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BostonFNP Guide 43,051 Views

Joined Apr 4, '11 - from 'Northshore, MA'. BostonFNP is a Primary Care NP. Posts: 4,719 (61% Liked) Likes: 11,443

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  • Jun 22

    I am "that" NP. I did a Direct Entry program and have not worked bedside, but went right into a NP position. That was 9 years ago. I've not had any issues working as a NP, and really don't use much of what I learned in the RN portion of my program. Some caveats-I had over 20 years of experience in a different health care role that had very little direct patient care, but I did have years of hospital experience in that role. I also work outpatient as a NP. I am not trained to do inpatient care. I think RN experience is very valuable if you are going to work in patient. I also went to a very rigorous and respected program, not an on-line, for profit, you're on your own program. Finally, I worked my butt off and did more clinical hours than were required. I knew I had more to prove, and I wanted to do the best I could for my patients. I've been very successful, and have been praised by patients, colleagues, and supervisors. I have no regrets taking this route.

    I think people can be successful in the Direct Entry programs, and can also fail in traditional programs even if they've had years of RN experience. It's very individual. Critical thinking skills and experiences in other careers can translate into success for graduates of direct entry programs. I precept student NPs from both paths, and I have had stellar DE students and crappy students with years of RN experience. Some RNs have difficulty transitioning to the provider role. DE students (at least the ones I've precepted) tend to be overachievers and will go above and beyond to learn. That's not to say I haven't had some fantastic traditional NP students, too. I will only precept for a few reputable schools, and will not precept for any for-profit schools that have low admission standards.

    Don't disregard Direct Entry grads. We're out there, we're not going away, and many of us are very competent and successful.

  • Jun 17

    Quote from MunoRN
    Also, federal laws don't override state laws, under the constitution state laws take precedence. The hierarchy goes: the Constitution, then state laws, then the federal government can make laws with respect to what states and the constitution haven't addressed.
    Actually the constitution states the fed laws supersedes state--article 6 supremacy clause

  • Jun 16

    I have seen GB syndrome once in 10 years on pediatric ICU nursing. That child walked out of the hospital when it was all over. I can't count (more than 20-30 maybe) the number of infants or immunocompromised children I have see die from vaccine preventable diseases. I'm not even talking about the ones who just got sick or ended up on ventilators for a few weeks. I'm talking post-mortem care on a 3 week old because someone somewhere didn't want to get a flu shot. Read the side effect list for Tylenol or your multivitamin. Everything is risk vs benefit.

  • Jun 11

    Quote from BostonFNP
    Respectfully, I disagree with this as an absolute.

    You are absolutely right that this is career of lifetime learning, in fact it really requires a commitment to lifetime learning. Just like RN practice, APNs demonstrate a basic competence by board exam but entry to practice signifies the beginning of the development of that practice. All novice providers whether they are NPs or PAs or physicians require years of on-the-job development. As such, and as you give credit to, much of practice is developed in the year or two following entry to practice, working on-the-job (really it is the only way to see the amount of patients that need to be seen to be competent independently.

    Nursing experience often helps student and novice NPs, depending on the quality of their experience and it's relation to their NP role. There are some skills that RNs have that make them excellent providers, but they are not tangible skills from my experience, rather they are things like being comfortable talking to patients, having a "6th sense" about a patient before they tank, a familiarity with the system in general.

    As you mention, nursing school gives a cursory introduction to skills and they are developed through experience: this means that, at times, they are developed incorrectly/poorly, or not developed at all depending on the type of RN experience. At times there can be difficulty with role transition/confusion with long-time RNs moving to the APN role. At times there can be over-confidence, which is one of the most dangerous things to a novice provider.

