Becoming an NP with little to no nursing experience??

[Blurr156]

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 certain practical reasons (including my union not helping to pay for it) I have been looking at other options, nursing/NP.

I was very excited to learn of a school near me that has a combined BSN/NP program for people with non-nursing bachelor degrees. I was about to start looking deeper into this program when a good friend of mine who is a member of an interview committee at a nearby hospital told me that I shouldn't do the program because I would have trouble getting a job.

The reason stated was because I wouldn't have been seen as having "paid my dues" as a nurse first.

Is this true?

I could understand why someone might feel that way about someone who went through this type of program never having worked in healthcare before. However, I like to think that to a certain degree I've paid my dues (I know it isn't nursing, but from a time in healthcare perspective).

My friend did say that I might be considered an exception to that rule. The program is at a VERY well known school and I was told by my friend even then it wouldn't matter. I was wondering what people here thought regarding this topic.

Thank you for any guidance you can provide.

[jjjoy, LPN]

In this alternate model of training up NPs directly without previous related experience, the question is how much education is necessary? Certainly, a different approach would be needed than that for RNs pursuing the NP role in an area in which they have years of experience.

I understand that FNPs generally learn to be holistic in regard to patient care, as opposed to just medically-oriented, however, they still will need some medical foundation. The training for a direct entry FNP would need to cover both diagnostic/treatment functions as well as the nursing angle. Though, since nursing theory is generally based on the premise that nurses don't make medical diagnoses, I'm not sure how that works into training up nurses who do in fact make medical diagnoses and can prescribe.

Is the basic idea that given a basic foundation (either pre-reqs or a related bachelor's degree) any mid-level provider can be trained up in 2-3 years versus the 5+ years for MDs (counting from the start of med school)? That could be the case. And if so, that will constitute a major shift in how people enter the practice of medicine (meaning diagnosing and treating disease processes). Interesting times!

[Barbiegirlnurse]

NP programs work to educate individuals to become safe to operate and enter the field. Each program begins with the assumption that everyone knows what they learned in undergraduate nursing school. BSN programs don't focus on one certain specialty. They are designed to produce a generalist nurse. So when entering a master's level NP school (not a bridge program), the curriculum is designed to teach students who are at the same level.

When I went to get my MSN, I went straight through after my BSN. I did it over three years so that I could work some and make enough money to pay for school. However, many of my classmates had been nurses for many years. They reported difficulty in having to change their way of thinking from a nurse to a NP, whereas I had an easy time adapting. Now that's not to say that there weren't certain instances where they felt their experience was helpful, but I didn't feel behind in any way by not having their expertise.

As for the comment on nursing theories not including the nurses making medical diagnoses, most nursing theories are either Grand theories or Middle range theories that are so broad in spectrum, they don't make the assumption that nurses are exempt from diagnosing. They are focusing on the bigger picture which is the health of the patient, the comfort of the patient, health promotion of the patient, etc. Although it is confusing there are still distinct differences in the practice of a NP and other healthcare professionals. The education of a NP and a physician is so vastly different.

I never went to become a NP because I wanted to practice medicine. I did it because I wanted to practice nursing at an advanced level, which includes some similar interventions to medical doctors. With similar goals it is hard not to have overlapping interventions. The education of the NP does include learning diagnostic tools and criteria for usage and learning how to prescribe. These concepts are integrated into the course work and they fit quite nicely with the utilization of nursing theory. Also, it is important to note that professional nursing practice is based on evidence based practice, meaning that the interventions we use and goals we set, are empirically based. Much nursing research, uses nursing theory as the theoretical framework of the research. This is how we come up with nursing (advanced practice nursing or RN) interventions. That is the process by which our practice is lead. It is not simply just following medicine. It is an exciting time for nursing!

[core0]

In this alternate model of training up NPs directly without previous related experience, the question is how much education is necessary? Certainly, a different approach would be needed than that for RNs pursuing the NP role in an area in which they have years of experience.

