Writing the Prescription to Fix Broken Nurse Practitioner (NP) Education (Pt. I)

[cjcsoon2bnp]

NURSE PRACTITIONER HISTORY

When Drs. Loretta Ford, RN and Henry Silver, MD developed the first NP certificate program in 1965 it provided experienced registered nurses (RN) with the additional training to work in pediatric primary care settings collaboratively with physicians to manage acute and chronic illness (American Academy of Nurse Practitioners, n.d.). Drs. Ford and Silver believed that majority of the healthcare needs presenting in pediatric primary care settings could safety be overseen by nurses with advanced training in physical assessment, pathophysiology, pharmacology, and disease management. After creating the program at UC, Dr. Ford continued to work to develop the NP role and advocate for its implementation throughout the country. Since the NP role began, education has evolved from certificate to graduate degree programs and now includes acute and primary care specialties serving patients across the lifespan. NPs work in clinics, community settings, hospitals and private offices; some work completely independently while others work collaboratively in multidisciplinary treatment teams.

Even with all of the progress achieved in advancing the NP role, debate continues regarding the necessary education and training required for NPs. Some of the biggest points of dispute include minimum number of clinical practice hours, degree for entry to practice, prerequisite RN experience, and necessity of post-graduate residency/fellowship training. In this two-part series I will discuss each of these topics and offer my take on what is broken within the current system and then suggestions on how we can improve it for future practitioners. Please keep in mind that these are my opinions and do not reflect the views of any college/university or professional organization. This is not a critique of any specific education program but rather a general commentary about NP education in the United States with the hope of starting an open and productive dialog between members of this forum.

EDUCATION SYSTEM PROBLEMS

The first NP programs were designed to build upon the practice of experienced nurses but as time has marched on we have seen the emergence of new educational formats including online and accelerated programs. Students can now complete NP programs in online classrooms from anywhere in the world and non-nursing professionals from a variety of backgrounds can join our field through accelerated degree programs. Utilizing new educational tools and alternative paths to entry are important to remaining current but these methods present challenges for maintaining quality standards and the "nurse" identity of nurse practitioner. Studies have found that having previous clinical experience as an RN was not associated with improved academic success or stronger clinical skills as a new NP (El-Banna et al., 2015; Rich, 2005, Rich & Rodriguez, 2002). While I won't debate that non-nursing professionals can effectively complete accelerated programs and become successful NPs, I believe that these NPs miss out on critical socialization aspects of being an RN and are less likely to identify with the "nurse" aspect of being a nurse practitioner.

Another issue that comes under frequent discussion is the variation of clinical practicum hours that NP students have to complete depending on their program. The Commission on Collegiate Nursing Education (CCNE) mandates that programs have a minimum of 500 direct patient care hours but offer few other specific guidelines (2016). A review of programs from around the country, the average number of clinical practicum hours range from 500 - 1000 hours when a masters degree or post-graduate certificate is conferred and 750 - 1250 when a doctoral degree is awarded. At first glance, one might assume that the higher clinical hours associated with completing a doctoral program would mean more direct patient care hours but in most circumstances the additional hours are for the completion of a capstone quality improvement or research project. This has come under serious discussion as it has been suggested that the entry degree to practice be changed from the Master of Science in Nursing (MSN) to the Doctor of Nursing Practice (DNP). The idea of raising education requirements and improving scholarship is good in theory but many question the "value add" of the DNP degree for NP when the additional clinical hours required for the degree are not typically related to direct patient care but are instead focused on a quality improvement or research project. The purpose of this article is not to debate the merits of a particular degree but to consider its value specifically as it relates to improving the ability of a NP to provide direct patient care as a clinician.