    In my experience, there are great student NPs with no nursing (or very limited) experience and terrible students with lots of nursing experience and vice-versa. It would be wonderful if we had large studies that looked at this to remove individual variability, but there are only a few (and they suggest RN experience is not an important predictor of NP role transition or skills). I can say, having educated a pretty decent number of student NPs, is that the variability between individuals is greater then the variability of their prior RN experience. The thing I dislike the most is student NPs that are going to NP school, doing NP clinicals while trying to also learn the RN role in the first 1-2 years as an RN, and I feel the end up doing poorly at both.
    I could not agree with this more. I have precepted NP students for many years, and I have not found that years of experience as an RN to be strongly correlated with the skills and effectiveness of the NP student. It's really about thinking autonomously and critically. If anything, I have anecdotally found that more than 10 years or so experience as an RN to be negatively associated with these abilities, in particular for the primary care role. I too would love to study this as I believe the results would not support many years of inpatient experience prior to entering an NP program.

    I had one year experience as a visiting Peds RN prior to entering my PNP program 20 years ago. I continued working during my masters as a visiting nurse, which was actually an appropriate experience for primary care. I never worked a day in my life in a hospital or an acute care setting. And you are correct in saying that you develop the skills as an NP in the first year or two of practice. I truly believe that it's the ability of the candidate to think critically and autonomously foremost, and the standard of education at their program secondly. I have found that RN experience may or may not benefit, depending on the speciality. Not every RN is cut out to be an NP. I believe that if anything, NP programs should be more selective about the academic ability of the student rather than the years of RN experience. There are too many NP programs that are accepting inappropriate candidates from an academic standpoint.

  • Apr 24

    I was interested to see the percentage of nurses with a BSN vs. other degrees, especially as I look around and see other healthcare professions such as pharmacy and PT moving to the professional doctorate as the entry to the profession. That has paid off well for them insofar as it has reduced the supply and increased the wages of those practitioners due to demand. Interesting to contemplate if nursing could do the same, but as someone who has been in healthcare for 30+ years, this debate has been going on for many a year.

  • Apr 22

    I think maybe the author misunderstood the Villanova article, Magnet does not actually require 50% or more of staff nurses to have a BSN, it only requirement is for management staff.

    I think it's important when discussing this to understand evidence on outcomes, what steps have been taken since these studies, and the rationale behind the IOM recommendations, all of which are commonly misunderstood.

    The studies that show differing outcomes between Associate and Bachelor level graduates looked at nurses who graduated from these programs in the 70's, 80's, and 90's, and as a result of these studies there has been a shift in Associates programs to adopting BSN curriculum, since that is the presumed source of the differing outcomes. There have been no studies to evaluate the effect of this change, so we can't really say if current ADN grads are likely to produce poorer outcomes in their patients. Assuming the same variations in outcomes still exists despite these changes would be like if you found a patient was hypertensive, so you gave an antihypertensive, then without rechecking the BP just assumed they were still hypertensive.

    The IOM didn't recommend that we no longer utilize ADN programs, and given the negative effect that would have on nursing education that would be counterproductive if our goal is to improve nursing education. They suggested moving towards a more standardized curriculum with ADN programs adopting BSN curriculum, a process which is already well underway. They also suggesting achieving these BSN goals by simply renaming ADN programs as BSN programs (the would also require ADN students fulfill their remaining general credit requirements that their pre-requisites don't cover), in theory this could be done by simply making current ADN programs satellite programs of current BSN granting universities. As it turns out, it's relatively easy make ADN program satellite BSN programs in terms of curriculum, but convincing BSN granting institutions to change from the current RN-to-BSN programs they offer isn't all that easy since this would typically result in a loss of income. But since the differences in outcomes these studies found were likely not due to the three letters that describe someone's education, but rather the substance of the education itself, there hasn't been a significant push to force that issue.

  • Apr 21

    Just want to give you an update.

    Because of your comments re. too many errant student threads in the General Nursing forum and our own observations, we have been investigating and discovered a glitch that affected the topic submission process in the General Student forum and a couple of other forums. This caused threads that were meant for other forums to get posted in General Nursing. That has been fixed now, so hopefully that will solve part of the problem.

  • Apr 20

    That is the better option in most cases, Rocknurse. However, if your overall impression of the rotation with this team is not favorable, I think you also owe it to future students to provide evaluation and recommendation to your program that this might not be a clinical site worth keeping on the list.