I understand that FNPs generally learn to be holistic in regard to patient care, as opposed to just medically-oriented, however, they still will need some medical foundation. The training for a direct entry FNP would need to cover both diagnostic/treatment functions as well as the nursing angle. Though, since nursing theory is generally based on the premise that nurses don't make medical diagnoses, I'm not sure how that works into training up nurses who do in fact make medical diagnoses and can prescribe.

Is the basic idea that given a basic foundation (either pre-reqs or a related bachelor's degree) any mid-level provider can be trained up in 2-3 years versus the 5+ years for MDs (counting from the start of med school)? That could be the case. And if so, that will constitute a major shift in how people enter the practice of medicine (meaning diagnosing and treating disease processes). Interesting times!

This model has existed for 40 years as the physician assistant model. Historically it has been a condensed form of the the physician training model with emphasis on producing a generalized medical practitioner. A similar model the anesthesiologist assistant has existed for 35 years.

The NP concept differs (at least in my opinion) because it has historically taken nurses with significant experience in the particular nursing specialty and given them additional instruction in diagnosis and treatment. This model started to break down in the 70's and 80's with the disappearance (for the most part) of the office nurse who had formed the backbone of the FNP program and the move toward shorter courses of instruction in the name of accesability. While some ANP fields such as the CMN, NNP and CRNA have kept a requirement for experience in the field for admission to their programs, others have not.

The fundamental question then becomes if there is no value in nursing as a prerequisite for NP school then what is the difference between an NP and PA except that by requirements NP's have less didactic training and less exposure to clinical elements of medicine. There has been at least one study (from Canada) and a number of position papers that call for extending NP clinical and didactic hours. Keep in mind that most of these papers and studies were done before the increase in direct entry NP programs. If you are going to decrease the nursing experience further then to what extent if any do you need to increase didactic and clinical experience.

The other issue is what amount of nursing experience is necessary. There are a number of studies on this mostly dealing with critical thinking (CT) skills. Leaving aside my own biases about critical thinking as a measure, the optimum amount of experience seems to hover around two years (with the exception of one study that showed a negative correlation with age and experience). Interestingly this correlates with anectdotal experience of nurse managers who frequently require (or desire) two years of experience for new hires.

I would invite those with opinions on the lack of worth of nursing experience to look at this paper which summarizes the 2000 NONPF meeting. While it is 7 years old many of the same issue were revisited in the 2007 meeting.

http://www.medscape.com/viewarticle/424117

David Carpenter, PA-C

[mvanz9999, RN]

But who EXACTLY is becoming an NP with less than 2 years of experience? If you read Barbiegirlnurse's post, she states "When I went to get my MSN, I went straight through after my BSN. I did it over three years so that I could work some and make enough money to pay for school."

That's 3 years of experience.

How about model-schmodel? This is the primary problem with change in healthcare. I have posted about this a million times before. Healthcare is a dinosaur when it comes to change. Statements like "this model has existed for 40 years" have no meaning, because they do not define whether that model is the most efficient or best method of training, but they do demonstrate the current paradigm of "we've always done it this way". Which is a ridiculous reason to continue doing something.

The report you provide indicates that a task force recommends a minimum of 1-2 years of clinical experience for NEONATAL NURSE PRACTITIONERS. Does this translate to other NP specialties? I don't know, the question isn't addressed. (As an aside both myself and Barbiegirlnurse will have the 1-2 years of clinical experience prior to graduation anyway).

The only other specialty addressed is Acute Care Nurse Practitioners, which speaks nothing about pre-admission clinical experience. It does recommend that more clinical hours should be incorporated into the training program.

[core0]

But who EXACTLY is becoming an NP with less than 2 years of experience? If you read Barbiegirlnurse's post, she states "When I went to get my MSN, I went straight through after my BSN. I did it over three years so that I could work some and make enough money to pay for school."

That's 3 years of experience.