Another major hurdle for many programs is securing appropriate clinical sites and preceptors. Many prospective NP students and healthcare professionals outside of nursing are unaware that in a number of programs it is the responsibility for students to find their own preceptors and clinical sites, which is challenging and results in unnecessary delays for program completion. For the more programs that take the responsibility of matching students with preceptors it can still be difficulty because most nursing programs do not pay experienced practitioners a stipend for having a student work with them and instead rely on volunteering and offers of continuing education credits or course credit at the affiliated college/university. In this writer's opinion, forcing students to find their own preceptors is inappropriate and contributes to a lack of standardization in quality education. Also, by not offering some form of financial compensation or stipend to preceptors it sends the message that the preceptor's time is not valuable and the education of NPs is less valuable than physicians or physician assistants (many PA and medical school programs provide financial compensation to preceptors for their time working with students).

In the next segment I will discuss some problems seen with the modern graduate student and then provide a "prescription" for how fix a broken system. My question for the readers is, do you think that any major change is needed to this system at all? Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape? Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)?

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REFERENCES

American Academy of Nurse Practitioners. (n.d.). Historical timeline. Retrieved from AANP - Historical Timeline

Commission on Collegiate Nursing Education. (2016). Frequently asked questions: Clinical practice experiences. Retrieved from American Association of Colleges of Nursing (AACN) > Home

El-Banna, M., Briggs, L. A., Leslie, M. S., Athey, E. K., Pericak, A., Falk, N. L., & Greene, J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5), 276-280. doi: 10.3928/01484834-20150417-05

Rich, E. (2005). Does RN experience relate to NP clinical skills?. Nurse Practitioner, 30(12), 53-56.

Rich, E., & Rodriguez, L. (2002). A qualitative study of perceptions regarding the non-nurse college graduate nurse practitioner. Journal of the New York State Nurses Association, 33(2), 31-35.

[ivanh3]

No offense to the OP, but I think "broken" is a strong term. I do not feel that NP education is broken. Any program can be improved, and most quality programs (of any kind) constantly self evaluate to improve their product. I have to agree with the responder who stresses the importance of research and the avoidance of anecdotal experiences that may erroneously guide decision making. I have seen new grad NPs with plentiful nursing experience fail, and I have seen new grads with limited RN experiences excel. I have also seen the opposite occur. I have not stepped out of my fishbowl to research which is the norm. Instead I judge each NP by their actions. I learn from both. I "steal" techniques and knowledge from those I think are sharp and use this to develop my own style, and I learn what not to do from others. New NPs often bring new and fresh approaches and they keep me on my toes.

In terms of NP vs PA education I can say this. I didn't want to go to PA school. I may admire the rigor of their programs, but I don't see a better or worse final product. In my region all job postings are "NP/PA" or "PA/NP" but never one or the other alone. I work with PAs and man are they sharp, but so are the NPs where I work. We have to be. It is a high acuity, high volume setting, and we all turn to each for help. I was full time in school, but I was able to work. I was able to be part of my newborn son's life. My wife went part time to NP school which was a bonus for our family. BTW she totally kicks ass in her "nurse practishery" skills.

Let's continue to improve our programs and our practice, but strong language like "broken" is not helpful or accurate.

My .02

[Corey Narry, MSN, RN, NP]

Here's my prescription:

Keep all current Consensus Model based NP programs in the specialties they were intended to train NP's on.

Form a new regulatory body tasked with only accrediting NP programs similar to COA for CRNA's and ACME for CNM's. Regulatory body to formulate new standards for NP education including but not limited to:

- Ensuring that clinical preceptors are affiliated with the specific programs as faculty members. Students are not to find their own preceptors period.

- Preceptors in each program, at a minimum, should be representative of the broad spectrum of specialties required in each of the Consensus Model-based NP track. FNP programs at a minimum, should have a faculty preceptor for Pediatrics, Women's Health, Family Practice, Primary Care Internal Medicine, and Fast Track/Urgent Care.

Similarly, all AGACNP programs must have preceptors for Adult Emergency Medicine, Hospitalist Medicine, and Critical Care. Subspecialty preceptors are available as needed for elective clinical rotations that students pick based on their goals (i.e., Cardiology, Nephrology, etc).

