Becoming an NP with little to no nursing experience?? - page 22

Hello to all!!! I have worked as a parmamedic for 20 years, have a B.A. in Economics, and I wanted to advance my career in healthcare. I was originally looking to pursue the PA route, but for... Read More

  1. by   Barbiegirlnurse
    To CoreO: I have to say that I do partially agree with what you said about NP schools preparring NPs for professional practice. In my program we did have one whole semester of professional policy issues in advanced practice,(dealing with insurance, managed care, political involvement of the profession, etc), one semester of Practice Management (dealing with establishing practice [business plan for independent practice, collaborative practice with physician on site, and other practice settings], and one semester of professional issues in APN practice (dealing with legalities of practice, differing state guidelines, prescriptive authority, as well as establishing work contracts, interview techniques, etc.).

    That stated, I still feel like I would like someone who has been in the healthcare profession, longer than I have to give me advice on certain specifics (like your info on contract agreements, for example]. Many students have very different internship settings, (rural;urban; primary care facility; health departments; walk in clinics, etc.) These differences open the door for disparities among NP students in relation, not only to clinical experiences, but also the professional role as it relates to NP issues.

    And John: You are right that the NP profession is different than the PA. The PA is based on the medical model and is (from what I understand) more clinically focused in certain areas, whereas the NP profession is based on core nursing foundations grounded in nursing theory. These guide the profession of nursing toward more advanced practice (including the need and role for NPs, as well as the need for nurse educators and nurse researchers). I know that all of the nursing specialties (educator, NP, researcher, among others) sound totally separate from each other, but they are in fact intertwined, and largely reliant on one another. This is where the nursing theories are operationalized in the APN, and put into practice, mentoring,and research. I can definitely see where many nurses don't see as much importance in these things, but I do-- I find them so interesting (and many challenging to grasp!). As a nurse, this is where I draw from and relate my experiences. For a PA, this is totally different. While they share many commonalities with NPs, they are a different breed all together. To me this is a great thing in the healthcare setting, because each is bringing something unique and special to patient care (and research!), and can learn from the other profession.
    Last edit by Barbiegirlnurse on Jun 8, '07
  2. by   jjjoy
    Quote from Barbiegirlnurse
    The PA is based on the medical model and is (from what I understand) more clinically focused in certain areas, whereas the NP profession is based on core nursing foundations grounded in nursing theory. These guide the profession of nursing toward more advanced practice...
    If direct-entry NP education can graduate an equally prepared mid-level provider as a PA program, including clinical experience, a strong pathophys/pharmacologic foundation and the nursing aspects as well, then does that mean that PA programs could be shorter and still train competent mid-level providers?

    Another question: Nursing practice is built on the foundation of the "nursing model" which has been elaborated on and is taught in nursing programs. What IS the "medical model" and is it something that medical students/PA students explicitly learn in the way that nurses are taught nursing theory and the like?
  3. by   core0
    Quote from jjjoy
    if direct-entry np education can graduate an equally prepared mid-level provider as a pa program, including clinical experience, a strong pathophys/pharmacologic foundation and the nursing aspects as well, then does that mean that pa programs could be shorter and still train competent mid-level providers?

    this has been tried and rejected. in the late 1960s as more pa programs developed there were a number of different models. the ama commissioned the national academy of sciences to look at this. there report can be found here:
    http://www.pahx.org/archives_detail.asp?id=4
    it is very hard to read but the area of interest is on pages 2-4 (which are actually the 8th-10th pages of the document). essentially the report stated that:
    the ad hoc committee report classified physician assistants according to the degree of specialization, level of clinical decision-making (judgment) and length of training.these types "are distinguished primarily by the nature of the service each is best equipped to render by virtue of the depth and breadth of their medical knowledge and experience."accordingly, pas are classified as type a, type b and type c assistants.

    there were three models used at the time. the model used at duke (one year of didactic training followed by a year of clinical training in a broad spectrum of medicine. the model used at medex - shorter didactic training followed by 9 months of clinicals with a single physician. the other model which did not exist at the time of the report but was being developed by dr. silver was the child health associate (cha) model.

