Becoming an NP with little to no nursing experience??

core0 · Jun 3, 2007

to jjoy:
as for prerequisite differences, remember that not all nps go through bridge program. all np students have a background in nursing which includes clinical hours and internships, (even if in a bridge program, they must become a rn and do necessary clinical rotations and internships). this is important to note, because this is additional education in both the classroom and clinical settings that is often overlooked. i am not sure what most pas major in for their undergraduate degrees, but the majority of majors would not include comparable healthcare related experience to that of a rn (new graduate or bridge program rn). this could be the reason for any variance in clinical hours. i am not sure how many hours pas must complete for their education, but for my np education i had to have 650 internship hours of direct patient care and undergraduate i had clinical rotations in addition to a 200 hour practicum my last semester. i am curious if anyone cares to let me know. thank you for your thought provoking response!
i'll address the np clinical hours issue. the nonpf recommends that dual certification programs get hours for both certifications. also some programs choose to get additional exposure. finally many fnp programs are moving to more hours to cover the entire lifespan.
as far as pa hours i would suggest you look at this thread:
https://allnurses.com/forums/f34/clinical-differences-nps-pas-83016.html
there is some good and not so good information there. the short answer is there is no specific requirement. instead pas are required to have clinical experience in a variety of medical environments including family practice, peds, im, em, surgery, psychiatry, and ob. the shortest program that i am aware of is about 1400 hours (a dual pa/np program). the longest is over 3000 hours.
to coreo:
to answer your question about the ana it serves all nurses including those in advanced practice (cns, crna, np, etc.) the reason that it is so important is that it is carried out at both national and state levels. this is why it has such a vital role for nurses. you are right that the aanp and acnp are professional organizations for nps. while both are certifying agencies for nps, the acnp is not exclusively for nps. thanks for posting the organizational websites for pas. i am sure that they will prove to be enlightening.
the problem is that who speaks for the nps? the ana, the aanp or the acnp? if you speak with a divided voice you tend to get ignored. while nps may have some items in common with nursing, their advanced practice leads to unique situations such as billing which are not generally a problem in other areas of nursing. the other issue is that ana does a number of other things including functioning as a union in some states. this may lead to divided priorities.
i did not, however, care for your analogy of physicians being godzilla, nurses being the japanese army guys, etc..... you must be under the impression that nurses are intimidated by physicians. that is a huge misconception! nursing and medicine are two of the oldest professions in the world. it would be hard for one to exist without the other. to say that pas have to take the heat when nps make physicians mad is an unfair overstatement. is the real problem deeper than this? does your interest in nps stem from real "self-defense" or from fear of competition in the workforce? i am asking this of you, because i know many nps fear the competition for jobs, business, and respect in the world of healthcare. however, the main concern should actually be for improving the lives and health of our patients.
nursing and medicine have to coexist. does advance practice nursing and medicine have to coexist? that is the real question. i will put this in perspective. i am past president of my state pa chapter and past president of my specialty pa group. i have served in the rule making body of the pa academy (the hod). i think that this gives me some perspective on this issue. when i look at my email on the subject and my action lists there are three recurring themes. physicians mad at nursing (for example the current fracas between the crna's and anesthesiologists),nurses attempting to impose nursing rules on other professions and nurse infighting that affects pas.
i have in my inbox currently a bylaws change requiring all pas to have an msn in order to comply with "medicare billing rules". i initially got involved in the pa political realm when a local rnfa tried to get all nps and pas banned from the or since "only rnfas have the necessary training to work in the or". or the attempt to have pas show they have critical care experience since "acnps are the preferred provider for inpatient medicine" (this was actually an unexpected byproduct of an acnp's attempt to get a hospital based job that was held by a fnp). like it or not pas and nps tend to get painted with the same broad brush. this leads the uneducated to think that issues that apply to apns also apply to pas (whether applicable or not).
i have no fear of nps. i work with them every day. most of them are just as sick of the infighting as i am. if i had my way our second npp would have been an np. i care about the ability to do the job. however, my various positions require me to understand not only np training but nursing issues as they affect pas.
we could argue all day about which program does what, which has more autonomy, or which profession is actually better. the truth is that in all honesty it doesn't matter. it's not the profession that makes a np or pa a good healthcare provider, but how he or she operates on a daily basis to improve the lives of others through care, skill, and interventions based on the standards and core values of his or her profession.
i agree. i have tremendous respect for the nps that i work with. they do a yeomans job and provide great care. on an operational level i have serious reservations on the way that np education is conducted (to actually return to the subject of this thread). i feel that there is inadequate supervision of the process which leads to program abuses to np students. there are multiple certifying agencies and accrediting agencies which allows the programs to certify at the lowest level.
np students tolerate things that would be unthinkable in any other educational environment much less a medical education environment. in my opinion this is what leads to the large number of nps that are not practicing as nps. i think that a lot of np students (some who have posted here) are sold a bill of goods by programs that are more interested in money than producing excellent clinicians (although in all honesty that same charge has been leveled at some pa programs). as an educational consumer a np student has none of the information needed to evaluate a program including acceptance rates, graduation rates, and certification pass rates.
as for your studies to get your phd., be sure to research the use of the term "doctor" for individuals other than medical doctors. this has become such a hot topic for physicians. they definitely don't want any other profession to use the term in the healthcare setting. how does it make you feel to work for a degree that mds don't want you to get the respect of the proper name? their reason for doing this is so that the public won't have any misconceptions about who the "real" doctor (meaning md) is. i am just a bit curious. i see some pro's and con's to both sides.