How about model-schmodel? This is the primary problem with change in healthcare. I have posted about this a million times before. Healthcare is a dinosaur when it comes to change. Statements like "this model has existed for 40 years" have no meaning, because they do not define whether that model is the most efficient or best method of training, but they do demonstrate the current paradigm of "we've always done it this way". Which is a ridiculous reason to continue doing something.

The report you provide indicates that a task force recommends a minimum of 1-2 years of clinical experience for NEONATAL NURSE PRACTITIONERS. Does this translate to other NP specialties? I don't know, the question isn't addressed. (As an aside both myself and Barbiegirlnurse will have the 1-2 years of clinical experience prior to graduation anyway).

The only other specialty addressed is Acute Care Nurse Practitioners, which speaks nothing about pre-admission clinical experience. It does recommend that more clinical hours should be incorporated into the training program.

Healthcare is a dinosaur because it is ultimately about patient safety. You can propose your new model and try it out. A few hundred bodies later you find out you are wrong. If anything there has been insufficent examination of these new NP training models. Are they producing competent safe NP's. Nobody knows. You really don't know how many direct entry NP's are practicing or how many are passing their certification exams because the NP certification and training is so fragmented. If you think that I am the only one that this this then you should take a look at this:

http://www.nonpf.com/NONPF2005/Meetings/ThursdayPlenary.pdf

This is from the 2007 NONPF Conference

Reasons Presented for a Future APRN Model:

Lack of common definitions related to APRN roles

Lack of standardization in programs leading to APRN preparation

Initial accreditation/approval necessary

Blended programs with variable clinical hours

Inconsistent Master’s Essentials compliance

Programs graduating students that cannot be licensed

These concerns from what I have heard come mostly from the BONs who are concerned that in the light of day they cannot demonstrate that NPs meet the recommendations of the Pew commission:

Emphasized the need for regulation to be evidenced based, consistent, and protective of patients.

So your cavalier dismissal of the "model" is not evidence based. You have a feeling that you can provide care in a new model. Maybe you can, but proving it is another thing. Obviously at the very least the educators and the BONs are concerned with the product. An example of this is your "three years experience". While you will have been working for three years, three years of part time while going to school is not three years experience. From the educator side you can read this as the one of the major reasons for the DNP. From another point of view, you can make up for the greater experience that the early NP's had by extending NP training.

David Carpenter, PA-C

[jjjoy, LPN]

Is the basic idea that given a basic foundation (either pre-reqs or a related bachelor's degree) any mid-level provider can be trained up in 2-3 years versus the 5+ years for MDs (counting from the start of med school)? That could be the case. And if so, that will constitute a major shift in how people enter the practice of medicine (meaning diagnosing and treating disease processes). Interesting times!

By this, I mean that PA and MD programs generally require a certain level of prereqs that nursing programs do not. While nurses may have taken a full year of O Chem, or upper division microbio, most programs only require a one term intro course, whereas PA prereqs more closely mirror med school requirements. Since an NP can work at the level of PA without having to take the equivalent coursework and without having to invest several years gaining experience as a nurse in a specialty area, then that's a major shift in how one qualifies to practice at that level.

One can argue that those "weeder" courses are just that and not really necessary and I could certainly see that. Again, though, it's still a significant shift in required education to function in that scope as those courses are the ones that often disuade people from pursuing medicine (cuz if they don't perform well in them, they'll have a hard time getting into medical school.) Thus, if the direct-entry NP programs are successful, I imagine the competition for admission will only continue to grow.

[jjjoy, LPN]

My nursing school taught nursing theories involving nurses helping patients acheive a quality of life, or maintain the highest level of functioning, etc.

Certainly, prescribing treatments fits in there. I'd imagine, though, that when a facility hires an NP or PA, they want someone who will quickly dispense with the basic cases leaving the more expensive doctors' time to deal with more complex cases. They aren't hiring an NP for them to practice more holistically. Diagnose that ear infection and move on. Of course, it's ideal if one can assess the parents' situation, if the child is developing appropriately, etc, but I'd think a good MD or PA would do the same - they don't take that time because of limited resources. Traditionally, NPs could take more time with patients as they were paid less than MDs, but as NPs become more commonplace, I can imagine they get constrained by the same limits that conscientious MDs and PAs do.