    the report labeled the medex and cha models as type b because they trained in only a specific type of medicine (fp and peds). medex programs eventually changed their didactic component and added additional rotations. the 7 medex programs still place a heavy emphasis on family practice medicine. the cha program did not change its training program for some time and graduates were not eligible for certifcation as pas until the 1980s. they have since modified the program to cover the required elements and are certified as pas.

    this has been looked at again in the early 90s with reference to the orthopedic physician assistant and by the nih in the 90s. all of these studies agreed that to produce a pa that is able to integrate and interpret medical findings on the basis of generalized medical knowledge extensive didactic and clinical training was needed. the original report recommended two years. if anything with the advances in medical knowledge pa programs are getting longer rather than shorter.

    this is from dr. estes, one of the founders of the pa professiona education was patterned after medical education, but there are important differences. "pa education aims at producing a generalist, and all graduates take a certification examination covering the knowledge and skills required in primary care. pas must be recertified every six years, and the generalist content of this exam is the same, no matter what specialty the examinee has pursued since the last exam. a pa who has worked in orthopedics, or endocrinology, or pediatrics must demonstrate knowledge of generalist topics."

    the general consensus is that to produce a pa capable of preforming in the generalist role you need at least two years of full time (40 hours per week) didactic and clinical training.

    another question: nursing practice is built on the foundation of the "nursing model" which has been elaborated on and is taught in nursing programs. what is the "medical model" and is it something that medical students/pa students explicitly learn in the way that nurses are taught nursing theory and the like?
    i can't speak to nursing theory and the like, but the general theory of medical education is that there is set of procedures in which all physicians are trained. this set includes complaint, history, examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment.
    http://en.wikipedia.org/wiki/medical_model (for proper credit)
    in the last 40 years preventive health has been added to this model as it does not fit into the original complaint driven model. the general theory is that all physician receive the same basic education in all aspects of medicine. this is also the basis of internship for those that are specializing. for example a psychiatrist will have a small amount of exposure to surgery and internal medicine in both their clinical and didactic training.

    most of the nps that i work with operate in the medical model.

    i would assume that the posters here are much more educated on the nursing theory than i am. the essential difference in nursing theories seems to be that the biomedical model (which is probably closest to the medical model) contrasts with the social model which places an emphasis on societal and personal changes to make people healthier. i am not sure how many nurses if any use either of these models in daily practice.

    in practice i would guess that nursing education tends to focus on specific fields of nursing whereas medical education provides a general medical framework which physicians are expected to hone through residency and fellowship. in nursing this can be seen in the age specific or setting specific nature of np specialization. this is in contrast to physician specialization which tends to cross setting boundaries and in some cases age boundaries. in parallel pas are provided with a general medical education and particular additional education is left up to the supervising physician in regards to that particular practice of medicine. the important difference is that pas are still required to have a knowledge base in general medicine whereas the physician may or may not depending on their specialty.

    david carpenter, pa-c
  4. by   Atl_John
    Thanks David for that explanation on the medical model. I am glad that you put that NP's work off of the medical model. I know I will probably offend a NP by saying that, and they will point out that I'm still getting my BSN so I have no basis for saying that. So there I've already said it. However I still agree with you. Nursing theory I or I should say theories. There are quite a few of them, and some would say they are all different and that they are really all the same. To help explain nursing theory I can talk specifically about one that I use (I actually use two when I see a patient during clinicals). Its called Henderson's Model. And in Henderson's model she lists a bunch (theres like 25 or something along those lines) of key things that should be taken into account when planning your plan of care. When you start reading these things they are primarily based on Maslow's Hiarchy of needs. Things like ABC's are right there at the top, infections are on there, etc, its a big list. So after I've done a physicial (assessment as they would say here) I then take all the problems I've found and I use Henderson's Theory to prioritize which I do first. Thats basically a nursing theory. If you reallllly want more, I'll get out my Fundamentals book and i'll type out the couple paragraph blurb they have on her and I'll list thing things so you can see what it is. But thats only if you really want to know. Hope that helped
  5. by   core0
    Quote from Atl_John
    Thanks David for that explanation on the medical model. I am glad that you put that NP's work off of the medical model. I know I will probably offend a NP by saying that, and they will point out that I'm still getting my BSN so I have no basis for saying that. So there I've already said it. However I still agree with you. Nursing theory I or I should say theories. There are quite a few of them, and some would say they are all different and that they are really all the same. To help explain nursing theory I can talk specifically about one that I use (I actually use two when I see a patient during clinicals). Its called Henderson's Model. And in Henderson's model she lists a bunch (theres like 25 or something along those lines) of key things that should be taken into account when planning your plan of care. When you start reading these things they are primarily based on Maslow's Hiarchy of needs. Things like ABC's are right there at the top, infections are on there, etc, its a big list. So after I've done a physicial (assessment as they would say here) I then take all the problems I've found and I use Henderson's Theory to prioritize which I do first. Thats basically a nursing theory. If you reallllly want more, I'll get out my Fundamentals book and i'll type out the couple paragraph blurb they have on her and I'll list thing things so you can see what it is. But thats only if you really want to know. Hope that helped
    My only real experience with nursing theory was my one class that I took. That pretty much ended any desire I had to go into nursing.