- Increase the clinical hour requirement to 1000 hours. Restructure clinical rotations in a manner that promotes consistency which may mean having the student be in the clinical setting 5 days a week for a month at a time.

- All distance-accessible and on-campus programs must be compliant with the regulatory standards. In order to allow institutions some time to make arrangements to be compliant, a gradual phase in of the new standards must occur over a period of 5 years after which all institutions must meet the new standards to receive accreditation from the new governing body. Non-compliant institutions can not have their graduates sit for national certification.

- All new NP programs being developed or in the planning stages of admitting students must comply with the newly established administrative and regulatory guidelines for accreditation.

Roll back the recommendation to make DNP the entry to practice requirement. Make the DNP available as an option for NP's to advance into Leadership, Policy Making, Consulting, etc. roles.

[shibaowner, MSN, RN, NP]

Let me start off by saying I am a PA for many years with many NP friends and colleagues. Almost all (but not all) have echoed that they would have loved to have had the initial education PAs have had. Not trying to say PAs are better or worse, just talking about education. In fact, I think we all wind up on the same roof, doing much of the same thing. Still, I will throw in my two cents putting in some questions you may want to consider about education moving forward.

-PA education is standardized, at least 27 months long and full time. There are no part time programs. Most programs are modeled after one another. My program was 50 hours a week in class and clinical first year and second year 80 hours a week of rotations through all of the major medical specialties functioning as an "intern". We learned all procedures physicians learn and were ready to function fairly well upon graduation. We were in the best sense medical generalists and were expected to find our specialty later in our rotations or after graduation. Again generalists, not specialists upon graduation.

-NP education seems to be less standardized (on line, two years full time, 2 programs integrated fully with PA programs) and generally shorter programs in hours. I have heard the argument that is because most applicants have RN experience. Again, my friends tell me this prior RN experience is sharply decreasing these days and also what is being asked of the new NP knowledge wise has increased significantly. Both professions are being asked to step into positions which were unheard of 15-20 years ago.

Another large difference between NPs and PAs is that all NPs specialize in their initial education. Again, PAs do not and are less restricted because of this. Pediatric, women's health, acute care, etc. Do you want to continue this or expand this should be another question to consider?

-What is interesting is that PA education, IMHO, will be taking a serious look at itself in view of PAs now looking for full practice authority/responsibility (we call it optimal team practice-as it comes with more), and also we are at the beginning of the formation of add-on clinical doctorates at PA educational programs. I think we have 5 programs now. We also have over 140 postgraduate specialty residencies where one can learn a specialty after graduation. Traditionally, PAs learned their specialty while working in a clinical position, many at teaching hospitals.

-My belief is that we will see many more residencies where both NPs and PAs will join together learning a medical specialty and associated skills.

Thanks for allowing me to share some thoughts. Whatever comes of this, I wish you luck in the future. I know that in both professions change will be a constant and we will have to learn from one another.

Dave

First, there is nothing to prevent RNs from becoming PAs. If they want the PA education and to be a PA, then just apply to PA schools! No one is preventing this.

Second, NPs can practice independently. PAs can't, and given how the AMA operates, they will fight PAs tooth and nail on this. NPs have struggled mightily to achieve full practice authority in 23 states and I am not aware of any states that allow PAs full practice authority. The VA also gave NPs full practice authority. NPs are at the top of their profession and PAs will always be second fiddle to MDs and DOs in allopathic medicine.

PA schools appear to vary in length from 2 years to 2.5 years, approximately. Yes, PAs are generalists and NPs are not. Does that make PAs superior? I don't see how. If an NP wants to only do Peds or Womens' Health, they have the option to do so. NPs also specialize in primary care or acute care. That is why there are fewer clinical hours in NP school, because NPs are not trying to learn everything. If we wanted to do that, we'd go to med school or PA school.

