Beyond Bedside? Advanced Practice? Really?

Nurses General Nursing

Published

Call me naive, but maybe someone could explain something to me:

Why, in our profession, is it considered advanced NURSING practice to leave the bedside? The ADN goes in, does a shift, cares for his or her patient load, uses all their competency to care for real people in real beds.

But then the BSN comes along and wants to be manager, and that's considered "more professional." But that BSN isn't at the bedside anymore.

But then the BSN becomes an NP, and now they're practicing low-skilled medicine, which isn't nursing at all! But they are the "Advanced Practitioners?"

I understand nurses at the bedside. I understand, perhaps older nurses who can't do the physical stuff anymore, getting advanced degrees so they can teach nursing. And I get that someone on any unit, has to be the manager. But all of that focuses on the support and instruction of the bedside nurse.

Seriously, wouldn't technical nursing certifications like ACLS and CCRN (or the other specialty certifications) really be what makes a nurse "Advanced."

I mean if my name looks like this:

EGspirit, MS, APRN, ACNS-BC, CEN, FAWM, FAAN

am I even a nurse anymore?

Why can't caring be the profession and leave medicine and surgery to the doctors, and the Ph.Ds to the Nursing school professors? Wouldn't being really good at running a code or starting an IV, or even being really effective at feeding and bathing a patient be the definition of the advanced nurse?

Why in our profession are we always running away from the bedside? I mean, why be in the profession?

Just wondering and looking for opinions on the matter. :wideyed:

Specializes in ER, Corrections, Mental Health.

So many mis-spellings. Sorry guys

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It makes the RN look "less educated" in the eyes of the patient......after all, they don't have "advanced" in the title.

The RN **IS** less educated. That's a fact. Those of us who haven chosen not to further our education (and that would be me, too) have to own our choices. It does NOT mean the bedside RN is incompetent, but let's not pretend that those who went on to pursue and obtain advanced degrees haven't learned a good deal more than what an associate's or bachelor's degree can teach you. Experience counts, of course, and advanced certifications reveal additional expertise on the part of the RN, so those of us who have continued to delve into our specialties should be able to feel good and confident about that without denigrating others who have advanced their education and scope as well. It's not a contest.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
The RN **IS** less educated. That's a fact. Those of us who haven chosen not to further our education (and that would be me, too) have to own our choices. It does NOT mean the bedside RN is incompetent, but let's not pretend that those who went on to pursue and obtain advanced degrees haven't learned a good deal more than what an associate's or bachelor's degree can teach you. Experience counts, of course, and advanced certifications reveal additional expertise on the part of the RN, so those of us who have continued to delve into our specialties should be able to feel good and confident about that without denigrating others who have advanced their education and scope as well. It's not a contest.

At my hospital, on your name badge it also identifies BSN/MSN etc (along with our first and last name, which I'm not a fan of). When I was still in orientation, a patient noticed my name tag and made a comment about what a great nurse I must because because I have my MSN. I did mention that my MSN is in management, and doesn't really improve my ability to provide their care, but I hope that they would be happy with the care I could provide either way. It surprised me that someone would really zero in on the letters on my badge and quickly make assumptions about my competence. That's too bad because there are some nurses on my floor without an MSN that can run rings around me, I hope to some day be as good as they are. It's not about alphabet soup after your name, it's providing the best care.

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So why nursing? Why not business or finance or law? But whatever. I've worked around nurses who won't even give PRN pain meds when they're due, because it means they will have to chart it. I've watched many nurses ignore patients stewing in their own sh.. and pi.. , and nothing I say is going to change the world. And I'm sure not going to do it with this post. But for the love of God, why not go into insurance or teaching high school?

Because I like science and medicine, and I like helping patients. I enjoy being a nurse, I don't mind getting my (gloved) hands dirty. I'll jump right in and change a patient, make sure they are clean and comfy, and help other nurses pass meds. But maybe I don't like being chronically understaffed and mistreated. It takes its toll on a person after awhile. To those nurses who have worked bedside for decades, I absolutely respect you. I know it's not something I'd want to do for a long period of time. We need nurses who work in insurance review, home healthcare, pediatric offices, advanced practice, dialysis, case management, etc, in addition to bedside. None of those jobs are easy, but they may appeal to nurses who have different strengths.

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Specializes in Critical Care.

Honestly most doctors I've worked with are decent, smart and treat the nurses and staff with respect. I've only encountered a few arrogant ones over the years or ones that need anger management.