    As far as NPs in practice, pretty much everyone uses a SOAP format. This really folows a medical model in the Subjective, Objective, Assessment and Plan. Some of the older physicians use a Hx, PE, Impression, and Plan format. Pretty much the same thing.

    David Carpenter, PA-C
    Last edit by core0 on Jun 8, '07
  6. by   mvanz9999
    Quote from core0
    My only real experience with nursing theory was my one class that I took. That pretty much ended any desire I had to go into nursing.
    Why?.........
  7. by   Atl_John
    CoreO- Even in nursing we use SOAP, PIE, SOAPIE, SOAPIER......am I missing any others. Now while our S-what they say is wrong O-what we can physically see, are probably the same, the A I believe is where you do your diagnoses/ r/o's, and then P is your treatment, same in nursing.

    I must say I HATED nursing theory I thought it was the stupidest crap I had ever had to deal with. I didnt' understand it I didnt' want to understand it all I wanted was a way of figuring out which problem the patient had was the most problematic using medical knowledge. Whats going to kill my pt. the fastest???? During the Peds Rotation in Atlanta, the NP there that was our preceptor showed me how Nursing Theories actually give us that ability if we just know how to use them. It kind of opened up my eyes to nursing theories. Dont' get me wrong I still find them pretttttty boring and at times particular ones are rather.....obscure but when theya re understood and used they seem to work rather well. I look forward to really being able to incorporate elements of both the medical and the nursing model in patient care, that way the patient gets the best of both worlds.
  8. by   core0
    Quote from mvanz9999
    Why?.........
    At the risk of seriously derailing this thread. I find Nursing Theory intellectually dishonest. Nursing theory grew out of the desire to show the worth of nursing versus medicine. I have no problem with this and I think that nursing interventions have long shown their worth as a separate practice outside of medicine.

    However, in developing nursing theory, nursing was force to use terminology to define itself separately from medicine. This resulted in developing a language which is almost impenetrable to both those within and outside the profession. Furthermore this is hampered by taxonomy that is even more difficult to comprehend. For example Alteration in comfort related to trauma as evidenced by patient reporting to discomfort. Or you can say patient reports pain from a broken leg. There are many nursing interventions that can address this and they work quite well. However, the amount of work that goes into documenting nursing theory is immense and in my opinion is wasteful.

    My favorite is Alteration in cardiac output: decreased. Or you could say low blood pressure. In an effort to prove that they are outside of medicine they cannot "diagnose". Hence the language. There is no reason that nursing cannot use medical diagnosis and implement nursing interventions. There is no need to reinvent the wheel.

    There actually was a group called nurses against nursing diagnosis. There is also a lot of nursing literature arguing against nursing diagnosis. I had a real problem taking classes and parroting information when I didn't believe in the concept.

    David Carpenter, PA-C
  9. by   Atl_John
    [quote=core0;2241354]At the risk of seriously derailing this thread. I find Nursing Theory intellectually dishonest. Nursing theory grew out of the desire to show the worth of nursing versus medicine. I have no problem with this and I think that nursing interventions have long shown their worth as a separate practice outside of medicine.

    However, in developing nursing theory, nursing was force to use terminology to define itself separately from medicine. This resulted in developing a language which is almost impenetrable to both those within and outside the profession. Furthermore this is hampered by taxonomy that is even more difficult to comprehend. For example Alteration in comfort related to trauma as evidenced by patient reporting to discomfort. Or you can say patient reports pain from a broken leg. There are many nursing interventions that can address this and they work quite well. However, the amount of work that goes into documenting nursing theory is immense and in my opinion is wasteful.

