What do ER's hire more: PA-C, FNP or ACNP ?

FNPdude74 · May 1, 2011

Reeya, I was a student worker. Most of the time I was doing the same thing all the time such as simple set ups, etc. The MD was nice enough to teach me as we went along and gave me resources to read. He even let me sit through anatomy lab classes when I had the time. Just to clarify my position there...But yes, I didn't learn in depth as the medical students did. It's not a DNP program that has the EM residency, it's through the employers. I didn't say the EM residency was THROUGH the DNP program. Also about the experience part, I'm not asking for work experience, just the experience of enduring this NP to MD thing.

TakeBack · May 2, 2011

I guess you are referring to me. I didnt insist the need to not cover ECG/auscultation. What I said was NP is "advance practice nursing"...that builds on RN skills. Mind you RN just dont wipe the butts..they are also very knowledgeable especially those who have yrs of experience in acute care. Now what good it would be to teach a MICU, SICU RNs what a MI looks like on EKG?? Guess what they already know it !!! What a diastolic murmur sounds like...they already know it !! They dont need to be taught how to auscultate or how to read EKG.. but rather they learn pathophysiology of why/how it happens. Thats why NP school that requires RN to have at least a yr of acute experience skips basic clinical skills...IV skills, wound care skills, NG tubes etc to add a few.
If a patient has a MI, is the MI on strip gonna look different if a RN reads or per your argument diagnostic clinician reads it?? FYI, an experienced RN is very knowledgeable and yrs of experience does matter. Sometimes they tell new residents what they should do next. ANP is advance nursing practice...those who say RN experience has nothing to do with NP school because it is medical education... i just think they are confused. Good for them if they can do without it.

This is all opinion.

First, teaching physical diagnosis in the construct of a clinical medicine unit is different than teaching it as part of a nursing assessment unit. If you can't assure that every NP is coming in with the same experience, that they've all heard the critical murmurs and can differentiate between MR and AS, that they can differentiate VT and aberrant SVT, that they can differentiate flutter and 2:1 2nd degree, then the programs are not meeting a uniform mission statement-which should be to produce a clinician that can meet a minimum standard (which is being billed by your leadership and many of its ranks, several that I've read on this forum, as equivalent to physicians). You can't bank on each RN coming in with equivalent experience which they can use to "test out" of core concepts.

I have worked with nurses for over 15 yrs. I was a HHA, CNA, and ICU tech prior to becoming a cardiac PA. I know nursing work very well at this point. I have worked with easily several thousand RNs so far, both in those former roles and now as a PA. Most of them have been unit or tele RNs. I mean no disrespect to any of them when I say that mastering basic skills like ECG analysis and auscultation does not happen at that level. I look at heart rhythms all day, every day. Nursing diagnosis or arrhythmias is good, but it is nowhere near 100%. It is not 100% for PAs, NPs, or non-cardiologists. Just using that one aspect of medicine as an example, we can't hang our hat on nursing experience as an acceptable substitute. Diastolic murmurs? Residency trained MDs have been proven in the literature to be awful at picking these up.

In PA school we all come in with varying degrees of clinical experience. But the RTs don't get to skip ABG analysis. The rad techs don't skip plain film radiology. We all meet the same standard.

Previous experience is a foundation for continuing education, not a substitute (especially if you are training potentially independent providers!).......

BTW how is NP school "medical education"? Don't NPs practice "advanced nursing"? If the practice medicine they should be under the BOMs.....

nomadcrna, DNP, CRNA, NP · May 2, 2011

First, why is a PA on our "nursing" forum?

Second, the vast majority of physicians except the cardiologists I know have very little knowledge when it comes to differentiating between MR and AS. They will be lucky to recognize VT, forget about ashmans or aberrant conduction. So your examples are not even close to valid. Unless you are in a cardiac specialty, it is doubtful that you will be up on those.

I could ask the same about you, are you able to do a retrograde intubation? How about a fiberoptic intubation, central line or chest tube? Surgical airway? Be honest. If you have been a cardiac PA then I sincerely doubt you can do those things. Why not, were you not prepared in your training? Probably not, because the initial education is a basic medical education. You specialized afterwards. Does this make you a bad PA? Of course not, its just not your specialty.

NP build on our previous knowledge. We also have to meet the same standards as all other NP (boards).

I can do all those things and have done them many times. I can also read a 12 lead very well, thanks. I spent 6 years as an RN on CCU. Marriott was my bible for years. I have to disagree with you btw, pretty much all the RNs on the CCU unit were very adept at reading EKGs.

