What kinds of patients do you see?

NPinWCH · May 26, 2012

I'm an FNP, with now 1 yr experience as such, but I had 15 yrs experience as an RN. Most of my RN experience was in L&D. I work in a busy family practice with 3 MDs and one other FNP. I see newborns all the way through 90 yr olds. I do preventative medicine and then I see some extremely complicated patients. Yes, many of them see specialists that co-manage, but let me point out that even then you still need to have a grasp of things.

You have to remember, you are the PCP and often, WAY too often, the specialists are not communicating with each other. My practice is rural, many of my patients have no insurance or only have some kind of limited charity care, so I have many patients who can afford to see me, but have no way to afford a specialist, so I am it. I treat some very complicated things...it is me. I may manage to get them in with cardio x 1 for a recommendation, but then it's up to me. I do consult with my fellow MDs and the NP in my practice, who are great and help me tremendously. I also read, research and look things up constantly.

zenman · May 26, 2012

I also read, research and look things up constantly.

This never stops, just in case you think you get to relax when you finish school. I have books and articles scattered all over the place.

greygooseuria · May 27, 2012

I am in NP school now, with one year left to go. I've been an RN for almost 3 years and have worked in acute care peds, med/surg and in rehab/LTC.

The aspect I have found most useful from my nursing career is my assessment skills. However, I am in a program with a bunch of direct entry people and they're doing just fine. Honestly, you don't NEED bedside RN experience to be a great NP....it'll help during school, but once you're out on your own everything will eventually level off. My med/surg experience helps if someone comes into the office having an MI (I had 3 just this past semester in clinical) but other than that I haven't found it really does since the patho I learned from reading and classes. I mean, you can certainly see manifestations of patho in practice but I don't think it's a necessary prerequisite. Ironically, the area I've found most helpful in clinicals is my experience in LTC and in medical/surgical rehab. Often times you're the charge nurse and in charge of assessing the patient and directing their care, so if you think critically you can recognize "hey, he should probably be on a diuretic/ACEI since he's diabetic" and call the MD/NP on call and get orders for it, which I feel prepares you for being an NP. In a hospital, there are lots of MDs/NPs to do all the thinking and I find I don't like that too much. The autonomy you get in LTC/rehab is really helpful.

mammac5 · May 27, 2012

As in every area of life, consider the advice of others when you've sought it. Discount most of the advice you receive that you did not seek. Some people will always want to offer their "requirements" for how you should or shouldn't do something. Nod your head politely and say something like, "That's an interesting point."

Nurse Maru · May 27, 2012

Uh, you do know PAs have 2,000 or so hours of clinical vs NPs 500 or so. So basically a PA with no experience and an NP with none...well, you see the difference.

Uh, allow me to tell you what I do know. I know that when I am finished with my DNP I will have logged 1750+ clinical hours in that program. I know I did over 350 hours in the last semester of my BSN alone. I know that by the time I practice as an NP, I will have many more than 2000 clinical hours invested.

I also know that apparently, thousands upon thousands of practice hours have failed to turn some marginal nurses that I know into models of competence and efficiency. The value of any combination of education and experience lies in the nurse, not the raw numbers of time.

zenman · May 28, 2012

Uh, allow me to tell you what I do know. I know that when I am finished with my DNP I will have logged 1750+ clinical hours in that program. I know I did over 350 hours in the last semester of my BSN alone. I know that by the time I practice as an NP, I will have many more than 2000 clinical hours invested.

Yes, IMO it would be nice if you had 2,000 hours in your NP program and at least 2,000 more of real clinical hours plus clinically relevant courses in your DNP program.

I also know that apparently, thousands upon thousands of practice hours have failed to turn some marginal nurses that I know into models of competence and efficiency. The value of any combination of education and experience lies in the nurse, not the raw numbers of time.

That is true and I've seen physicians finish with umpteen hours and not be able to walk a straight line. I agree it would be nice to have an individualized training program for NPs, but it's like the military...you are training the masses and everyone is assumed to be the same when they start.

Nurse Maru · May 28, 2012

Yes, IMO it would be nice if you had 2,000 hours in your NP program and at least 2,000 more of real clinical hours plus clinically relevant courses in your DNP program.

I believe that one is called "moving the goalposts." You held 2000 clinical hours as evidence of the superior standards of training for the PA, so lets just go ahead and leave it there. I mean sure, we could bid the hours up like some imaginary poker game, but that's just silly, so let's not.