    HAHAHAHA................THANK YOU !!!!!!!!!! God I wish I could e-mail this to my professors. They would tell you David that the reason you have Nursing Diagnoses in the horribly obscure format that you do is so that you can prioritize your plan of care for the patient, organize the things going on with the patient, and it is a working example of evidenced based practice. I don't need a nursing diagnosis to tell me a patient is in pain if they have a broken leg or that they have decreased CO with CHF, etc. That came from applications of common sense and pathophysiology.

    My favorite is Alteration in cardiac output: decreased. Or you could say low blood pressure. In an effort to prove that they are outside of medicine they cannot "diagnose". Hence the language. There is no reason that nursing cannot use medical diagnosis and implement nursing interventions. There is no need to reinvent the wheel.

    They (whoever they are) would say that since we are nurses and dont' practice medicine we can't use medical diagnoses (unless your a NP obviously). That instead we use nursing diagnosies to actual or potential responses to illness or injury. I'm taking it that you havn't seen the Enhanced Readiness for (Spiritual Wellbeing, enhanced coping, etc).......Diagnoses yet? Those just make me cringe

    There actually was a group called nurses against nursing diagnosis. There is also a lot of nursing literature arguing against nursing diagnosis. I had a real problem taking classes and parroting information when I didn't believe in the concept. [Quote/]

    It seems that you only have nursing diagnoses in school from what I've been told the vast majority of nurses don't use nursing diagnoses anymore in the hospital setting. I have no idea if NP's use them, any NP's like to shed some light on that subject??? This is one of the reasons that I want my preceptors for my ACNP/RNFA to be either a PA or a MD. I want to experience the medical model by those who practice it on a day to day basis. Help incorporate it into the nursing knowledge that I have already.
  10. by   Barbiegirlnurse
    Wow, you all really dislike nursing theory! I can appreciate our difference of opinion and take no offense. We are on here to discuss, and if we all agreed--what would we learn? So, that being said--the topic of nursing diagnoses seems to be the second most popular dislike. While I'll agree that they can be viewed as troublesome, time consuming and worthless to some, they are actually beneficial to others. For instance, it sets a standard language with which nurses can relate patient information and develop plan of care. For instance Risk for Fall, related to unsteady gait, secondary to recent Right total knee replacement, gives a lot of information about what some of nursing's priorities for this patient should be. The diagnosis is much clearer than if in report the nurse gave the patient's medical diagnosis only and reported only medical findings. The nursing diagnosis is used as part of the nursing process. It is what guides patient care. For example, using the nursing diagnosis above- the nursing process would dictate that interventions be led to provide for patient safety (call light in reach, floor clear of clutter, making sure tolieting needs are met, not leaving the patient alone on the bedside commode, ROM exercises, etc.) These are all nursing interventions that are not spelled out anywhere by the medical team, yet if these things were not done, the patient would most likely suffer a fall, injury, or worse. And, yes I have used Nursing diagnoses in my practice at the hospital as a RN. We even have interdisciplinary careplan meetings twice a week with the medical staff, OT, PT, and speech therapy. We have to report our diagnoses and plan of care and organize our plan of care to fit in with other care the patient is receiving from other team members. As a NP, you may not do specific written care plans, but the same concepts apply when you are forming your treatment plan.

    There is such a problem in nursing, with being able to communicate our language to those outside of the profession. Many feel that others will think that the Nursing process is unimportant or redundant to the medical process. It is, however, very important and necessary.

    Now on nursing theories-- although they are thought to be useless, they ARE in fact important in research and practice. Nursing theories can provide rationale for conducting studies, as well as guide the research variables and questions. Additionally, theories can be used in practice to better understand patient behavior, suggest interventions, and provide for a way to look at the effectiveness of the intervention.

    In the past, nurses used Nightingale's environmental model, the medical model, and borrowed theories from other disciplines as a basis for nursing research. In the 1960s-1970s several grand nursing theories and a few middle range theories were developed. In more recent years, nursing research has tended to use more middle range nursing theories, rather than grand theories, due to fewer concepts and the theory itself being more concrete. As nursing knowledge, scientific evidence, and philosophy are not static, nursing theory will continue to evolve and change to meet the needs for research.