ON the medicine vs nursing thing. Look at this web site from my credentialing organization.

http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf

We do both nursing and "medical" care. We are controlled by nursing boards because WE ARE NURSES.

Now, no offense intended but as a PA you have no clue about what we do or our education. You are a guest on our nursing boards. How you would like it if I went to the PA board and started talking about my personal opinion on your lack of education or how I think your school should be?

This is all opinion.
First, teaching physical diagnosis in the construct of a clinical medicine unit is different than teaching it as part of a nursing assessment unit. If you can't assure that every NP is coming in with the same experience, that they've all heard the critical murmurs and can differentiate between MR and AS, that they can differentiate VT and aberrant SVT, that they can differentiate flutter and 2:1 2nd degree, then the programs are not meeting a uniform mission statement-which should be to produce a clinician that can meet a minimum standard (which is being billed by your leadership and many of its ranks, several that I've read on this forum, as equivalent to physicians). You can't bank on each RN coming in with equivalent experience which they can use to "test out" of core concepts.
I have worked with nurses for over 15 yrs. I was a HHA, CNA, and ICU tech prior to becoming a cardiac PA. I know nursing work very well at this point. I have worked with easily several thousand RNs so far, both in those former roles and now as a PA. Most of them have been unit or tele RNs. I mean no disrespect to any of them when I say that mastering basic skills like ECG analysis and auscultation does not happen at that level. I look at heart rhythms all day, every day. Nursing diagnosis or arrhythmias is good, but it is nowhere near 100%. It is not 100% for PAs, NPs, or non-cardiologists. Just using that one aspect of medicine as an example, we can't hang our hat on nursing experience as an acceptable substitute. Diastolic murmurs? Residency trained MDs have been proven in the literature to be awful at picking these up.
In PA school we all come in with varying degrees of clinical experience. But the RTs don't get to skip ABG analysis. The rad techs don't skip plain film radiology. We all meet the same standard.
Previous experience is a foundation for continuing education, not a substitute (especially if you are training potentially independent providers!).......
BTW how is NP school "medical education"? Don't NPs practice "advanced nursing"? If the practice medicine they should be under the BOMs.....

FNPdude74 · May 2, 2011

I can do all those things and have done them many times. I can also read a 12 lead very well, thanks. I spent 6 years as an RN on CCU. Marriott was my bible for years. I have to disagree with you btw, pretty much all the RNs on the CCU unit were very adept at reading EKGs.
ON the medicine vs nursing thing. Look at this web site from my credentialing organization.
http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf
We do both nursing and "medical" care. We are controlled by nursing boards because WE ARE NURSES.
Now, no offense intended but as a PA you have no clue about what we do or our education. You are a guest on our nursing boards. How you would like it if I went to the PA board and started talking about my personal opinion on your lack of education or how I think your school should be?

Now now let's all get along. I would say I'm amazed on how ICU RNs read EKGs so well. I'm sure cardiologists see things more in depth because thats pretty much what they look at all day, the heart. My uncle is a cardiologist and I showed him this post and he agreed. He loves to work with nurses. Funny though, he sees APRNs as colleagues and sees other cardiologists (not all) as potential competitors in business. That's his opinion and should not be generalized toward all cardiologists.

TakeBack · May 2, 2011

First, why is a PA on our "nursing" forum?
The same reason we invite and welcome NPs to the PA forum where I am a moderator. Because interdisciplinary discussion is beneficial to all (something I thought nursing theory advocates!)
Second, the vast majority of physicians except the cardiologists I know have very little knowledge when it comes to differentiating between MR and AS. They will be lucky to recognize VT, forget about ashmans or aberrant conduction.
If a PA, NP, Doc, or RN who does any form of adult or general practice can't recognize VT then they have no job practicing medicine. Besides, it was the other person I was responding to (not ME) who said her NP student colleagues had already mastered these skills (murmurs, ECG).
So your examples are not even close to valid. Unless you are in a cardiac specialty, it is doubtful that you will be up on those.
I could ask the same about you, are you able to do a retrograde intubation? How about a fiberoptic intubation, central line or chest tube? Surgical airway? Be honest. If you have been a cardiac PA then I sincerely doubt you can do those things.
I am a cardiac PA and I have intubated, put in every type of line/chest tube you can imagine. FO and retrograde is usually the arena for anesthesia or EM/medics.
Why not, were you not prepared in your training?
See above!
Probably not, because the initial education is a basic medical education. You specialized afterwards. Does this make you a bad PA? Of course not, its just not your specialty.
Exactly . PAs all have the same standard generalist education that doesn't omit anything based on presumed previous experience.
NP build on our previous knowledge. We also have to meet the same standards as all other NP (boards).
I can do all those things and have done them many times. I can also read a 12 lead very well, thanks. I spent 6 years as an RN on CCU. Marriott was my bible for years. I have to disagree with you btw, pretty much all the RNs on the CCU unit were very adept at reading EKGs.
ON the medicine vs nursing thing. Look at this web site from my credentialing organization.
http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf
We do both nursing and "medical" care. We are controlled by nursing boards because WE ARE NURSES.
Many of your representatives are quite vocal that they practice nursing, not medicine. Again, just what I have seen here and elsewhere. Not my words. Additionally being a CRNA is not the same as an NP so these aren't apples to apples comparisons.
Now, no offense intended but as a PA you have no clue about what we do or our education.
Then why are NP program curricula not standardized?
You are a guest on our nursing boards. How you would like it if I went to the PA board and started talking about my personal opinion on your lack of education or how I think your school should be?