i have looked at this extensively and while the physicians i work with support me completely, it would be inappropriate for me to use this is clinical practice. this misrepresents what i am. it is completely appropriate in an academic setting. the title dr. in the us has quite a different meaning in the us than it does in britain. in britain physicians are referred to as dr. using the original latin of "teacher". it is an honorific. the md on the other hand is only for physicians that have completed significant academic work advancing medicine (surgeons having descended from barbers always use mr/miss). the british reject any "professional" doctorate including the us md (and presumably the dnp). i completely agree with the ama that in a clinical medical setting the only people using the term dr. should be mds and dos. if you want to use your dnp it is completely acceptable to say i am john smith dnp. it is inappropriate to say i am dr. smith without a qualifier.

to once again get back to original subject again. i counted the number of nps working in the four hospitals i went to this weekend who are working as rns and came up with four. three are very experience rns that cannot find an np job with the same pay they can make as rns. one is a direct entry np that cannot find an np job (there is also one nd that i don't know how to categorize). in this market anyway the nps jobs seem to require extensive nursing experience relevant to the job usually accompanied by strong relevant clinical experience. whether that applies in other markets is unknown. i will also say that almost every npp job i have seen filled in the last three years was filled by word of mouth. if you do not have the contacts in the nursing community (or pa community) then your chances of accessing these jobs approach zero.

david carpenter, pa-c

Barbiegirlnurse · Jun 3, 2007

To CoreO:

Thank you so much for your reply. The insight that you offer is very helpful to me, as new entry into the NP field. I do agree with what you are saying on the use of the word Doctor in a healthcare setting. It can be very misleading to the public. Still, though, think about all of the clinical psychologists, optomotrists, pharmacists, chiropractors, etc (all with doctorates) that use the term in clinical practice. Do you feel that they are going to give resistance to the change? Is it fair that they have been using the term in clinical practice, without problem for such a long time? Why has it been accepted for them to use the term, but with the rise of the DNP (among the rise of other healthcare related doctorates), it is now so controversial? I agree with you that it must be stated when you first make patient contact and introduce yourself, to let them know your title PA, NP, etc. And as I am sure you have experienced, many patients will try to call you Doctor time and time again. I ALWAYS politely explain to them my position and title. Sometimes I think that it would be more professional to use the term Nurse in front of my name, instead of the informal first name only. Do you run across this same type of problem as a PA?

To answer your question about who speaks for NPs, overall it is the ANA. The AANP and ACNP are the credentialing organizations. When a NP is certified, they can choose to go with either one or both. A NP or NP student can also choose to join either organization. The organization assists NPs by way of offering educational workshops at conferences, keeping members informed of APN political agenda, allowing for networking of NPs, etc. Politically speaking, the ANA is the overreaching professional organization for all nurses, including those in advanced practices. I do though, however, agree with you that the conflict of interest when the ANA may have divided interests. Another concern is that the ANA also competes with the NLN as the organization of choice. This is such a problem! As I am certain you know, when you don't speak as a unified voice in a profession, your needs and wants tend to fall on deaf ears. Are the majority of PAs politically active? This is of great concern for nurses, as the majority are not.

