Time to remove the "nurse" in APN?

[Jedrnurse]

More and more, I am seeing posts from people who want to leap straight from taking the NCLEX into an advanced practice role. (Often you see plans of "pre-nursing" students already plotting their CRNA careers, but that's another story.)

Also, an increasing number of schools are designing programs that greatly reduce or eliminate the need/chance for actual nursing experience before acceptance.

It's almost as if the advanced practice role is becoming ever more distant from its origins, i.e. hands on nursing.

On top of that, with questionable programs opening up (which often results in weak practitioners), is it possible that nursing as a whole gets a black eye by association?

Bottom line: is it time for a divorce? Should advanced practice nurses be retitled and called something along the lines of physician's assistants?

[Ruby Vee, BSN]

Still taking isolated incidents and slamming and entire group of professionals with that label. No one has explained the difference to me between Np without bedside experience, and a resident. Technically the Np is a full hospital employee, but still associates with the MD in the same as a resident does. And you even illustrated that with your scenario. It's almost the exact same thing. It's really pretty absurd. I think ya'll just salty. If you want to sit here and bad mouth Nps by personal bias and isolated incidents (I. E. Sharing subjective narratives with can't be verified) over data involving entire profession (I. E. number of nps who've had a malpractice case immediately after hire), then you are just gossiping and I'm done here.

A resident has supervision. An NP without bedside experience, once she is off orientation (which can be up to six months but it still significantly short of the 1 year minimum of residency for a medical school graduate) she practices independently. Without bedside experience, she doesn't know what she doesn't know. Sadly, a good percentage of the straight to NP graduates come to us with a large chip on their shoulders because they've been told that they don't even know what they don't know and they're convinced that's wrong. An NP without bedside experience who is as humble as a first year medical resident might LEARN -- the residents do. But I've heard a number of them saying that "the nurses all hate me because I'm better than they are" and other such malarkey.

The NP model was built upon being "Advanced Practice Nursing." If you haven't ever practiced nursing, it is difficult to see how you could possibly have built upon your nursing knowledge to become and advanced practitioner.

[shibaowner, MSN, RN, NP]

At the bottom of your post your bio says you are from "California." The NP Scope of Practice in CA says that if you are practicing as a NP there you will be working under standardized procedures if you are diagnosing/treating patients (RN's work under standardized procedures too), and the standardized procedures that you work under require physician supervision.

If you read the John Hopkins study that suggests medical errors are the third leading cause of death in the US, you will learn that patients deaths due to medical errors are not recorded on a patient's death certificate, and there is no national database where patients deaths due to medical errors are recorded. So it is futile for you to say that there should be evidence if it is a bad idea to allow NP's to practice independently.

While there is a shortage of primary care providers, it is important to safeguard the standard of care. Many physicians (and others) object to dilution of the standard of care.

Money is the dominant factor, and there is much money to be made. Who lobbies for independent NP practice?

Wow! You are really reaching now! Please take a class in logic.

[Boomer MS, RN]

A resident has supervision. An NP without bedside experience, once she is off orientation (which can be up to six months but it still significantly short of the 1 year minimum of residency for a medical school graduate) she practices independently. Without bedside experience, she doesn't know what she doesn't know. Sadly, a good percentage of the straight to NP graduates come to us with a large chip on their shoulders because they've been told that they don't even know what they don't know and they're convinced that's wrong. An NP without bedside experience who is as humble as a first year medical resident might LEARN -- the residents do. But I've heard a number of them saying that "the nurses all hate me because I'm better than they are" and other such malarkey.

The NP model was built upon being "Advanced Practice Nursing." If you haven't ever practiced nursing, it is difficult to see how you could possibly have built upon your nursing knowledge to become and advanced practitioner.

I could not agree more with the above comments. The comment about the physician doing an internship or R-1(minimum) training right out of school illustrates the point for anyone being a provider needs more education and training. Why is nursing any different? And the current trend for many MDs is to do a Fellowship after the residency. Why there is a shift in the Advanced Practice nursing model is astounding to me. Anyone in that role can learn how to be a provider, just as an MD and PA learn.