I'd love it because it would give us all a better understading of each other. It's alot better than implying that PAs shouldn't be on your "nursing" forum. I've encountered this antagonistic attitude on this forum before, but thankfully my presence was quickly backed up by one of your kind moderators.

Come on over to physicianassistantforum.com any time!

nomadcrna, DNP, CRNA, NP · May 2, 2011

I've yet to see a PA do a central line or chest tube. I've let a few try to intubate and help to teach them how. So IF you do those, you most likely learned them afterwards or your particular program is an aberration. I know they don't teach those skills in the basic PA program unless you truly search them out. Don't get me wrong, I'm all for PAs doing them. My point is that they are not generally taught in the basic program.

So my point(that seems to be lost on you) that most specialized training occurs after the basic program.

My other point is that I'd welcome PAs and have in the past that come here to have adult discussions and not a PA who tries to argue about training issues.

I would never think of going to the PA forums to bad mouth PA training. I've been involved in teaching many PA students in the ER and the OR. I've seen good and bad PAs as well. I still would never dream of going to YOUR forum and flame your training.

nomadcrna, DNP, CRNA, NP · May 2, 2011

BTW, we have had many PAs here. I did not imply that a PA should not be here, just a PA that is arrogant enough to tell us how we should be educated.

Maybe that is why you have encountered an antagonistic attitude in the past.

I'd love it because it would give us all a better understading of each other. It's alot better than implying that PAs shouldn't be on your "nursing" forum. I've encountered this antagonistic attitude on this forum before, but thankfully my presence was quickly backed up by one of your kind moderators.
Come on over to physicianassistantforum.com any time!

TakeBack · May 3, 2011

I've yet to see a PA do a central line or chest tube. I've let a few try to intubate and help to teach them how. So IF you do those, you most likely learned them afterwards or your particular program is an aberration. I know they don't teach those skills in the basic PA program unless you truly search them out.
So my point(that seems to be lost on you) that most specialized training occurs after the basic program.
My other point is that I'd welcome PAs and have in the past that come here to have adult discussions and not one who tries to argue out training issues.
I would never think of going to the PA forums to bad mouth PA training. I've been involved in teaching many PA students in the ER and the OR. I've seen good and bad PAs as well. I still would never dream of going to YOUR forum and flame your training.

Everyone's personal experiences color their views. If you work around PAs who practice in surgery, EM, or critical care you will see the standard work is that they do those core procedures- lines/tubes/taps/airways. But that is besides the point.

The conversation started with the statement that a "good" NP program would meet the objectives needed, implying there are those that don't. My observation is that if NPs want to apply themselves to the same standard of patient care as physicians, who have well regimented and thorough educational structure, then it would serve them well to live to that same standard. Enter the previous comment about NP curriculum and the concept of what skills are mastered prior to NP school. It is my (admitted) bias that in PA education, all comers are treated the same. Just as each NP entering class is heterogenous, so are PA programs. They wouldn't skip ACLS for the medics, even though it is "old hat"- because they learn a new application for it in the new construct they are being trained in- as a generalist diagnostic clinician.

So this is not really about chest tubes and intubations at all.

The question is- do nurses come into NP training with nursing experience which obviates the need to teach those things in NP school? This is 1) probably not the norm, and 2) takes away any standard process (such as medical model training) which is universal among program graduates. The point was NOT which advanced skills are taught after school, but rather, that it is ensured that generalist skills are taught.

The fact remains that NPs and PAs are both trained to become non physician clinicians. There is a history of our legislative rights influencing each other. Like it or not we are in the same boat. Neither profession will become eradicated due to the presence of the other. Given those facts, it is incumbent on us to understand ourselves and each other. In my years of looking at NP clinicians (who I share an office with), NP training and NP policy, it seems there are some serious questions to be answered. I've posted about these before- namely about the practice of holistic nursing vs the practice of medicine.