  • Apr 20

    Quote from quazar
    I am currently seeing 3 NPs in 3 separate specialties (I have issues....LOL). It never occurred to me to investigate their backgrounds until last week, when I had an issue with one of them making some questionable judgment calls with regards to my treatment. It was then and only then that I investigated her background.

    I always, always, ALWAYS investigate my MDs prior to seeing them, however. All of the NPs I am seeing are the care extenders of carefully selected MDs. I went ahead and looked up the backgrounds of the other two NPs I see. The one I have an issue with went straight from undergrad to graduate school. I have no idea if that affected her lack of proper clinical judgment and not being up to date on the latest evidenced based practice. Of the three NPs I see, she is the "greenest." One NP I see was a physician in another country. The other, who is actually my primary care provider, had 24 years' nursing experience prior to obtaining her APRN. I have never had an issue with the other two providers.

    Anecdotal evidence, yes, however, there it is.
    If not a secret, how exactly you "investigate" your providers, especially if you have no idea whatsoever what did they actually do during their training and no means to check it?

    (contrary to public knowledge, not all medical residencies, as well as not all NP programs are created equal, and the big names may or may not play any role in the process. And if one of my patients suddenly starts to ask questions "to investigate" my past, I'll be happy to refer him to Boards website to see that my clean license, and ask a person running the desk to send the letter informing him that he has 30 days to request his full medical record to present to another provider of his choice).

  • Apr 7

    Quote from BostonFNP
    or c) preceptors refusing to take students without a relationship with the academic program.
    That. And for those of us not affiliated with anyone, I think it is or obligation to refuse to participate in this. It’s not a matter of “remember how you started, give someone else a chance”, it’s a matter of making sure our profession continues to provide high-quality.

    I worked with a cardiologist years ago who was a trained obstetrician. He wanted to become a cardiologist, so another cardiologist provided him OJT. He actually acquired privileges in 3 different hospitals for cath, intervention and pacemaker implants. His work was mediocre, at best. As new cardiologists came along who were fellowship-trained, his work was called into question. Eventually, the hospitals were forced to rescind all of the privileges except cardiac cath, and he could only do heart caths when an interventionalist was present in the hospital. This stopped his practice, but many, many patients had ill-placed stents before that happened.

  • Apr 6

    Quote from ModernRN
    Please nurses, stand up for yourselves and the patients! Healthcare is evolving to the physicians doing hardly anything and putting all responsibility on the nurse. I feel the shift is for the doctor to spend less time with patients so they can see more pt's which only equals more money for doctors. Conflict of interest in my opinion.
    More money for whom?

    I take it you haven't been watching this situation evolve for very long!

    These physicians of whom you speak - are they employed, or in private practice?

    Man, it is depressing to hear a nurse comment about this situation using the same verbiage as a completely uninformed lay person.

  • Apr 4

    So, for some reason the quote feature just will not work for me (certain I am doing it wrong) but this response is clearly in reference to the OP's claim that my practice of suggesting, accepting and carrying out verbal orders is somehow practicing beyond my scope.

    Have you actually worked in a real, busy teaching hospital for more that a month? Seriously, sorry for the sarcasm, but please don't spread these unrealistic expectations to new nurses. Our docs work 14-40 hour shifts with no sleep and get paid the equivalent of 6$/hr for the first 3-4 years of residency. They have ratios of up to 20 patients PER RESIDENT, and as much as you, the OP hate to admit it, have and EXPONENTIALLY higher level of responsibility, accountability, liability and intellectual input for EACH patient than we do.

    I might get some flak for writing this, but we all know, deep down, these 1st year residents have more medical knowledge and (medicine, NOT nursing) critical thinking than any of us will after 20 years of nursing. Again, I was the one who insisted we are a TEAM - and we are, but for the love of Pete, to blast a doc who has 3x as many patients, is covering up to 8 other teams' patients, admitting in the ED and managing other specialty services...and refuse to suggest and take verbal or phone orders? You are out out of line, my friend. You really, really are.