If you haven't ever practiced nursing, it is difficult to see how you could possibly have built upon your nursing knowledge to become and advanced practitioner. Amen.

[operations]

So if you were to put a minimum requirement on clinical experience for Nps, what would you suggest it be? And would it have to matter that that person practiced as an RN specifically (instead of emt, or other provider) ? Would they have to be a hospital RN or could they have worked in a different role? How could it be measured that this is the appropriate level of experience?

[Ruby Vee, BSN]

So if you were to put a minimum requirement on clinical experience for Nps, what would you suggest it be? And would it have to matter that that person practiced as an RN specifically (instead of emt, or other provider) ? Would they have to be a hospital RN or could they have worked in a different role? How could it be measured that this is the appropriate level of experience?

The "appropriate" level of experience for admission to an NP program used to be five years. It's an arbitrary number, but it seems to have generated a generation of stellar nurse practitioners. That's five years as a nurse at the bedside. No shortcuts. An NP who wishes to work in primary care may do very well with five years of experience as an RN in a primary care role. Someone who wishes to be an acute care nurse practitioner would seem to do better with acute care experience.

EMTs, RTs and others who were interested in the role usually went to PA school instead. I've known some awesome PAs as well.

The biggest reason we seem to have such a glut of unqualified nurse practitioners is that the schools urge nurses to get advanced degrees as soon as they achieve their BSN. Perhaps I am crass to mention this, but it seems to be about the (tuition) money.

[Boomer MS, RN]

So if you were to put a minimum requirement on clinical experience for Nps, what would you suggest it be? And would it have to matter that that person practiced as an RN specifically (instead of emt, or other provider) ? Would they have to be a hospital RN or could they have worked in a different role? How could it be measured that this is the appropriate level of experience?

I honestly do not know the amount of minimum requirement for clinical experience, and I would leave that recommendation to the experienced educators. And yes, I advocate RN experience for an EMT, paramedic or RT, meaning becoming an RN. There are medics who have extensive experience in Iraq or Afghanistan who might find some of the NP course work easier because of his/her experience. For the ACNP applicant, the specialty I am most familiar with, I think hospital experience in an acute care setting is necessary, preferably the ICU or ED. I have no opinion for a primary care provider in an office practice setting because it is not a role I know much about clinically.

This debate seems to go and on presently. It was not an issue a few years ago when the application standards were quite different than today when more schools have opened and have promised a sometimes quicker way to become an NP. Disheartening, IMO.

[Boomer MS, RN]

I'm not sure what your response to me is saying.

1. I stated RN experience is not beneficial to a primary care NP and the studies bear this out. Do you have evidence to the contrary specific to PRIMARY care?

2. I indicated RN experience is probably helpful to an ACUTE care NP. Most reputable NP schools require RN experience for ACUTE care NPs.

3. Anecdotes are not evidence. I have a lot of anecdotes about RNs that appear incompetent and so forth.

4. There is absolutely no need for a live in person class unless the instructor is going to interact with the students. If the instructor is just going to lecture, then I can watch a recorded video of that. I can then email or call the professor with specific questions. In addition, with modern technology, a live class can be conducted via Adobe Connect so that the students see and hear the professor in real time, and they can ask questions real time via the online education platform.

I respectfully disagree with #4 above. There was a time when some of us were in academic lectures (undergrad) (200+) on the hard sciences, and all the students, including me, benefitted greatly by being able to ask questions during the lecture. Maybe you find in person lectures unnecessary, but saying "there is absolutely no need" is not gospel. The trend is for online, and I admit I am no fan. I'm so grateful I was able to get my BSN and MS before this became more main stream. I appreciated being able to talk face to face with all my professors and having conferences with my classmates in the flesh. Times have changed with the Internet for sure with some benefits. I find it all a trade off.