Reading more of the posts on this board I see claims of equivalence with physician training, which prompted this back and forth. The difference (which I find interesting) is that PAs are pushing for bridge programs (accelerated pathway to MD/DO) while NPs are claiming equal training right out of the gate. Some on this thread have indicated this is a bit premature, and I agre. And that is how we got to the issue at hand- how is NP education, with it's lack of uniform standardization in clinical content, and relatively more limited clinical hours than MD (and PA) education, able to claim equivalence?

The answer often seems to be the value of previous nursing experience. Both NPs and PAs enter school with previous health care experience. It seems logical that both should use that experience as a foundation, not a short cut.

Sorry for the long winded explanation but it's a serious topic and it seems a bit obtuse to reduce it to claims of a flame-war, which it's not (IMO).

Antagonism is understandable given the subject matter, but reflection on 1) where we each are as a profession, 2) what our goals are, and 3) what barriers stand in the way (physician obstructionism, legal standards) should rise above that (my 0.02).

And again, I invite you the PAForum (or check out clincian1) sonce we get a better unserstanding if we check out the neighbor's yard once in a while.

nomadcrna, DNP, CRNA, NP · May 3, 2011

I'm on clinician 1. I have been impressed by Dave's posts in the past. I've never seen him post in an antagonistic fashion before. I'll attribute this to the written word. I often post then re-read later and think that I did not mean to sound like that.

This whole technique issue started with the EKG, heart sounds and such. I was using the same example to show that there is a basic education and then the education you get afterwards. Initials do not mean much to me. I've seen good and bad in all camps. The person decides what they want to learn. NP and PAs just have to ask usually to be taught something.

I do agree with much of what you are saying though. NP DO tend to build on nursing experience to a greater extent then PAs. Does this make better training? Not even close. It CAN if the NP has the correct experience in ICU/CCU or ER type practice. The PA can offer the same with previous paramedic experience, excellent experience for ER work.

I would love to see NP programs at all levels model more after the PA programs and away from the BS crap that we have to learn now. I am also a proponent of the DNP program giving an FNP first then a specialty in the later part of the program such as acute care, ER, pedi, anesthesia etc. You should see me get yelled at by most of my CRNA colleagues. But it would make them better anesthetists.

I think PAs should also get independent practice. All health care practitioners have to practice collaborative medicine today. I (or you) can get a consult with "xyz" just as a family practice or IM physician does.

I have been screaming for awhile now to change the DNP programs toward more clinical education and less evidenced based medicine and research education. I think we (PAs and NP) are poised to advance our professions and we need to be aggressive and push ahead with better education and increasing our practice rights.

I would also support a bridge program. I doubt that will happen anytime soon. I've been fighting the practice battle for 20 years as a CRNA and though we have independent practice, it came at a price. I refuse to work in an anesthesia team model and I refuse to work supervised as an FNP. I am more than willing to collaborate and consult though.

This is turning into an interesting discussion.

PMFB-RN, RN · May 3, 2011

Now, DNPs will be pushing hard to gain complete autonomy in other states.

*** I find this very interesting. The two state university DNP programs (CRNA & NP) whose students do clinicals where I work went from MSN to DNP without adding a single hour of clinical time or a single clinical based class. Students now go for 9-12 months of DNP work, all academic, then go directly into the exact same CRNA and NP program the MSN students were doing. I don't know but my guess is that it is similar for other programs.

What basis does adding an academic degree on the end of or start of the standard MSN program give for advocating for more independant practice?

nomadcrna, DNP, CRNA, NP · May 3, 2011

I agree that the ivory tower educational types are missing the boat on this one. Instead of EBM, they should be having rotations or mini fellowship in various specialties. I was very disappointed in my DNAP program. When compared to others, it was very good but only because all the dnp/dnap programs are teaching the same way. At least my DNAP program had a bunch more patho-phys and pharmacology.

*** I find this very interesting. The two state university DNP programs (CRNA & NP) whose students do clinicals where I work went from MSN to DNP without adding a single hour of clinical time or a single clinical based class. Students now go for 9-12 months of DNP work, all academic, then go directly into the exact same CRNA and NP program the MSN students were doing. I don't know but my guess is that it is similar for other programs.
What basis does adding an academic degree on the end of or start of the standard MSN program give for advocating for more independant practice?

MurseTinz, BSN, RN · Jul 30, 2018

Can I ask your thoughts on the new ENP cert for FNP's?