I can empathize with the NPs you saw over the weekend still working at the hospital. It is hard to find a NP job right now. I had expected the job market to be better, but I feel that with increasing "Minute clinics" physician and NP offices are expecting to have a decreased need to hire in additional staff. (Also, as a side note, many hospitals will not pay more to a nurse who gets their MSN. So while these nurses' education level has increased, their wages, many times have not if they are still working as a RN in a similar capacity, even though they could be held accountable to a higher standard of care.) Where I live, the RN background is important to employers, but they are more interested in the education and clinical experience in advanced practice.

Trauma Columnist · Jun 3, 2007

Barbie - this thread is getting interesting! I am a CNS who works in an NP role. I had 12 years of RN experience prior to becoming an APN. You are so right that the job market is very tight for APNs at the moment. I think the entry level NPs might have a hard time finding a position simply because the competition is so keen. I did my APN after getting an MSN with a non-clinical focus. I was still working as a staff nurse with an MSN and I wasn't the only one either. Not one cent more for pay either.

David - I like some of your comments and disagree with some others. However, that is what debate is all about. I know that nowadays PA programs are masters-level and I had actually considered going for the DNP degree. However, since again it will not advance my career one iota, the purpose eludes me at this time.

Going back to the entry level NP, the competition is fierce for jobs and since that is the ultimate goal, if I was a student I would want to talk with some grads of these programs to see what kind of jobs they are getting. And...the bottom line for hospitals and practices is that they want the most bang for their buck. When I graduated last year, I had been working for 10 years at the same big hospital. They offered me $5000 less than what I was currently making to take a position as a "new-grad APN." Nope and double nope. I went looking for a private practice position and again they were offering less than what I was currently making as a staff nurse. However, I bargained up $20,000 and have been very happy with my pay and benefits. If I had been an entry-level NP, I would have had to take what was offered without any negotion room. My 12 years as an RN should count for something. Yes, I was a new grad APN, but not an inexperienced one.

Barbiegirlnurse · Jun 5, 2007

To TraumaRN,

On the subject of still working as a staff RN after graduation: The hospital that I work at didn't even want to change my creditentials on my name badge to include MSN. They said that it didn't matter and there was no need to include it. I found this disheartening, as I have worked so hard for those three little letters! You used to be able to tell a nurses education from the nursing hat, as different education levels had different stripes. I don't see how including MSN on a name badge is any different. After a rather long conversation with the HR department at my hospital, they agreed to change my name badge. But, (you guessed it!), no change in pay.

It is sad that a hospital will pay extra for different certifications (like ACLS, among other non-CPR type certifications), but not for a nurse obtaining his or her Master's degree. It is impossible to go back to the way of thinking you had before getting the degree, so you ARE operating at a different level. You can't unlearn or ignore the advanced assessment skills required for NP training, therefore you bring an added component to hospital care. I LOVE bedside care at the hospital, and would probably stay on PRN as a staff nurse to help out if they would just validate there is value in advanced education in nursing. It wouldn't even have to be a great increase in pay, just a small difference would be sufficient, because it is not about the money. It is about respect. Do you think that I should fight harder, to make it easier for future nurses in the same situation at my hospital? The only other MSN in the whole organization is the DON. There have been other MSN nurses, but all have chosen to leave, due to no increase in pay, and the attitude towards them.

As for competition for jobs being fierce, it truly is. The job market is so very tight, right now, especially for new graduates. When you negotiated for your current job, did you do a contract? If so, what kind of things did you include? I am wanting to include things like malpractice insurance, continuing education, membership fees to professional organizations, and Sigma Theta Tau, and compensation for attending professional conferences. At what point do I bring these things up during negotiations? Any input would be helpful! Thanks!

jjjoy, LPN · Jun 5, 2007

Do you think perhaps that part of the push for DE NPs is that NPs with lots of experience do have more job choices and can command a higher salary? To the number crunchers and hiring personnel, a new grad NP probably sounds pretty good. They'd be much more willing to accept relatively lower wages just for the experience and less likely to leave an NP job for a better-paying bedside RN job, as many NPs have done.