I have great respect for doctors, they work long hours, and have spent many years in school. I had no idea how hard it is just to get chosen for the specialty you want and the years after med school. There are more med students then residencies available so some aren't accepted and our left in limbo.

Plus something as simple as CP has a differential diagnosis of 5-7 different things. That is a lot of responsibility, it can occasionally even be a sign of cancer. Who knew?

I really haven't encountered arrogant NP's, although many are newer grads and exude more self confidence than I did when I was a new grad. I remember working with one of the first RN's to become an NP and listening to her thought process about a patient's diagnosis after she was in school and I could see the difference in knowledge. I respect NP's and studies have shown their care is as good as a primary care doctor.

NP's were started as a way to provide medical care to under served areas in the country and the PA programs were developed to help medics transition from the military and use their skills. It's true doctors and PA's have more clinical hours than NP's, but usually NP have been working as RN's so have some relevant on the job experience.

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Because I like science and medicine, and I like helping patients. I enjoy being a nurse, I don't mind getting my (gloved) hands dirty. I'll jump right in and change a patient, make sure they are clean and comfy, and help other nurses pass meds. But maybe I don't like being chronically understaffed and mistreated. It takes its toll on a person after awhile. To those nurses who have worked bedside for decades, I absolutely respect you. I know it's not something I'd want to do for a long period of time. We need nurses who work in insurance review, home healthcare, pediatric offices, advanced practice, dialysis, case management, etc, in addition to bedside. None of those jobs are easy, but they may appeal to nurses who have different strengths.

This was perfect. We all have different strengths and weaknesses, so why are nurses getting attacked for finding something within the field that works better with their personality? For instance, I'm a more quiet person and I don't build relationships easily. I personally don't think I would be a good fit in a nursing home because from my clinical experiences, it seems as though the elderly seem much more at ease with people who are friendly and can easily see them as family because... Well, they kind of are their new "extended" family now.

But I don't think that means that I shouldn't be a nurse. I absolutely love science and human physiology, and I'd love to be challenged and I think it's important for me to have a career that's mentally stimulating. I think that I have certain qualities that would prove to be beneficial in the field of nursing, even if it's not always at the bedside.

And if I have it in me to want to further my education so that I can find a better niche in nursing (as there are many) then you better believe I'm going to and not hold myself back because some random person has a pre-conceived and ignorant notion of what he thinks I should be doing with my life to fit his own image.

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Specializes in Critical Care.

I know all about the TEAM. And I recognize your need to fall back on that. But I'm not talking about the team. I'm talking about what constitutes a truly "advanced" nurse, not what constitutes a pharmacist or a social worker or a housekeeper.

An article I recently read in a nursing magazine. The editor wrote, and I paraphrase: "Nurses start at the bedside, but some choose to increase their professional abilities by becoming an advanced practice nurse, or even a DNP." And of course, this editor had all the initials after her name.

So, I got to thinking about what really was a professional nurse, what was a nurse, and why is it that everyone you talk to is either going or planning on going to NP school.

I know the answer: Nursing is hard. But take out the hard and it's not great anymore.

There are ways to improve morale and keep more nurses at the bedside. A no lift environment which the VA has achieved with ceiling lifts. Safe patient ratios with adequate nurses and ancillary staff such as CNA's, transporters, IV nurse and stat nurse and a hands on supervisor.

I remember when we used to have good staffing and resources, the only thing we didn't have was a no lift environment. Patients have gotten heavier over the years where 300-500 pound patients are much more common now whereas they were rare when I first became a nurse. We finally have hover mats, but have lost all the other resources and now have higher patient ratios with increased acuity due to new treatments, meds, technology that keeps people alive longer and sicker.

More nurses would stay at the bedside if working conditions were improved such as a good strong union can help with or mandated staffing ratio's like CA.

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Specializes in ER, Corrections, Mental Health.