Of course, bedside nursing doesn't fit the nursing school description either, does it? Nursing school acute care nursing is also about holistic care, therapeutic listening, etc when the reality is more about monitoring for changes in status and getting a slew of tasks done (medication administration, walking post-op patients, prepping patients for tests, etc) -anything else is cut out when time is limited (which is most of the time).

I apologize for my less than linear postings. I do find such topics very interesting!

[Barbiegirlnurse]

In response to the comment that PA's require a certain level of upper level classes in their prerequisite training, so do nurses. For a BSN degree, I took two whole years of prerequisites including statistics, Anatomy and physiology, advanced A and P, Microbiology, and chemistry, among other classes. The last two years, I took only nursing courses. (They are by no means easy). I am offended that someone would compare PA preparation to undergraduate nursing work and incenuate that BSN course work is much easier. If we want to play fair, lets not get into comparing apples and oranges because a PA is clearly not a NP. There are so many differences.

Additionally, when the paradigm shifts and all NPs move to the DNP, where will that leave PAs. Are there any professional organizations for PAs? To the best of my knowledge there are not. They are governed and protected by the AMA. Where will this shift in education level leave them. Nurses have their own professional organization, (ANA) that governs and sets the standards of practice. It is time for PAs to stop arguing with nurses and NPs and try getting some some autonomy from the AMA. This should be more of a concern for individuals in this field.

[zenman]

I respect your views and am very sorry you are having a difficult time understanding where I am coming from.

If you're responding to my one sentence..."You know someone is really going to call you on this one, lol!" ...then you have no idea of my views nor should you feel sorry that I am having a difficult time understanding where I am coming from since I made no mention of either.

CoreO did call you...partly on it in case you missed it.

MDs and PAs can enter with no experience because their clinical time is much greater. I don't know why you lumped pharmacists in your comment as they are a different animal.

[core0]

In response to the comment that PA's require a certain level of upper level classes in their prerequisite training, so do nurses. For a BSN degree, I took two whole years of prerequisites including statistics, Anatomy and physiology, advanced A and P, Microbiology, and chemistry, among other classes. The last two years, I took only nursing courses. (They are by no means easy). I am offended that someone would compare PA preparation to undergraduate nursing work and incenuate that BSN course work is much easier. If we want to play fair, lets not get into comparing apples and oranges because a PA is clearly not a NP. There are so many differences.

Additionally, when the paradigm shifts and all NPs move to the DNP, where will that leave PAs. Are there any professional organizations for PAs? To the best of my knowledge there are not. They are governed and protected by the AMA. Where will this shift in education level leave them. Nurses have their own professional organization, (ANA) that governs and sets the standards of practice. It is time for PAs to stop arguing with nurses and NPs and try getting some some autonomy from the AMA. This should be more of a concern for individuals in this field.

The PAs have an organization. It is called the AAPA

http://www.aapa.org/

They also have a credentialling organization called the NCCPA

http://www.nccpa.net/

The have a credentialling organization for programs called ARC-PA:

http://www.arc-pa.org/

Finally there is a organization for programs and educators PAEA:

http://www.paeaonline.org/

Notice all of these are independent organizations whose only job is described above. We have AMA representation on the NCCPA board and input in the ARC-PA. This is because we work with the supervision of physicians. This has been a productive relationship for forty years and there is no reason to change it. We are doing fine.

The reason that I have an interest in NP regulation is twofold. One is that I am doing work for my PhD on medical delivery systems and have received a lot of good information about NP delivery here. The other is simply self defense. The physicians are Godzilla. The NPs and nurses are the little japanese army guys shooting at Godzilla. The PAs are the japanese running around going "look Godzilla" (or the science guys trying to get Godzilla to go back into the ocean). Sometimes when the nurses piss off Godzilla he also takes out the PAs. It is my best interest to understand NP issues so I can figure out when they are going to piss off Godzilla.