core0 · Jun 5, 2007

to traumarn,
on the subject of still working as a staff rn after graduation: the hospital that i work at didn't even want to change my creditentials on my name badge to include msn. they said that it didn't matter and there was no need to include it. i found this disheartening, as i have worked so hard for those three little letters! you used to be able to tell a nurses education from the nursing hat, as different education levels had different stripes. i don't see how including msn on a name badge is any different. after a rather long conversation with the hr department at my hospital, they agreed to change my name badge. but, (you guessed it!), no change in pay.
the thing you have to think about is that what does it do for the hospital. if you are working in an anp role then they can bill for your services and you should get more pay. similarly if you working in an educator role then that is hopefully better compensated. but from an hospital point of view, the anp working in a staff role does not do a substantially different job than a bsn (or adn) and brings substantially more liability.
it is sad that a hospital will pay extra for different certifications (like acls, among other non-cpr type certifications), but not for a nurse obtaining his or her master's degree. it is impossible to go back to the way of thinking you had before getting the degree, so you are operating at a different level. you can't unlearn or ignore the advanced assessment skills required for np training, therefore you bring an added component to hospital care. i love bedside care at the hospital, and would probably stay on prn as a staff nurse to help out if they would just validate there is value in advanced education in nursing. it wouldn't even have to be a great increase in pay, just a small difference would be sufficient, because it is not about the money. it is about respect. do you think that i should fight harder, to make it easier for future nurses in the same situation at my hospital? the only other msn in the whole organization is the don. there have been other msn nurses, but all have chosen to leave, due to no increase in pay, and the attitude towards them.
see above. you can't unlearn those advanced assessment skills, but you are not in a role where you can use them. so they have all the liability and none of the benefits of an apn. now a msn in a management role can hopefully show some benefit from the degree. that is the choice between np and not. the hospital pays for the other extras because they make the nurse more valuable (useful in more areas).
as for competition for jobs being fierce, it truly is. the job market is so very tight, right now, especially for new graduates. when you negotiated for your current job, did you do a contract? if so, what kind of things did you include? i am wanting to include things like malpractice insurance, continuing education, membership fees to professional organizations, and sigma theta tau, and compensation for attending professional conferences. at what point do i bring these things up during negotiations? any input would be helpful! thanks!

bring those things up early in the contract process. what employers hate is a rolling list of demands. you have to look at the total compensation of the package. i took my current job with an offer of $5k less than another because the education reimbursment was worth $15k a year more. a good source for this is:

http://www.aapa.org/gandp/anatomy.html

http://www.aapa.org/gandp/checklist.html

while these are pa resources the principle is the same for any npp. if anybody has good specific np resources i would be interested. ideally contract and benefits should be covered in school along with coding. my minimum for a contract is malpractice insurance covered with tail (it is important to get this in writing), 5 days and $1500 cme, and all professional organizations and certifications covered. realistically go for $2500 cme as that will allow you to do one big and one smaller conference. of course i can ask for this with six years experience is specialty care. except for the malpractice none of these should be a deal breaker for a new grad. if you don't get everything you want the first contract there is always the next one. you have a lot more leverage with a little experience.

david carpenter, pa-c

Barbiegirlnurse · Jun 5, 2007

CoreO

Thanks for the tips for contract negotiations! We did go through it in school and did sample contracts, but I didn't know if it was realistic to expect to get the same things in the real setting. The preceptor I worked with for my practicum owned her own practice and did not employ other NPs, so she wasn't as helpful on this topic. Many Thanks!!

Atl_John · Jun 6, 2007

I must say I am just in awe by all of the conversation going on here. Everyone is so very passionate about their positions and beliefs its great to see. As a BSN student in an accelerated program (1st BS was in Inter. Bus/Marketing/German) entirely non-nursing related. I originally started out doing pre-reqs to get into PA school (Emory was first choice). I did not get in (big suprise) wasn't really expecting too on the first time. Well, I decided to try nursing as plan B, and I'm very happy that I choose to be a nurse. I had to take more pre-reqs to get into nursing than I did at Emory for their PA program and thus have now found myself here at Auburn getting my BSN, I graduate in Dec. Well, even while I have gone through nursing I have still wanted to be a PA and its only recently that I've found how much I LOVE critical care. So.....ACNP it is for me hopefully starting Spring 08 doing it part time while working full time. I do believe that getting some more experience would be highly beneficial to me in my masters level of study. I'm glad however that I can start my masters without having to have experience.