So let's take a look at clinical hours: Most BSN programs leading to an RN are about 1,000 clinical hours. Can't go to NP schools unless you have a BSN. NP schools are about 500-700 clinical hours depending on specialty. That's 1,500 clinical hours. In addition, most NPs do have clinical experience working as RNs - typically 1 to 5 years, which is 2,000 to 10,000 clinical hours. My research indicates PA school has about 1500 to 2000 clinical hours.

NPs can easily add or change specialities through OJT or post-master's certificate programs. It seems more efficient and cost-effective to me to get the NP in say AG primary care and then get a certificate in PMHNP or in acute care AGNP, etc., if necessary. There are a plethora of specialties and post grad training available to NPs.

Finally, over 100 studies have demonstrated that NPs provide as good, or better, care than MDs. If it ain't broke, don't fix it.

For all of you RNs and NPs that think PAs are superior, then just go to PA school!

[MurseJJ]

So let's take a look at clinical hours: Most BSN programs leading to an RN are about 1,000 clinical hours. Can't go to NP schools unless you have a BSN. NP schools are about 500-700 clinical hours depending on specialty. That's 1,500 clinical hours. In addition, most NPs do have clinical experience working as RNs - typically 1 to 5 years, which is 2,000 to 10,000 clinical hours. My research indicates PA school has about 1500 to 2000 clinical hours.

The argument of course would be that the clinical hours from the BSN program and RN experience, while healthcare experience, is not provider-level experience, which is what NP/PA school teaches.

[shibaowner, MSN, RN, NP]

The argument of course would be that the clinical hours from the BSN program and RN experience, while healthcare experience, is not provider-level experience, which is what NP/PA school teaches.

You have a point. However, NPs specialize and PAs don't. I've been looking at PA school curriculums and their clinicals cover everything - primary care, acute care, ob/gyn, peds, rural health, etc. First, in most NP programs there are separate track for acute care vs primary care for adult and geriatric and family nps. Second, some NP programs are focused only on peds, women, etc. Therefore, I fail to see how the number of clinical hours is inadequate for NPs given their specialization. I'm not aware of any studies showing that PAs provide superior care. Again, there is nothing stopping people from going to PA school if they think that is the better route.

[Dodongo, APRN, NP]

You have a point. However, NPs specialize and PAs don't. I've been looking at PA school curriculums and their clinicals cover everything - primary care, acute care, ob/gyn, peds, rural health, etc. First, in most NP programs there are separate track for acute care vs primary care for adult and geriatric and family nps. Second, some NP programs are focused only on peds, women, etc. Therefore, I fail to see how the number of clinical hours is inadequate for NPs given their specialization. I'm not aware of any studies showing that PAs provide superior care. Again, there is nothing stopping people from going to PA school if they think that is the better route.

I see the point you're trying to make but you have a majority of students pursuing the FNP degree and then not practicing in primary care, rather, treating it like a PA degree, thinking they can practice in any area they so desire upon graduation. So you have an FNP program providing 700 clinical hours and students thinking they are ready to practice wherever they want. Hours spent in a BSN program do not count, nor do hours working as a RN. You are not evaluating as a provider, diagnosing or prescribing, etc.

[cjcsoon2bnp, MSN, RN, NP]

No offense to the OP, but I think "broken" is a strong term. I do not feel that NP education is broken. Any program can be improved, and most quality programs (of any kind) constantly self evaluate to improve their product. I have to agree with the responder who stresses the importance of research and the avoidance of anecdotal experiences that may erroneously guide decision making. I have seen new grad NPs with plentiful nursing experience fail, and I have seen new grads with limited RN experiences excel. I have also seen the opposite occur. I have not stepped out of my fishbowl to research which is the norm. Instead I judge each NP by their actions. I learn from both. I "steal" techniques and knowledge from those I think are sharp and use this to develop my own style, and I learn what not to do from others. New NPs often bring new and fresh approaches and they keep me on my toes.

