All Those NPs with No Bedside Experience

[Ruby Vee, BSN]

I'm sure I'm going to start a perfect storm of feces by saying this on allnurses, but here goes:

Nurse practitioners are getting dumber and dumber. There was a time when I would have used a nurse practitioner as my primary health provider without hesitation; when I would have even preferred an NP over an md. They were more careful, more thorough, and listened better. There was a time when I preferred dealing with nps over residents as providers in the ICU. They were more careful, more thorough and listened better. Those times are past.

I'm not saying I don't work with some good nurse practitioners. I work with twelve of them on a regular basis, and three of them are excellent, one has potential. The rest . . . Not so much.

It's not just that they're young and inexperienced. Youth is fleeting and inexperience can be cured. It's that they're not careful, not thorough and they don't seem to listen. Worse than that, at least six of the eight seem to believe that they're "Better than bedside nurses". Smarter, better educated, more aware of what's going on with the patient (from their vast experience and the copious time they spend with their patients in between shopping and doing crosswords on the internet) and better able to communicate with the attending physician than we are.

I don't deny that a nurse practitioner has a master's degree. But so do I, so does bethany, and so do some of my colleagues. One even has a phd. (OK, so it's in literature, but she has a phd.) yes, nps have more nursing education, but it seems that they have so little bedside experience they don't even know what they don't know.

The most dangerous nurse is one with about two years experience. They've got enough experience to be competent -- barely -- but not enough to know what they don't know, and too many of them think they know everything. Unfortunately, that's about the stage most of our nps were in when they graduated from their MSN programs and became nurse practitioners. So what we have in the ICU is eight nurse practitioners with two years or less of bedside experience, all of whom think they know everything they need to know about being a bedside nurse and most of whom think they know more than the experienced ICU nurse they're working with. But they don't.

Youth is fleeting and inexperience and ignorance are curable, but arrogance is dangerous. An NP who is so impressed with the initials after her name that she won't listen to the RN who has been at the bedside for ten years or more and who has been there, seen that is vastly more dangerous than a bedside RN with two years of experience. Even a two year nurse who is convinced she knows everything. Worse, the brand new nurses will listen to the NP with all of the initials after her name, whether or not she actually knows what's going on, before they'll listen to the experienced bedside nurse responsible for their orientation.

What brings on this rant, you ask? The NP who ordered amiodarone for the patient with the paced rhythm because she was so sure it was ventricular tachycardia. "We don't need to defibrillate him because he has a good blood pressure," she said self-importantly. "But let's load him with amiodarone." she wouldn't believe it was a paced rhythm when I showed her the rhythm strip with all those cute little pacer spikes. She wouldn't believe it was a paced rhythm when I showed her the 12 lead. Unfortunately, this is just one in a series of similar incidents.

About the amiodarone -- she did believe it was a paced rhythm when I showed her what happened when I turned off the pacer. (lots and lots of cute little pacer spikes and none of those wide qrs complexes she was so sure were v tach.)

They want to be nurse practitioners -- OK. That's great. But please listen to the experienced RN at the bedside. She just might teach you something.

[red2003xlt, LPN]

It's the race for cash; patient care and safety are secondary

[Tait, MSN, RN]

I understand your frustration Ruby and as always you have put it eloquently.

However...

there is a reason NP's do not have much bedside experience anymore and it is because we are burning them straight out of nursing. Increased patient loads, dramatically skyrocketing acuities, steadily decreasing resources, complete lack of mental health benefits, increased legality, and lateral violence are chasing new nurses out as fast as they can fill out the application to go back to school.

There are many facets behind the green NP other than just their lack of experience. Go back a few decades and nursing was a solid profession that you got into and stuck with (tell me you don't feel that vibe from nurses who have been in the profession for longer than say fifteen years). Today, to be honest, if you spend too much time at the bedside you risk depression, OCD, anxiety disorders, and all the health complications that come with it.