[operations]

I respectfully disagree with #4 above. There was a time when some of us were in academic lectures (undergrad) (200+) on the hard sciences, and all the students, including me, benefitted greatly by being able to ask questions during the lecture. Maybe you find in person lectures unnecessary, but saying "there is absolutely no need" is not gospel. The trend is for online, and I admit I am no fan. I'm so grateful I was able to get my BSN and MS before this became more main stream. I appreciated being able to talk face to face with all my professors and having conferences with my classmates in the flesh. Times have changed with the Internet for sure with some benefits. I find it all a trade off.

I think you misunderstood what she was inferring. What she meant is that an online education is just as effective as an in person education. There will be a difference learning styles appropriate for online, but the content and the outcomes are on par. Therefore, people who've taken these classes should be held in the same regard as if they were to take it in person. It wasn't inferring that there is no use for in person classes,or that it was a replacement, etc

[Boomer MS, RN]

I think you misunderstood what she was inferring. What she meant is that an online education is just as effective as an in person education. There will be a difference learning styles appropriate for online, but the content and the outcomes are on par. Therefore, people who've taken these classes should be held in the same regard as if they were to take it in person. It wasn't inferring that there is no use for in person classes,or that it was a replacement, etc

I did not misunderstand the comment. Please reread #4. Perhaps the OP can speak for him/herself.

[operations]

I understand that advanced practice was initiated by just that, expanding knowledge based on expertise, but at some point we have to level with pragmatics a bit. I would say 5 years is a bit of a delay. Not that it isn't good to have more experience but it doesn't always mean better, as in, you willhave a peak and taper. If I was someone who is planning out their future, and you tell me I have to have a bachelors and then work five years just so I can go to school and then work as a clinician with very restricted priveledges and pay, I most certainly will laugh at you. And many other people will reject this. Some of them because they want to slid by, but some who really have talent and are just looking for the best option. I think a couple years at the most is enough, if not you are just delaying education. Yes you need to see the patients, recognize the disease processes that you will commonly encounter vs special cases, understand the way the hospital works, but you do not need to have a expertise in doing tasks you won't be doing in you goal career.

Internship may be the answer to that. Have the students be able to complete their education and get experience doing the role they want to master. Make it mandatory for 6-12 months after they finish school, and make it paid. Waive it if they have X amount of experience being a rn in acute care. And allow people into the program that are exceptional. If someone is truly exceptional, I really believe they will be safe to release to the public in 6-12 month's

All in all, with the need for clinicians, and so many people understandably turning away from the excessive requirements that medical training would demand on their lives, surely there are pragmatic ways we can design medical education, without affecting standard of care. We are losing so much talent unnecessarily. I think incompetent graduates derive from the admissions office. I don't think experience has as much to do with it as allowing the wrong person to be in that position. Let's face it, think of the people that you've known were incompetent. There was something missing in that person that experience can't fix. A talented person is cautious and has high adaptability. Doesn't overestimate themselves and hits the books if necessary. I always favor talent over experience for this reason.

[operations]

I did not misunderstand the comment. Please reread #4. Perhaps the OP can speak for him/herself.

I'm not sure what you understood from the comment then. Ok. The whole conversation was about people who think online education isn't as good as in person education. Ok, I guess talk to her then if you want, idk.

[EJN, RN, BSN]

Operations: I just have a random thought... Don't waste your breath. There are people who feel entitled to vilify and smear others because they feel that they, and only they, can ascertain who makes a competent provider and supply endless anecdotes about someone they know” who was almost killed by a NP who they disapprove of. They have decided that young people are bad, online classes are bad, progress is bad -- No amount of evidence is going to persuade them against their supreme excellence for being old and being unable to evolve... After all, everything was excellent 20 years ago and we should all just stay there permanently. No matter how strong the evidence is proving competence in those they disapprove, their bias will always rule supreme. This type of threads pop up every so often in order for them to reassure themselves of their superiority and to squash anyone who may disagree or may have evidence that contradicts their 'truth'.