In terms of NP vs PA education I can say this. I didn't want to go to PA school. I may admire the rigor of their programs, but I don't see a better or worse final product. In my region all job postings are "NP/PA" or "PA/NP" but never one or the other alone. I work with PAs and man are they sharp, but so are the NPs where I work. We have to be. It is a high acuity, high volume setting, and we all turn to each for help. I was full time in school, but I was able to work. I was able to be part of my newborn son's life. My wife went part time to NP school which was a bonus for our family. BTW she totally kicks ass in her "nurse practishery" skills.

Let's continue to improve our programs and our practice, but strong language like "broken" is not helpful or accurate.

My .02

Ivan, I appreciate your feedback and did not create this post solely for the purposes of offending anyone or diminishing any education track. I understand the word "broken" may have come across a little strong, it was primarily for the purpose of drawing attention to the issue but to an extent I think there are some significant (but not insurmountable) problems with the current system that aren't being addressed much to the frustration of many current students (and their preceptors as well as nursing faculty members).

If I may offer a bit of background on myself to provide some context to my perspective. I'm a FNP student who works in the ED setting currently and would like to be an ED NP after I graduate at the end of the year. I'm a full time student at the moment and I work part time so I can have time with my wife and new baby as well. I'm currently doing an elective clinical in the ED and some discussion with my fellow students, faculty members and my preceptors helped to inspire me to write this. I'm not trying to discredit NP education at all and I am not disillusioned with it. On the contrary, I think we have come far as a profession and we have even more room to grow which will only help to secure our position in healthcare for years to come. I'm not suggesting that we make NP programs = PA programs because they come from two different models and there are some great things we do now that allows improved access to education for RNs who want to become NPs (part-time and distance programs for example). I'm suggesting that we look across the aisle at other disaplines and see what works for those programs and see if we are able to adapt some of the teaching methods and practice principles to help us be better equipped to serve our patients.

!Chris

[JellyDonut]

One does not make policy decisions based on anecdotal evidence and personal biases. Period. NPs who think that is good practice demonstrate a poor education and lack of understanding of evidence based medicine. Things change all the time in medicine, based on new evidence. For example, the JNC 8 changed treatment guidelines for HTN based on health outcomes. These decisions are not based on the personal biases of practitioners. And a practitioner that does not adjust their practice based on new evidence is a poor practitioner indeed. So, I would hire a new grad NP w/o RN experience who understands this over a new grad NP with 20 years' RN experience who practices based on personal biases and anecdotal evidence.

That said, I do believe more studies should be done on NPs w/o RN experience vs NPs with RN experience. However, the studies that have been done (and these date back to the 1990s) indicate that RN experience is not needed to be a good NP. (I did not cite older studies.)

In addition, there is a big difference between an NP in primary care vs acute care. I am in primary care and outpatient mental health care. I fail to see how RN hospital experience is such a big help in the outpatient environment. We are not administering medications, running IVs, or providing personal care to patients. RNs do not take extensive histories, perform diagnostic PEs, diagnose, or write medical orders. In addition, few RNs work in the outpatient environment - VS and basic intake is generally performed by medical assistants.

So, here is my anecdotal experience. I attended Johns Hopkins - certainly no "diploma mill." About half the class had worked as RNs (I did not have RN experience). The first semester of MSN NP program, we had a semester course in physical exam skills. I went into this PE course thinking the RNs would have a real advantage. Much to my surprise, they did not. I performed better than most of the students with RN experience with regard to PE skills.

Fast forward to my geriatric clinical in a SNF. My preceptor was a wonderful NP, but she was a bit miffed I did not have RN experience. So when my clinical faculty instructor from Hopkins visited for the mid term clinical check up, my preceptor voiced her concern. The JHUSON instructor asked for an example of how this had impacted my actual performance. The preceptor could not think of anything except I didn't know some acronyms. She also spoke privately with my JHUSON instructor. Afterwards, my instructor, who has been an NP for over 30 years, told me that she didn't know those acronyms, either! Well, they were institution-specific terms, so why would the preceptor expect everyone to know those terms? My JHUSON instructor, let's call her Betty, was very highly regarded and respected by the students and faculty. She was also a preceptor, in addition to being an instructor. She told me the studies supported NPs w/o RN experience, which is why JHUSON made the change to admit these students. She also said that she personally had never seen that RN experience was of much benefit in working with outpatient populations (although the RN experience would be an advantage in working with inpatients).