The RN and APRN are two very different roles. It does not mean that the RN is less educated than the APRN. You can have an MSN and not be a practitioner. APRNs, in my opinion, do not provide nursing services, they provide medical services, and we are lucky to have them to do so. The fact remains, however, that the core of nursing was never meant to include writing prescriptions and making medical decisions-that was left to the physician staff. When APRN practice began, they shifted from practicing nursing to practicing medicine. I agree that there is a difference between an RN and APRN, but disagree in the titles, and the statement that they have more education, because that may not always be the case. In fact, if you had a certified wound care RN discussing a patients plan of care with an ER APRN, the RN would be the more advanced clinician here. They would have more working knowledge of the situation than most ER APRNs, so the fact that the APRN has "more education" to me is an invalid point......their education is different. I think most APRNs would agree that they are practicing medicine, not nursing. Nursing is at the bedside for hours during the shift (the NPs are usually only at the bedside for a few minutes). Additionally, the RN staff is coordinating procedures, meds, etc, which the APRN is not doing......instead they are writing admission and discharge orders, consulting with cardiology, etc......which are all aspects of practicing medicine, not nursing.

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I think that it is very confusing to patients when a nurse walks in the room and tells them they will be the nurse providing their care, then comes the NP and explains to the patient that they are the advanced nurse. It sore of does make the bedside RN look less competent. I think that NPs are really providing more medical services to patients, not nursin services and I think it takes away from both professions to refer to NPs as advanced nurses. It makes the RN look "less educated" in the eyes of the patient......after all, they don't have "advanced" in the title. It also lessens the importance of the NP role because patients equate them to being "just a nurse." In my setting (ER), patients being cared for by an NP often ask when they will see a doctor. When I explain that they have seen an APRN, they seem confused and will sometimes question why they have only seen a nurse? The provider status is not there in the title of "nurse practitioner." If you think about, any level nurse, be it LPN, RN, BSN, is a practitioner of nursing. I think APRNs need a title change, maybe something like Advanced Clinician or something of the sort. The nursing profession has become very confusing with the role titles. As I said, anyone that is a nurse is technically a practitioner of nursing. I think to preserve respect for both professions we need a title change. Also, I feel that APRNs do not really offer expanded nursing services, they offer medical services. Nursing was never about prescribing medications and ordering CT scans, so to equate that to expanded nursing practice is not very accurate.....those are medical services. I think the APRN is very important, just as the RN is as well, however I do agree that at times it does seem like that to refer to an APRN as the advanced nurse is a bit of put down to the RN staff.

I have never, in my >30 years of nursing, heard anyone introduce her/himself to a client as the "advanced nurse." It is always (in my experience) "nurse practitioner," "nurse anesthetist," "nurse midwife." Not "the advanced nurse." For all the time and effort people here spend fretting over these kinds of issues, this and whether or not advanced practice nurses with doctorates should be able to be referred to as "doctor" so-and-so in the clinical setting, I haven't run into any actual clients who have difficulty figuring out who is who and what the different individuals' roles are.

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Yeah I agree the whole "advanced nurse" title seems to be an issue with nurses and nobody else.

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Specializes in Adult Internal Medicine.
There's nothing logical about any of this. It's my opinion. It's what I feel should be true.

This about sums up the issue.

Its not about what is true or not true, its about what the OP feels should be true . Facts, evidenced based practice, ethics, the scientific process yields to individual beliefs, as ungrounded in reality as they may be.

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This about sums up the issue.

Its not about what is true or not true, its about what the OP feels should be true . Facts, evidenced based practice, ethics, the scientific process yields to individual beliefs, as ungrounded in reality as they may be.

Exactly. And where are we? Are we writing policy for the state legislature? No. We're in a social media forum.

But I wouldn't be so quick to denigrate my "feelings" on the subject, for as long as nurses "feel" punked by MDs, they will continue to try to pretend they are "just as good as" MDs and will debase themselves as they seek MD approval. And THAT is the worst possible path the nursing profession can walk.

There is no shame in leaving nursing to become a PA. There is no shame in leaving nursing to go to medical school. But there is a real shame in feeling that nurses are "less than" doctors just because they take "medical" orders from doctors. Nurses are the profession of caring. MDs are the profession of applied science whereby they diagnose and prescribe or perform treatments. But when nurses try to play catch up to MDs they are admitting that their profession is less than the MD profession, and absolutely nothing could be further from the truth.

In fact, medicine will always fail. People will all die eventually. Nursing, the care we give for those who cannot care for themselves, never fails. MDs have to act like asses to nurses and pretend to be superior, because deep down they know they cannot give people what they promise. They know they cannot save a life.

We should not have NPs in the nursing profession. They should should be a completely separate profession on the side of medicine.

Because remember, there are two elements in healthcare, two primary actors: the MD and the RN, and everyone else is an assistant to one or the other.

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