    While I can see how an average nurse may not find as much value in nursing theory, it is vital to the nurse researcher. The theories provide a framework with which to base the research (hypotheses, subjects, interventions, etc). This research can lead to better evidence based practice for nurses, by utilizing interventions that have shown in numerous duplicated studies to provide better outcomes (whether it be better understanding of a patient's feeling of isolation, self-concept, body image,etc. or providing a new intervention that can decrease a patient's hospital stay, increase positive health related behaviors, or increase compliance with therapeutic regimen, etc.).

    Nursing theory is a relatively new concept. When you look at the grand scheme of things, modern nursing theory has only been around for less than a hundred years. Still, many scientific nursing research articles use borrowed theories from other disciplines. Nursing philosophy changes and knowledge evolves over time. With the growing interest in nursing research, nursing theory will likely continue to expand. Although some nurses find little to no value in nursing theory, others believe that it is a necessary concept, without which, much scientific knowledge about nursing would be lost.
    Last edit by Barbiegirlnurse on Jun 9, '07
  11. by   jjjoy
    You can have nursing theory without nursing diagnoses as they currently exist. And you can have nursing care plans based on medical diagnoses, presenting symptoms, and potential problems.

    You have a patient with several issues and needs. First list the needs and issues.

    Hip replacement (primary reason for admit)
    Hypertension (continuing issue)
    Etc

    Then you list the appropriate interventions

    fall precautions
    ambulation with assistance
    pain management
    etc

    In report, the off-going nurse says ".... 2-day post-op hip replacement, continue on fall precautions, up with assistance, ambulated with PT twice, pain being managed with XXXX at XXXX, etc..." Of course, the nurse does need to know the rationale for the interventions, but there's no need to spell it out in daily practice. Medical diagnoses are not "fractured tibia due to external mechanical force exceeding bone strength" or "myocardial infarction due to lack of oxygen to heart tissue."

    As we know, nursing education needs to include the WHY and not just WHAT of nursing. Students will learn that the reason for assistance with ambulation is that there's an increased risk for falls due to an unsteady gait due to the hip replacment.

    Thus, even without a formally constructed nursing diagnosis, the nurses can (and do) know that a given patient is "at risk for falls due to unsteady gait due to hip replacement." Maybe nurse researchers and theorists find nursing diagnoses in their current format a useful tool. But I think students and practicing nurses are not well served by them and that there are better, clearer ways of articulating and teaching the what and why of nursing.
    Last edit by jjjoy on Jun 9, '07
  12. by   jjjoy
    Here's another thought on Nursing Dx.

    I could argue that there's no reason for most nurses to "diagnose" at all. Diagnosing involves the presence of symptomatology with unknown etiology. Before you can fix the problem, you have to figure out what's causing the problem.

    But nursing care doesn't involve figuring out what's causing the problem.
    Acute nursing care is assisting the patient in the process of dealing with the problem. The nurse then needs to identify the best way to do this. That involves ASSESSING but not DIAGNOSING.
  13. by   Barbiegirlnurse
    Nursing diagnoses are not the same as medical diagnoses. Most nursing diagnoses give the diagnosis and a "secondary to" statement. The "secondary to" statement includes the etiology that is affecting the patient's homeostasis. Most times it is this part of the nursing diagnosis that includes the actual medical problem. It is NOT nurses making medical diagnoses.

    Also with your list of patient needs there are plenty of reasons to use Nursing diagnoses when planning care. For instance, if someone has had a hip replacement--wouldn't you also consider body image issues? While not a medical priority, shouldn't nurses consider how the scar would affect someone's body image and overall self perception. Additionally, nursing diagnoses are a very integral part of providing continuity of care between nurses. In my RN practice I found I used nursing diagnosis every day! Even when it is not actually spelled out on paper, these are the things that NANDA has spelled out for nurses to diagnose and treat with NURSING interventions. (without medical orders). It goes along with teaching students and reinforcing to nurses, what nurses can and should do in practice, given a certain situation.
    Last edit by Barbiegirlnurse on Jun 11, '07

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