In addition, throughout my clinicals and in my courses, all my preceptors and professors praised me for my ability to take a thorough H&P and produce excellent documentation. They complained that few students, including those with RN experience, had these skills. My write ups were a pleasure to read. And the H&P is a core fundamental skill for an NP, PA, or MD, the foundation for successful diagnoses and treatment.

My last clinical rotation was in a specialty outpatient private practice. The physical exam skills were not taught in the BSN, MSN, or even in medical school. My preceptors were 2 MDs and they told me that even the residents they precepted did not know these techniques - these had to be acquired through OJT. Nor would these techniques be known by an RN unless she had worked in a similar practice, but these practices don't employ RNs - they use medical assistants. The MDs wanted to hire me, but I had to return home to California, plus I had a public service requirement, or I would have gladly taken the job. So they asked me to help them hire an NP or PA. They were adamant they did not want to hire anyone who had only worked inpatient. The only RN experience that mattered to them was if the RN had worked in outpatient/primary care. In fact, based on previous hires, individuals who only had acute care inpatient experience performed poorly in their practice. We did not have IVs, administer medications, or provide personal patient care. The only 2 pieces of equipment were the VS machine and a machine to perform specialized procedures. So they were happy to consider a new grad NP (AGPC or FNP PC) w/o RN experience. What did give a candidate an edge was NP or PA experience relevant to the job at hand, but those candidates were in very short supply.

RNs are not all created equal. Some are crummy, most are average, and some are outstanding. I see no advantage to NP practice from crummy or mediocre RNs - a motivated, intelligent, capable non RN would make a better NP.

And for all the naysayers out there who don't like NPs like me and also for the NPs moaning and groaning about an inability to find a good job: I returned to SoCal and have had numerous recruiters contacting me about jobs in San Diego and OC. I chose to take a job in Redding because that job had the equivalent of a residency program (rigorous OJT) and this position fulfills my public service obligation and also pays top $. All the jobs I've been considered for pay A LOT of $. So lots and lots of people and organizations want to hire people like me. One of my school mates, w/o RN experience, graduated as an FNP in May, and just got hired for a very competitive NP residency program in the SF Bay Area. All of my JHUSON classmates w/o RN experience were hired within 3 months of graduation for top $ and by very prestigious and reputable organizations. So, naysay all you want, I have a great job, I'm doing well, my supervisors are happy, my patients love me, and I'm laughing all the way to the bank!

Anecdotal or otherwise experience with practitioners is more relevant to me than a study of 10 years ago that does not address performance in practice. There are exception to all rules and some neophyte NP may perform brilliantly and I applaud that, but I do work in a specialty where the acute care background does influence my decisions on who we hire. I have never worked day one in family practice and would probably flounder horribly.

You seem to have a wee bit of a chip on your shoulder. I hope you can work through it, because 10 years post graduate none of where you were trained or what your background was will matter. If you have not developed skills by then everyone around you will notice.

[elkpark]

So let's take a look at clinical hours: Most BSN programs leading to an RN are about 1,000 clinical hours. Can't go to NP schools unless you have a BSN. NP schools are about 500-700 clinical hours depending on specialty. That's 1,500 clinical hours. In addition, most NPs do have clinical experience working as RNs - typically 1 to 5 years, which is 2,000 to 10,000 clinical hours. My research indicates PA school has about 1500 to 2000 clinical hours.