    I don't know if I have ever meant this as strongly as I do now: YOU DO NOT KNOW WHAT YOU DON'T KNOW.

    If ANY of you have that level of disrespect, misunderstanding, lack of compassion, inability to be a team player...I'm just glad we don't work together. Cause that self centered, "i'm the only one who works hard, knows what's going on, is doing it right..." crap would never fly when I'm in charge.

    Docs must treat nurses with respect when I'm in charge. Nurses are held to the same standard.

  • Apr 4

    Quote from ModernRN
    What I am saying is that the physician should know their patients and write the orders accordingly. We have enough on our plates keeping the sick alive and having to question the physicians orders is absurd in my opinion.
    You don't believe that part of your job is advocating for your patient? Then you're not doing your job. Keeping the sick alive is a collaborative process between multiple health care disciplines. All this anger about what physicians are or are not doing and are or not being disciplined for doing or not doing it seems unhealthy for you AND your patients.

  • Apr 3

    1. Physicians still giving verbal orders - this has been noted as a national patient safety issue. So why can't the physicians protect patients safety? Are doctors truly concerned with pt's safety? If they are ignoring pt safety goals then I'd say no they aren't.

    This will need a culture change within your organization. I work as an NP in a university hospital and no nurse will ever enter a verbal order anymore and I don't blame them. In this age of EMR's, any provider can enter an order himself or herself in any location of the hospital that has access to a workstation (even call rooms for providers). Older providers who trained before the age of EMR will have to keep up and learn or quit.

    2. Why are nurses now responsible to make sure certain medications or therapies ordered such as Metoprolol or VTE prophylaxis? Nurses are getting burned because physicians aren't capable of being thorough enough to make sure they have ordered what is appropriate for their patient. This is just lousy of physicians in my opinion.

    Again, this is an institutional variation. Non APN's are not providers and their scope does not cover writing orders for VTE prophylaxis and beta blockers for whatever indication. You facility is taking a short cut to keep up with regulatory standards by making nurses take care of these issues instead of making providers accountable for this particular part of their role. This is not something nurses decide on where I work.

    3. Nurses having to get physicians to renew 24 hour restraint orders and foley cath orders. If your physician does not know the pt is in restraints or has a foley catheter that requires a new order then they are not fully aware of the pt they are managing care for and is not professional.

    You as the bedside nurses know more of the hour to hour the changes that happen to a patient. I wouldn't know if you're still concerned about patient safety, hence, the need for restraint. I don't feel restraints should be treated in an "auto pilot" way and nurses and providers should collaborate on their use. For that reason, I prefer being told that I need to renew restraint orders. Same with Foleys, I actually have had conversations with nurses who prefer their input prior to DCing indwelling catheters.

    4. Physicians are not giving report of their patients when another physician is taking over call. Calling a physician for help with a pt issue and the MD has no clue who you are talking about is poor physician management in my opinion and is a safety issue.

    It's hard to comment on this. Providers do give hand-offs to each other when they switch. I know we do as NP's in the ICU. However, I don't necessarily respond well to a call from a nurse saying "Mr. S PCO2 is 68". Give me a little bit of background so I can get a perspective of why you're calling me.

    Also realize that in some situations, a provider is carrying the pager for a large number of patients some of whom they only got a one liner about in terms of patient info. During hand off, a lot of the times we get sign out on what to expect as problems that may arise but I'm sure other issues will pop up unexpectedly. That's where SBAR or whatever system you use help.

  • Apr 3

    Quote from TheCommuter
    Life is not fair, isn't it? Physicians are not paid for what they do; instead, they are paid for what they know. The sooner people figure this one out, the less time-wasting rumination about "physicians hardly doing anything" occurs.

    This is one of the benefits of attaining a professional doctorate: being paid for abstract knowledge and consultative services while those with less years of educational attainment deal with the array of busy hands-on tasks. It is what it is.
    Reminds me of the frequent complaint of the nursing aides, the care techs, who insist that they do "all the work and the nurses just sit there at their computers doing nothing". Yes, that's exactly it, the educated and licensed nurses do nothing and the aides do it all. Breaking news!