med.;instruct re complications, schedule fu appointment.

Nurse: Review BP readings, recheck BP lying, sitting, standing (if possible), perform physical exam, inquire re life events/ situation at work/home, review diet intake past week( can they cook or is it prepared /retaurant meals, ability to afford food), check insurance or ability to afford medication and prescibe most cost efficient drug, give handout on diet, exercise, council re wt loss if needed,set goals with patient for treatment plan, begin teaching re HTN mgmt, nonpharmocologic mgmt of illness;make referrals to other resources: Nutrition counciling, social work for help with med payment possibly, visiting nurse for BP followup if significanly elevated and RX/instruction in self BP monitoring, set followup appointment.

At revisit, Was medication RX filled/compliance,attempts to follow plan, changes since last visit, praise for coming back and trying follow plan, more teaching, complications illness, need for life long periodic tune ups.

The above scenerio shows how the NP by using nursing theory takes a much broader viewpoint of the client and stressors affecting life, educates,mutually sets goals, treastment plan and followup to evaluate that plan...the essence of Caring in nursing.

Otherwise your are not practicing in your independent role but only functioning as an extension of the doctor role i.e. Physician assistant.

My $1.05 opinion!

[This message has been edited by NRSKarenRN (edited March 16, 2001).]

Chris-FNP · Mar 17, 2001

NRSKarenRN,

You make some valid points. But, I think in one sence your misreading some of what I said. Its not whether I completely agree with the way the real world has most NPs practice...its the realization of how things are in most places.

Please DO NOT make the statement that my post reflects inexperience. That fact is beside the point in this post. I've had experience in other areas of medicine aside from nursing before I became an NP. It does not take a rocket scientist to understand my role as a nurse first...I made that point clear. My comments merely reflect "the way it is" in most practices that use NPs.

NRSKarenRN,

You said...

Examples:

HTN Mmgt

"Doctor: Review BP readings taken by nurse/assistant over 1 or more visits, perform physical exam, diagnose problem, prescribe medication, diet, exercise, begin teaching re HTN mgmt. Schedule re visit.

RE visit: check BP readings, BP still high, more med.;instruct re complications, schedule fu appointment.

Nurse: Review BP readings, recheck BP lying, sitting, standing (if possible), perform physical exam, inquire re life events/ situation at work/home, review diet intake past week( can they cook or is it prepared /retaurant meals, ability to afford food), check insurance or ability to afford medication and prescibe most cost efficient drug, give handout on diet, exercise, council re wt loss if needed,set goals with patient for treatment plan, begin teaching re HTN mgmt, nonpharmocologic mgmt of illness;make referrals to other resources: Nutrition counciling, social work for help with med payment possibly, visiting nurse for BP followup if significanly elevated and RX/instruction in self BP monitoring, set followup appointment.

At revisit, Was medication RX filled/compliance,attempts to follow plan, changes since last visit, praise for coming back and trying follow plan, more teaching, complications illness, need for life long periodic tune ups."

Do I agree? Yep. Is that realistic in most places? Nope. You have 15 minutes NRSKarenRN. That's it. 15 minutes. A lot of practices want you to see 4 to 6 patients an hour. If you don't see that many patients...you are not productive to the financial end of the practice. If you find a practice that gives you 20 to 30 minutes for an office visit and 1 hour for a physical, then let me know. They are far and few between.

Your comments are the ideal NP. I am merely stating that the ideal NP role is not as common as one would hope.

Are you an NP? Are you a student NP?

Oh, and your blanket statement about how an MD handles HTN versus an NP is not warranted. I've worked with Docs that practice more like your idea of an NP and NPs that practice more like Docs. Doctor-bashing is another common trait that runs within the relm of nursing...especially in academic NP settings. It comes down to the PERSON and not their title.

Chris-FNP

fergus51 · Mar 17, 2001

Chris,

I am the one who made the sub-par comment, but if you read it I said the masters-non-nurses that I KNOW so I think I do have the right to say that without looking up research. I am not trying to put down an entire group of people. You obviously had the experience as an EMT and the drive to excell. Congrats and best wishes. The NPs here practice completely independantly and I personally would not go to a NP if he/she had never had supervised practice time. That's all. No cattiness meant by anything I said.

fergus51 · Mar 17, 2001

Oh, and Tim, I was not reffering to their value as a person when I said sub-par. Only their nursing skills. I wish people would take what I say at face value instead of putting their own ideas on it.

Tim-GNP · Mar 17, 2001

May I be so bold as to suggest that we keep these posts grounded in academic fact and underpinned with mutual respect versus mud-slinging??? This has, thus far, been the sanest post I have seen on this B.B. Please let us respect each other first, and list our reasons for disagreement-devoid of emotionally charged comments like 'Your lack of experience in this profession shows here..." This is demonstrating the nurses picking each other apart 'thing' again.

Regardless of preparation, there is the healthcare infrastructure that overrides all. Regardless of MD/NP/PA model, when your practice setting gives you 4 appointments in an hour time slot [3 of which are double books], the:

"inquire re life events/ situation at work/home, review diet intake past week( can they cook or is it prepared /retaurant meals, ability to afford food), check insurance or ability to afford medication and prescibe most cost efficient drug, give handout on diet, exercise, council re wt loss if needed,set goals with patient for treatment plan, begin teaching re HTN mgmt, nonpharmocologic mgmt of illness;make referrals to other resources: Nutrition counciling, social work for help with med payment possibly, visiting nurse for BP followup if significanly elevated and RX/instruction in self BP monitoring, set followup appointment..." that you propose, gets thrown out the window. Whether anyone wants to admit it or not.

Chris also brings up a good point about some physicians practicing as NP's practice. The collaborating physician I am closest to constantly hears me say to him "you would have made a great NP!" He is GREAT in the way he provides holistic care to his patients. I strive to be like him [no, that doesn't mean I want to be a Doctor, before anyone jumps on that], it just means I respect his medical knowledge as he applies it in a holistic manner. The system that he and I work in, however, ALLOWS us to be this way...

Where I work, NP's who have primary care clinics are given 1/2 hour with follow-up patients, and 1 hour with new patients. I have a wonderful opportunity to 'negotiate' treatment plans with patients, review their labs with them, compare them to last visit and show them where they improved, [or where improvement is needed]. My diabetics have to take off the shoes and roll up the pant legs with each visit including microfiliment testing... I do real fundoscopic exams... Sky is the limit [i usually wind up running 5-10 minutes late with each person, because I wind up doing a LOT of stuff]... I write out medication compliance sheets--- all those little extras that will aid their compliance with their 'negotiated' medication regimen.

Moral of my story???? It is often the system, versus the educational preparation. PA's could be like NP's, NP's could be like MD's, and MD's could be like NP's... The real question is, are you in the right environment and are you committed??? Just because someone is an NP does not mean that they have the aforementioned attributes. I have seen some wreckless things done by NP's.

My opinion: 100% free.

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Tis with our judgements as our watches, none go just alike, yet, each believes his own.

-Alexander Pope

Tim-GNP · Mar 17, 2001

By the way, Chris... I failed to ask, do you have A.N.C.C. accreditation as an F.N.P.? If not, are you accredited by an accrediting body, if so, which one?

I ask because I was under the impression that the type of program was all but extinct [i admit, I do not know it all, either]. I am very interested to know.

fergus51 · Mar 17, 2001

Tim I COULDN"T AGREE WITH YOU MORE about the respectful tone of the conversation!!! Your posts almost always seem that way and it makes them a pleasure to read.