A PA student may have no healthcare background and have no healthcare related licensure whatsoever and is furthermore much less likely to work as a licensed healthcare professional while attending - therefore gaining exactly 0 of these "real" clinical hours before becoming a PA. Conversely, most NP students will work in jobs as Baccalaureate degreed, Registered Nurses, as their programs require both, attaining 1000's of those "real" clinical hours in the 2-5 years they spend attaining their NP.

The argument for the requirement of time on the floor has already been deemed a failure, hence the forward movement of programs like those at Georgetown, Rush, George Washington, University of Pennsylvania, Johns Hopkins and so on and so on. Human beings are loathe to change and oftentimes human systems are only worse - but "we have always done it this way" is never an acceptable reason to maintain the status quo, and in the end that's really the only point left in this tired old subject because it stands independent of reason.

zenman · May 28, 2012

I believe that one is called "moving the goalposts." You held 2000 clinical hours as evidence of the superior standards of training for the PA, so lets just go ahead and leave it there. I mean sure, we could bid the hours up like some imaginary poker game, but that's just silly, so let's not.

No, I said, "Uh, you do know PAs have 2,000 or so hours of clinical vs NPs 500 or so. So basically a PA with no experience and an NP with none...well, you see the difference." It's only a direct comparison. I said nothing about superior standards. I hope you now see your error in thinking.

A PA student may have no healthcare background and have no healthcare related licensure whatsoever and is furthermore much less likely to work as a licensed healthcare professional while attending - therefore gaining exactly 0 of these "real" clinical hours before becoming a PA. Conversely, most NP students will work in jobs as Baccalaureate degreed, Registered Nurses, as their programs require both, attaining 1000's of those "real" clinical hours in the 2-5 years they spend attaining their NP.

This is off the wall. Whether anyone works while going to school has no bearing on any thing. Just delete this entire paragraph as having no relevance to anything.

The argument for the requirement of time on the floor has already been deemed a failure, hence the forward movement of programs like those at Georgetown, Rush, George Washington, University of Pennsylvania, Johns Hopkins and so on and so on. Human beings are loathe to change and oftentimes human systems are only worse - but "we have always done it this way" is never an acceptable reason to maintain the status quo, and in the end that's really the only point left in this tired old subject because it stands independent of reason.

Deemed a failure? By who? Give me a source. I've been known to directly contact heads of university programs in the past to verify their comments, so keep that in mind. I went to Rush, btw andI'm continually going to school or learning something. Believe me I know about change and have no problem with it. The fact that I'm 61 yrs old and have 42 years of experience certainly doesn't mean I believe in, "we've always done it this way." Independent of reason? Go find a professor of logic and tell him your story. I'll be waiting.

zenman · May 29, 2012

this is really good:

[color=#0726a7]nursing experience: the credibility conundrum. | nursesforchange.org

some comments from other forums:

“i've met excellent nps, however they typically have years of clinical experience w/ all kinds of pts in various settings.”

“hello as a soon to be graduate of np school i believe that my 10 years as a nurse has helped me be a better clinician.”

“i am a fnp with 25 years of nursing combined with 11 years as an np. i would highly recommend if you go the np route, to work as an rn for at least a few years before becoming an np. you gain valuable patient skills doing this.”

it’s not nursing but i asked my teacher wife, who is a whiz on neuroscience of learning, about whether teachers should get experience before going into a master programs: “yes. teach a while, then go for the masters. you have no clue what you are talking about until you have some experience first.”

since people are asking for this i’ll just post it here:

how to maximize your nursing experience for np school

you will hear some people say that prior experience in nursing school is not relevant to np school. think for a minute how much bs that is and how illogical it is. i’ve had physicians tell me that working as a cna helped them as a physician. and yet nursing experience doesn’t help you as an np? something is really wrong with this picture. i challenge anyone who doesn’t believe what i say to find a professor who teaches logic and sit down with them for awhile.

heck, what i learned kayaking in hawaii helped me in np school. i learned that you better be prepared; have all the needed equipment; have back-up systems; worry only about what was in your own kayak; know yourself and what you can handle; and sometimes all you can do is relax and go with it.

