The future of NP (practice / privileges) ??

Advanced Practice Columnist / Guide · Aug 25, 2008

Doctors for the most part go through the same types of programs before they specialize.
How long will the medical community, insurance companies and our clientele tolerate all the varied specializations without at least the same basic training?
Is this what the DNP is supposed to be addressing?

As advanced practice nurses, the basic training that all NP's have in common is the BSN. However, programs have evolved in many different directions thorugh the years and we now see NP programs using models such as ADN-MSN as well as direct entry MSN programs that do not grant a BSN at all. The concept of an experienced nurse with a BSN who becomes a specialist by obtaining a graduate degree to be a nurse practitioner is becoming more blurred than ever. You make a valid point that we need to re-examine NP educational models and come up with some kind of basic educational training that all NP students go through beyond the BSN.

Unfortuntaley, I don't see the DNP as the answer. Many BSN to DNP programs are now in existence. All of the ones I've looked at are very similar to the current MSN tracks for nurse practitioner training. That is, a student chooses a nurse practitioner specialization such as FNP or ANP and proceed to complete coursework leading to the DNP degree and eligibility to sit for the corresponding certification exam the individual NP received training on. I saw no generalist component in the clinical portion of DNP programs. However, there is definitely additional coursework in leadership, research utilization, and healthcare economics which I am not going to dispute are probably beneficial to NP practice.

I may be going against the grain here but I do believe that NP programs need some kind of overhaul. NP training has traditionally been about specialization. Historically, the first NP program trained nurses as pediatric primary care specialists. However, this model is becoming more of a downfall for NP's rather than an advantage. Employment is a big issue for graduates of NP programs. Nurses who are considering a career as nurse practitioners oftentimes choose the track that promises a higher chance of employability rather than the one that interests them the most. Numerous posts in this forum have advised students to consider the "broad" training FNP offers although technically, the "broadness" in the training is really about the age group of patients served and nothing more than that.

While I am not involved in the development of educational programs for NP's, I think the profesion will benefit from following elements of the generalist model PA's receive. The DNP could have been used to our advantage by devoting the first two years of the program for learning all the medical specialties from pediatrics to adult health with women's health and psych thrown in between. This will make the first two years as the basic training for all NP's. The final or third year could have been used for a focused residency in a specialty the student chooses such as adults, pediatrics, neonates, women, etc. This way, if a nurse practitioner wishes to change specialization after being in practice for a while, all that will be required is to go through the one year of residency necessary for the specialty certification.

I also think we should reconsider combining our NP tracks and specializations and not make them too redundant. Adult NP and ACNP could have been combined as one track with a single certification exam. The same could have been done for Pediatric NP and Acute Care Pediatric NP. Physicians who are trained in Internal Medicine or Pediatrics are not limited to hospital practice or clinics alone so why should NP's not follow that model?

This is all wishful thinking on my part and I know that there would be drawbacks to my idea. One, physicians will still question our competency even if these changes are implemented because the length of the training is not similar to theirs. But I believe that NP's are not physician replacements anyway so I stand by my ideas.

JALEXSHOE · Aug 25, 2008

I agree wholeheartedly...

Stef

RuralNP4KIDS · Aug 26, 2008

I completely agree. I have been a pediatric nurse for 17 years in the PICU and Peds ED. I am in my final year of my PNP which I am doing as primary care because I live in a rural area. But my preceptors are training me to do both. I am in the office and managing the acutely ill children and infants in the hospital. Granted the acuity is not always that high but I have been refreshed on intubation by anesthesia and I have been attending all c-sections. I don't aspire, at this point in my life, to work in the PICU as a NP but I would like to be able to manage my patients who are hospitalized. So I completely agree with merging primary care and acute care programs.

ANPFNPGNP · Aug 27, 2008

As advanced practice nurses, the basic training that all NP's have in common is the BSN. However, programs have evolved in many different directions thorugh the years and we now see NP programs using models such as ADN-MSN as well as direct entry MSN programs that do not grant a BSN at all.

I can't see using the BSN as the foundation b/c there is such a difference between the RN & NP roles. I would like to see all NP's educated as "generalists" and then if needed, they can obtain a post-Master's certification in the various specialties. It really doesn't make sense to me that someone can jump from a RN to an Acute Care NP in 2 years or less. However, I can see them becoming a FNP first, then specializing as an Acute Care NP...that's how the docs do it anyway!