You state the nurses have the own organization the ANA. Does the ANA represent only NPs or as they state do they represent all nurses? Does the ANA always have the best interests of the NPs at heart (I would point to the recent medicare billing changes as evidence that this is not the case)? I will point out that the NPs also have two other organizations the AANP and the ACNP that represent them. There are at least six certification organizations and two different organizations that accredit NP programs. Is it any wonder that the BONs don't have a lot of faith in the process?

As far as the paridigm shift with the move to the DNP I think that leaves the PA's just fine. You have mightily pissed off Godzilla. The BONs are moving toward independent practice only under the BON. This may be helpful, but when you remember that the great majority of NPs work for MD practices or hospitals under the direction of a physician this poses a quandry. The drive for independence may make them very leary to hire a DNP, locally we are already seeing this. PAs are just fine without independence thank you.

Going back to the topic I think that the DNP is a very good response to the lack of topical experience for nurses entering the NP field. The response from the PA profession (to use this as an example) to the increasing number of students without medical experience has been to lengthen the programs from and average of 24 months of full time education to an average of 26 months currently. Some programs have gone to 30 or 36 months in response to increased didactic training requirements. The DNP also answers the concerns of the BONs about training on the three P's. The problem that I see in examining different DNP programs is that there is still a wide variation in how these are being implimented. Also to train all these new DNPs you will still need the assistance of organized medicine. The drive for independence will probably interfere with this.

David Carpenter, PA-C

[jjjoy, LPN]

In regard to prerequisites...

my point is that many people choose against medical school because they didn't like or didn't do well in the math/science coursework.

Nursing programs' math/science requirement IS different. I'm not saying it's better or worse. I'm just commenting that there's a whole group of people out there who wouldn't consider nursing in any other context but would pursue becoming an NP.

Of course, there are other courses that they'll take in their pursuit to become an NP that MDs and PAs don't have to take.

Most med schools require the following science coursework

One year of Biology with lab

One year of Physics with lab (calculus is a pre-req)

One year of Inorganic Chemistry with lab

One year of Organic Chemistry with lab

Science requirements for direct-entry PMHNP at Vanderbuilt Univ

11 semester hours of Natural Science which must include: (3-4 courses)

-- human anatomy & physiology I and II

-- microbiology

3 semester hours of Statistics (1 course)

2-3 semester hours of Nutrition (1 course)

[Barbiegirlnurse]

To jjoy:

You bring up a valid concern with saying that some NPs go into the field, with no visible desire to become a nurse. However the two are so interconnected that it is impossible to be a NP, without the nursing process. NPs are advanced practicing nurses, and not physician extenders like some other mid-level practitioners. The education of a NP, even in a bridge program, has to include two advanced nursing research classes and nursing theory. These are in addition to the required nursing research for anyone from a BSN background. These classes are the ones that really define and validate the purpose of nursing and subsequent need for advanced practice nursing (in research, education, CNS, NP, etc.)

I can definitely appreciate how individuals from other disciplines could easily get that misconception. Historically nurses have been pretty silent and hesitant to speak up and let their presence be seen. This is also evident in the NP. NPs utilize many of the core concepts of nursing with each patient they see. However, most won't go on tell the patient that certain elements of their healthcare plan are based on nursing diagnoses and interventions (think :comfort, safety, body image, etc.) When I went to the National Conference for NPs a couple of weeks ago, the basics of nursing were evident in each workshop that I attended. It is strange that we communicate that way with each other, yet many individuals in the public would never have a clue that basic nursing care was even considered!

Your point is well taken. It really illuminates the general perception of NPs in the public eye. There is a wonderful book that deals with the miscommunications between nurses and the public, as well as the need for nurses to make their presence known in the media and political arena. If you are interested it is called From Silence to Voice by Bernice Buresh and Suzanne Gordon. It is such a great book for anyone in nursing (or interested in nursing issues).

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!

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.

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.

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.

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.