here’s what you can do, and it’s what i did once i made a decision to go to np school. i already had 37 years of clinical nursing experience in a variety of settings, including teaching and in management prior to np school. so not only did i work alongside many nursing peers, i taught students, and i saw how nurses functioned from a management perspective.

you will learn just by doing your job. with every very pair of lungs you listen to, or heart or bowel sounds you listen to, you are learning something. with every new med you hand out or every new disease you come across you are learning something. but instead of just doing your job maximize it by informing physicians you work with that you are going to np school and you would like their help.

with every med you hand out take time to learn it from a provider’s viewpoint. why is the physician giving this med versus another? teach yourself, then ask the physician. here’s an example. i have a depressed patient. give them an antidepressant, right? well, are they also anxious? psychotic? sleeping too much? not sleeping at all? drug/etoh abuse? ptsd also? past history with any psych meds? family member with psych history? did a certain antidepressant help their best friend? is there a history of multiple suicide attempts? do they also have ocd symptoms? potential for side effects with this patient? do they have insurance coverage or do i need to prescribe the cheap stuff? will it be too sedating for them? will they gain weight? do i need to start with a lower dose than usual? do i need to combine different classes of antidepressants? do they even need meds? how will my meds interact with their other meds? will their age matter? will their race matter? do they also have chronic pain? what if they have chronic pain, depression, and anxiety? get it? start thinking like this while you’re working. most physicians will be glad to help you. do the same with every new condition, surgery, or disease you run across. follow the physician in the patient’s room and watch them do exams. listen to the patient’s lung sounds prior to the physician and then chat with them or read their progress notes to see if you come to the same conclusions.

back to the depressed patient. they are depressed now but have they ever had a hypomanic episode? you could make them worse with an antidepressant. oh wait, i remember seeing some of these patients, even on our med floor, so i have an idea what to do! yea, that nursing experience helped!

[color=#333233]think you’ll never treat a psych patient? think again. i consult on med floors every day, as well as icu, ccu, and ed. over the last few days i’ve seen a patient with a pruritic rash. all her meds had been stopped in order to try to determine which med might be the cause. unfortunately, she was also bipolar. she was being treated with prednisone. do you know the side effects of steroids? you better with this lady!

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[color=#333233]it’s a lot of responsibility and you better have good sphincter control when you are the one making the decision.

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[color=#333233]my thoughts that prior experience will benefit you before np school still stands. however, if the only option you have is to go straight through then do so.

Editorial Team / Admin · May 30, 2012

Excellent, zenman.

myelin · May 30, 2012

I don't think anyone is saying that RN experience is irrelevant. What they're saying is that there is more than one way to skin a cat. There's more than one way to develop a background that will set someone up for success as a NP.

I, for example, will have little-to-no RN experience when I start my psych NP training. However, I have years of experience in differential diagnosis and assessment of psychiatric disorders under the guidance of clinical psychologists and graduate students. This was in a clinical research study where I trained for 8+ months in administering different assessments, including structured interviews, unstructured interviews, suicide risk, etc. I was in charge of making diagnostic decisions and if a case was complicated, we would discuss it as a team. All those hundreds of hours I spent won't count as "RN experience" or "healthcare experience" in the eyes of many people, but I see them as directly relevant to my future career. I would love to see someone tell me that this background won't help me as a clinician.

I think I'll post this on that blog and see what the blogger thinks...

zenman · May 30, 2012

I don't think anyone is saying that RN experience is irrelevant. What they're saying is that there is more than one way to skin a cat. There's more than one way to develop a background that will set someone up for success as a NP.

Oh, they do. But you're bringing up a different angle, lol!

I, for example, will have little-to-no RN experience when I start my psych NP training. However, I have years of experience in differential diagnosis and assessment of psychiatric disorders under the guidance of clinical psychologists and graduate students. This was in a clinical research study where I trained for 8+ months in administering different assessments, including structured interviews, unstructured interviews, suicide risk, etc. I was in charge of making diagnostic decisions and if a case was complicated, we would discuss it as a team. All those hundreds of hours I spent won't count as "RN experience" or "healthcare experience" in the eyes of many people, but I see them as directly relevant to my future career. I would love to see someone tell me that this background won't help me as a clinician.
I think I'll post this on that blog and see what the blogger thinks...

I think your experience is relevant. It's directly related to psych and will help you a lot. Those few psychologists who went and got their PMHNP probably found their experience very relevant also.