Core0-I loved the post to the article talking about increasing the education of NP's. I have often felt that NP programs lacked enough of the clinical aspects (diagnosing/tx/procedure/interpretation). While in a BSN program I do get clinical experience and one could argue that the 650 hours in a BSN and then the other 650 in a MSN and the hours you have as a nurse would equal that of a PA, I would probably have to agree with you that it doesn't. Not sure if you feel that way I'm assuming and hope I'm not wrong on that as to your belief. But working and thinking as a nurse even though we can often diagnose whats going on with our patient and we can have an idea of whats the treatment should be is A LOT different than starting all those clinical hours from the beginning with that mindset, etc. You start out diagnosing and going through the steps. We as nurses do not, it is something that is learned/taught while in practice or while in ANP school.

I have really gotten an appreciation for your profession and your knowledge. You would certainly be someone I would love to have as my preceptor. I enjoy reading your perceptions and it is nice to see a PA trying to understand their other profession. It is ashame that more NP's/PA's can't do that with one another. We could truly learn a lot from one another.

Barbiegirl (I think it was you),

If this wasn't you I apologize ahead of time and ask you to just ignore the rest of this. I remember a post talking about the need for Theory/Research courses in MSN education. While I think theory is important to practice it already guides my practice as a student (I'm a combo of Henderson/Watson). I do believe that our MSN programs lack in "intensity" compared with our PA brethren. Looking at some of what they have to go through and at the levels they have to do it, I often think that we have an inferior clinical/knowledge aspect to the PA model. They do all aspects and are sort of the handyman. I know I've not had whole courses just in Surgery or Surgical Disease, Gastroenterology, etc not to the lengths that they have. I don't know I might be wrong if I am Core/Barbiegirl please correct me.