Advanced Practice Columnist / Guide · Aug 27, 2008

It really doesn't make sense to me that someone can jump from a RN to an Acute Care NP in 2 years or less. However, I can see them becoming a FNP first, then specializing as an Acute Care NP...that's how the docs do it anyway!

Not entirely true if one views the FNP as analogous to a Family Practice Physician. Graduates of Family Practice residencies are not eligible for fellowships in many medical subspecialties such as Cardiology, Pulmonary Medicine, Critical Care Medicine, Oncology, Nephrology etc. (1). Graduates of Internal Medicine residencies are the ones who can apply for a majority of the medical subspecialties I mentioned (2). In addition, Internal Medicine Residency grads are already eligible to work as hospitalists without having to go through a fellowship so the FNP to ACNP analogy doesn't really apply.

But my point is similar to yours. Since the DNP is a three-year program for BSN and non-advanced practice nurses, why not adapt elements of the PA training model for the first two years in terms of training across all primary care specialties from children to adults, women's health to psych. Then, have students spend the final third year on the subspecialty specialization focus of the original NP tracks such as neonates, adults, women, behavioral health, etc. That way, it only takes an additional year of training to add another NP subspecialty and certification to one's credit. Also, streamilne the tracks and combine the redundant ones.

References:

(1) http://www.aafp.org/fellowships/

(2) http://www.acponline.org/residents_fellows/fellowships/

ANPFNPGNP · Aug 27, 2008

Not entirely true if one views the FNP as analogous to a Family Practice Physician. Graduates of Family Practice residencies are not eligible for fellowships in many medical subspecialties such as Cardiology, Pulmonary Medicine, Critical Care Medicine, Oncology, Nephrology etc. (1). Graduates of Internal Medicine residencies are the ones who can apply for a majority of the medical subspecialties I mentioned (2). In addition, Internal Medicine Residency grads are already eligible to work as hospitalists without having to go through a fellowship so the FNP to ACNP analogy doesn't really apply.
But my point is similar to yours. Since the DNP is a three-year program for BSN and non-advanced practice nurses, why not adapt elements of the PA training model for the first two years in terms of training across all primary care specialties from children to adults, women's health to psych. Then, have students spend the final third year on the subspecialty specialization focus of the original NP tracks such as neonates, adults, women, behavioral health, etc. That way, it only takes an additional year of training to add another NP subspecialty and certification to one's credit. Also, streamilne the tracks and combine the redundant ones.
References:
(1) http://www.aafp.org/fellowships/
(2) http://www.acponline.org/residents_fellows/fellowships/

I agree, this sounds like a good plan. It seems that the "powers that be" in nursing just can't ever seem to get it right. Case in point, I was already licensed as an ANP and GNP, but needed to get my FNP for job purposes. I just assumed that I would take a couple of classes and spend a few clinical hours in OB and pedes. Well, I only had to take a Child/Materal class, but the TX BON required me to complete a full 500 clinical hours in gero, adults, pedes & OB. It didn't matter that I was already licensed to see patients 12 years and up...I had to REPEAT clinical hours in those areas. Not only that, but I wasn't allowed to get paid! Yes, I was working for FREE anytime I saw patients over the age of 12, which was 75% of the time! The docs I worked with couldn't believe it...they were ecstatic! My professors did everything they could to help me, but the Board wouldn't budge.

There was another Adult NP in my class in the same boat. One of her preceptors told the office manager to double book when she was there, since she could legally bill for her services. After she left, the school tried to place another student with him, but he refused to precept any more students unless they were already licensed as Adult NP's. Can you believe this? Only in nursing...

jeepgirl, LPN, NP · Aug 28, 2008

Wow, I guess I am lucky. I am a PNP-PC and in my new job I will not only be covering office, but ER and hospital call. Totally, full on an equal in terms of responsibility, but just differing for the types of cases I will follow.