Now, of course, there are soon to be NP's like my good friend who simply are using nursing as a stepping stone to get where they want to be. That is a goal, and sometimes the quickest route isn't the best, but it gets you there. Hopefully there will be a strong nurse who will gently grab these new NP's by the chin and help guide them along their path. Because you can't change the trajectory, only try to help them navigate the obstacles.

[KeepItRealRN, BSN, RN]

All I can say to the OP is AMEN!

[JustBeachyNurse, LPN]

There are also the direct entry MSN/NP programs that only require a bachelor's degree no nursing experience or license. Recently encountered a APN who was a CPA then decided he wanted to be an APN. Went straight into an APN/MSN program. Apparently the CPA turned APN found a job working with a pulmonary group. He kept stating that he thought a 60 year smoker (unfiltered cigarettes a couple of packs a week, last cigarette was less than 18 hours prior) should have a pCO2 of 35 (pt was in respiratory distress, compensated respiratory acidosis and had a pC02 in the 70's). Could not explain whether the current diagnosis was CHF, COPD, or pulmonary edema when asked by a family member, just stuttered and walked away from the puzzled (and very worried) family members after asking if they thought the patient should be intubated. (It was obvious the BiPap wasn't working as the abdomen was clearly distending and pulse ox was still in the 80's) . Clearly had no significant bedside experience. Thank goodness for the experienced med/surg and ICU nurses stepped in helped the family and called a rapid response.

[SanFranSRNA]

Just curious...what do you think about PA?....no bedside experience..yet function similarly to NP.

[apocatastasis]

I'm an NP student, with slightly over 2 years of experience, and I resent the OP's post.

I say this as a ICU nurse who, with a measly YEAR of experience, had multiple opportunities to save the asses of SEVERAL "experienced" nurses both in ICU and in rapid responses on the floor.

I can also say this as an ER nurse who has had to take on facets of care of critically ill patients for allegedly "experienced" ER nurses who, for instance, couldn't use the IN-LINE SUCTION on a VENT. Don't even get me started on how these "experienced" nurses don't know how to properly start or to titrate nitro drips, pressors, or propofol.

I get the gist of your vent. A person is a fool if they say or think they know everything. This is independent of how much experience they have. Do not paint us all with such broad strokes.

[Jules A, MSN]

In my NP class there were people with no experience in the speciality and if that isn't shocking enough there was even one who had not even worked as a nurse because she went right from the quickie MSN to NP. :uhoh21:

[apocatastasis]

Also, the sword cuts both ways. There are a couple of "experienced" nurses (decades of direct patient experience) and they are on the whole TERRIBLE at learning to be providers and not bedside nurses.

RN experience is nice, but working as an NP is a very different role and involves a very different skill set and approach to the patient. I'd be damned if I let these nurses manage someone close to me's medications compared to the psych NP students who get it, even though some of them have even less experience than I do.

[Jules A, MSN]

I'd be damned if I let these nurses manage someone close to me's medications compared to the psych NP students who get it, even though some of them have even less experience than I do.

Personally I'd rather have a marginal psych nurse with some floor experience decide which psychiatric medication to give me in crisis than a new graduate NP who hasn't ever given any of those medications or seen the effects.

[apocatastasis]

Personally I'd rather have a marginal psych nurse with some floor experience decide which psychiatric medication to give me in crisis than a new graduate NP who hasn't ever given any of those medications or seen the effects.

If you're talking about me in particular, I have administered pretty much all of the major psychiatric medications many times.

I hope that this "marginal psych nurse" is good at diagnosis and aware of drug interactions, which, to be frank, are not taught to RNs. Hope they check to see you don't have any liver, kidney, cardiac issues or seizure history and are aware of medical differentials that you could have that can masquerade as psychiatric conditions. Because that is a subject that is comprehensively taught in RN school. Right?

Bedside experience is all well and good and useful, but much of it is not something that can simply be picked up by a "marginal" nurse during shifts on the floor.

[joanna73, BSN, RN]

Where I live you are required to have 2 to 3 years bedside experience before entering the program, and at least 2 reference letters. I have no idea why people would consider an NP program without prior nursing experience. It makes no sense, and how good can they possibly be without the hands on?