John

core0 · Jun 6, 2007

i must say i am just in awe by all of the conversation going on here. everyone is so very passionate about their positions and beliefs its great to see. as a bsn student in an accelerated program (1st bs was in inter. bus/marketing/german) entirely non-nursing related. i originally started out doing pre-reqs to get into pa school (emory was first choice). i did not get in (big suprise) wasn't really expecting too on the first time. well, i decided to try nursing as plan b, and i'm very happy that i choose to be a nurse. i had to take more pre-reqs to get into nursing than i did at emory for their pa program and thus have now found myself here at auburn getting my bsn, i graduate in dec. well, even while i have gone through nursing i have still wanted to be a pa and its only recently that i've found how much i love critical care. so.....acnp it is for me hopefully starting spring 08 doing it part time while working full time. i do believe that getting some more experience would be highly beneficial to me in my masters level of study. i'm glad however that i can start my masters without having to have experience.
you have an option that many students don't have. you can choose either np or pa. you have to look at the area that you want to work in and who is being hired there. if you wanted a job at vanderbilt for example, then i would tell you to go np 100%. there are few pa jobs there. on the other hand if you wanted a job at duke then pa would be the way to go. it all depends on the area. if you wanted to work in my area then it would be pa/np for primary care but pa pretty much solely for specialty care (except for cardiology). you have to know the market. i see a lot of nps (especially working in critical care) that get their fnp and don't understand why they can't find a specialty job. its kind of like real estate location location location. look critically at who is working where. not just where they are working but what they are doing. the cardiology nps that work in the same hospitals as i do are tremendously underutilized and very frustrated. not a good combination.
core0-i loved the post to the article talking about increasing the education of np's. i have often felt that np programs lacked enough of the clinical aspects (diagnosing/tx/procedure/interpretation). while in a bsn program i do get clinical experience and one could argue that the 650 hours in a bsn and then the other 650 in a msn and the hours you have as a nurse would equal that of a pa, i would probably have to agree with you that it doesn't. not sure if you feel that way i'm assuming and hope i'm not wrong on that as to your belief. but working and thinking as a nurse even though we can often diagnose whats going on with our patient and we can have an idea of whats the treatment should be is a lot different than starting all those clinical hours from the beginning with that mindset, etc. you start out diagnosing and going through the steps. we as nurses do not, it is something that is learned/taught while in practice or while in anp school.
personally i would agree with your assessment for some programs.there are some np programs that far exceed the minimum. unfortunately most programs simply adhere to the minimum. the main difference that i see between np and pa educational programs is not only in the hours, but the breadth of the experience. the original np concept (go buffs) was to take an experienced pediatric nurse and expand the practice of nursing into diagnosis and treatment as well as focusing on disease prevention and health maintenance. the pa concept was to take experienced corpsman and give them a broad medical training in all areas of medicine. while both professions have developed over the years the main difference between the two remains focused training in one area of nursing vs. broad training in all areas of medicine. in my mind the dnp takes care of concerns by several bon's on the depth of np pharmacology education and the extra hours in the nursing specialty come close to what i would consider minimum experience in a specialty.
i have really gotten an appreciation for your profession and your knowledge. you would certainly be someone i would love to have as my preceptor. i enjoy reading your perceptions and it is nice to see a pa trying to understand their other profession. it is ashame that more np's/pa's can't do that with one another. we could truly learn a lot from one another.
i start at emory in july. i would certainly be willing to entertain this. my current practice does not allow precepting, but i am interested in getting back into that part of the profession as well as doing some teaching.
i think that np programs do a particular disservice to their students in preparing them for practice. in my program we had at least one hour per week on practice issues. some of it was things like the history of the pa profession, some on what the educational backgrounds of other professionals (not just nps but speech path ot etc. we also had classes on coding, billing, charting and contracts. part of this was interviewing. total about 50 hours over a year and another 10 hours or so during clinicals.
i haven't seen these skills demonstrated by nps that have applied to our practice. i have seen a number of nps self immolate over the simple question of how well would you work with pas. now the obvious answer is something on the order of we are all part of health care team. now imagine my surprise when i hear "well obviously the pas have much less education than nps. after all we have masters and they merely have a certificate". this while sitting across the table from four pas all of who have master's. unfortunately by the third time that happened i was not surprised. the unfortunate outcome of this is that when they went to replace me the physicians in the practice refused to interview an np candidate that i thought might be a good fit. so we will continue to be an all pa practice for now. unfortunately at least one of the programs is good at putting out widely inaccurate information about pas. when the students accept this information without critically examining it then things usually don't work out well.
barbiegirl (i think it was you),
if this wasn't you i apologize ahead of time and ask you to just ignore the rest of this. i remember a post talking about the need for theory/research courses in msn education. while i think theory is important to practice it already guides my practice as a student (i'm a combo of henderson/watson). i do believe that our msn programs lack in "intensity" compared with our pa brethren. looking at some of what they have to go through and at the levels they have to do it, i often think that we have an inferior clinical/knowledge aspect to the pa model. they do all aspects and are sort of the handyman. i know i've not had whole courses just in surgery or surgical disease, gastroenterology, etc not to the lengths that they have. i don't know i might be wrong if i am core/barbiegirl please correct me.
john

the interesting thing is that depending on previous experience nps and pas may start at radically different levels. however, after about two years there is very little difference in practice patterns.

getting back to the actual subject of the op (sorry siri). i had an interesting conversation with a patient today who was a director of a technical school (lpn, rt and dental hygenist). he stated that several of his rts had gone on to pa school recently. we were discussing my classes experience. now the pa market has changed dramatically in the last six years with the explosion of pa programs. most students in my class had multiple offers. the pas that had the best offers were those who had previous experience. the 4 rts in my class had multiple offers from pulmonologists. the lab tech had 11 offers from heme/onc groups. discussing this with my former program director, he is seeing the same thing. the students without previous medical experience can find jobs but it is a struggle. the students with prior medical experience are getting multiple offers.

my thoughts are that students with prior nursing experience have the following advantages:

knowledge of the local medical community

contacts withing the local nursing community

particular skillsets as nurses that employers may find valuable

known experience in nursing that provides a proven track record

on the other hand there was an interesting post in another thread. is the fact that direct nps are not earning a big salary as a nurse viewed as a positive factor by employers. in our market experienced nurses that are looking for jobs as nps cannot get salaries comparable to what they are making as nurses except in specialty groups. for the primary care jobs, nps without experience seem to have a better chance. one advantage that pas have (from my perspective) is that you have nothing to fall back on. you either go into the profession or not. there is no other level to work in as a pa.

good luck

david carpenter, pa-c

Barbiegirlnurse · Jun 8, 2007

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.

jjjoy, LPN · Jun 8, 2007

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?

core0 · Jun 8, 2007

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 profession:pa 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