In the first place, it is entirely possible to go to NP school without a BSN -- witness the kazillion direct-entry programs that take people with no nursing experience or background whatsoever, ram them through a "quick 'n dirty" basic nursing education and put them directly into advanced practice programs. There are plenty of ADN-to-MSN programs out there, as well. And I don't have any idea what the proportions are these days of experienced-RN grad school applicants vs. direct-entry applicants, but I am certainly not willing to assume that it is true that "most" NPs have 1-5 years experience working as RNs. In the graduate program I attended, none of the direct entry students were working as RNs in school, and they all graduated and went into advanced practice without a single day of RN experience.

In the second place, am I the only person who's greatly amused that the same person who has been arguing that previous nursing experience is not necessary for advanced practice nursing, and that NPs without previous nursing experience are better clinicians that experienced-RN NPs is now pointing to NPs' previous nursing experience as making up for the fact that NPs have so many fewer hours of clinical education than PAs?

[BostonFNP, APRN]

My question for the readers is, do you think that any major change is needed to this system at all?

1. I agree with many other here that there need to be changed made to the NP education system on a whole. This change needs to be focused on identifying and removing sub-par NP programs; they, at best, do both the NP and entire nursing profession a disservice.

As far as identifying these sup-par programs is, itself, controversial. I would argue that all programs with board pass rates less than 80%, more students than preceptors, and all for-profit programs should be placed on a short warning and then removed if not remediated.

Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape?

2. Not all NP programs are equal. While hard data on this is scarce, as mentioned above, there are available metrics which could be utilized to identify these programs.

I would go on to say that no NP program (or medical school or PA school) makes any novice provider "fully ready". That is an unfair bar to set; much like medicine, nursing needs to have safeguards in place to ensure that novice NPs have appropriate supervision in their developing novice practice, especially in states with independent practice. Collaboration and mentorship are extremely important in the novice years.

Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)?

3. Someone recently said nobody knew that health care could be so complicated”. There are problems with education. There are problems with healthcare institutions. There are problems with individuals, or course. We need to focus on the things we can change in our own court, and lobby for things that need to change outside of that. Nurses are the largest body of healthcare professionals and, often, we don't do enough to drive change in a healthcare system that should be dominated by nursing influence.

[shibaowner, MSN, RN, NP]

In the first place, it is entirely possible to go to NP school without a BSN -- witness the kazillion direct-entry programs that take people with no nursing experience or background whatsoever, ram them through a "quick 'n dirty" basic nursing education and put them directly into advanced practice programs. There are plenty of ADN-to-MSN programs out there, as well. And I don't have any idea what the proportions are these days of experienced-RN grad school applicants vs. direct-entry applicants, but I am certainly not willing to assume that it is true that "most" NPs have 1-5 years experience working as RNs. In the graduate program I attended, none of the direct entry students were working as RNs in school, and they all graduated and went into advanced practice without a single day of RN experience.

In the second place, am I the only person who's greatly amused that the same person who has been arguing that previous nursing experience is not necessary for advanced practice nursing, and that NPs without previous nursing experience are better clinicians that experienced-RN NPs is now pointing to NPs' previous nursing experience as making up for the fact that NPs have so many fewer hours of clinical education than PAs?

I am not aware of any reputable direct entry MSN programs that produce NPs without a BSN. Direct entry MSN programs are clear that students will be able to apply for an RN and are considered clinical nurse leaders or some such. Such students must complete a post-master's NP certificate in order to became an NP, which usually takes an additional 2 years.

As for ADNs having bridge programs to MSN, so what? These folks are RNs. As long as the curriculum covers all the material required for a BSN and MSN, as the reputable programs do, that's fine.

I will address your other comments later.

[Corey Narry, MSN, RN, NP]

I am not aware of any reputable direct entry MSN programs that produce NPs without a BSN.

There are direct entry programs that do not award a BSN. Students graduate with an MS and that's it. Off hand both UCSF and Columbia's programs are set-up like that and I had to check their websites to confirm. FWIW, both are USNWR top-rated institutions.

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