jeepgirl, LPN, NP · Aug 28, 2008

I agree, this sounds like a good plan. It seems that the "powers that be" in nursing just can't ever seem to get it right. Case in point, I was already licensed as an ANP and GNP, but needed to get my FNP for job purposes. I just assumed that I would take a couple of classes and spend a few clinical hours in OB and pedes. Well, I only had to take a Child/Materal class, but the TX BON required me to complete a full 500 clinical hours in gero, adults, pedes & OB. It didn't matter that I was already licensed to see patients 12 years and up...I had to REPEAT clinical hours in those areas. Not only that, but I wasn't allowed to get paid! Yes, I was working for FREE anytime I saw patients over the age of 12, which was 75% of the time! The docs I worked with couldn't believe it...they were ecstatic! My professors did everything they could to help me, but the Board wouldn't budge.
There was another Adult NP in my class in the same boat. One of her preceptors told the office manager to double book when she was there, since she could legally bill for her services. After she left, the school tried to place another student with him, but he refused to precept any more students unless they were already licensed as Adult NP's. Can you believe this? Only in nursing...

LOL in your case, if you had just gotten the PNP, wouldn't you have been golden??!

ANPFNPGNP · Aug 28, 2008

LOL in your case, if you had just gotten the PNP, wouldn't you have been golden??!

Except, I wouldn't be able to see OB patients, since the ANP certification doesn't cover that. I suppose I could also get the WHNP cert too, but then I still wouldn't be golden b/c I still couldn't see psych patients or work as a first assist or in the ICU...isn't this ridiculous?

christvs, DNP, RN, NP · Sep 4, 2008

As advanced practice nurses, the basic training that all NP's have in common is the BSN. However, programs have evolved in many different directions thorugh the years and we now see NP programs using models such as ADN-MSN as well as direct entry MSN programs that do not grant a BSN at all. The concept of an experienced nurse with a BSN who becomes a specialist by obtaining a graduate degree to be a nurse practitioner is becoming more blurred than ever. You make a valid point that we need to re-examine NP educational models and come up with some kind of basic educational training that all NP students go through beyond the BSN.
Unfortuntaley, I don't see the DNP as the answer. Many BSN to DNP programs are now in existence. All of the ones I've looked at are very similar to the current MSN tracks for nurse practitioner training. That is, a student chooses a nurse practitioner specialization such as FNP or ANP and proceed to complete coursework leading to the DNP degree and eligibility to sit for the corresponding certification exam the individual NP received training on. I saw no generalist component in the clinical portion of DNP programs. However, there is definitely additional coursework in leadership, research utilization, and healthcare economics which I am not going to dispute are probably beneficial to NP practice.
I may be going against the grain here but I do believe that NP programs need some kind of overhaul. NP training has traditionally been about specialization. Historically, the first NP program trained nurses as pediatric primary care specialists. However, this model is becoming more of a downfall for NP's rather than an advantage. Employment is a big issue for graduates of NP programs. Nurses who are considering a career as nurse practitioners oftentimes choose the track that promises a higher chance of employability rather than the one that interests them the most. Numerous posts in this forum have advised students to consider the "broad" training FNP offers although technically, the "broadness" in the training is really about the age group of patients served and nothing more than that.
While I am not involved in the development of educational programs for NP's, I think the profesion will benefit from following elements of the generalist model PA's receive. The DNP could have been used to our advantage by devoting the first two years of the program for learning all the medical specialties from pediatrics to adult health with women's health and psych thrown in between. This will make the first two years as the basic training for all NP's. The final or third year could have been used for a focused residency in a specialty the student chooses such as adults, pediatrics, neonates, women, etc. This way, if a nurse practitioner wishes to change specialization after being in practice for a while, all that will be required is to go through the one year of residency necessary for the specialty certification.
I also think we should reconsider combining our NP tracks and specializations and not make them too redundant. Adult NP and ACNP could have been combined as one track with a single certification exam. The same could have been done for Pediatric NP and Acute Care Pediatric NP. Physicians who are trained in Internal Medicine or Pediatrics are not limited to hospital practice or clinics alone so why should NP's not follow that model?
This is all wishful thinking on my part and I know that there would be drawbacks to my idea. One, physicians will still question our competency even if these changes are implemented because the length of the training is not similar to theirs. But I believe that NP's are not physician replacements anyway so I stand by my ideas.

Wow, you really have some great ideas. :) I seriously think you should design a DNP program in my area, just like the one you described in your post: 2 years of clinical rotations in all areas, and then focus on your specialty area the last year. What a great idea! If there was a DNP program like that, one in which I felt I could improve my NP clinical skills, then I would sign up for that program in a heartbeat.