Brave or just stupid?

[Polly Peptide]

I am yet another mid-life career-changer. I've been afraid to even post on this board, as I believe I will get attacked by all the nursing traditionalists. But I would like the opinions of the experienced, and I can't get them without putting myself out there. Besides, if I am going to tread this path, I need to develop a thick skin.

I've wanted to work on the clinical side of healthcare for most of my life. Since I was a kid, I wanted to BE something – CRNA, radiologist, ER doc, pharmacist, nurse practitioner. The various options cycled through my mind, but I just KNEW I was going to grow up to be one of these. I've always been fascinated by the human body, disease processes, how the mind works, even down to nerve impulses and what causes that movement from neuron to neuron. I have always wanted to know the why.” Just what” has never been good enough.

I got to college and my dad didn't believe I could handle pre-med/medical school. It took the wind out of my sails. I didn't even understand I could apply for student loans. I did what he told me, got my business degree, and got out.

Within two years of graduating, I wanted to go back to school. However, I soon got married and my husband wasn't ready. Then I landed a lucrative job on the business side of healthcare, in a sales role. I liken this to golden handcuffs.” The money was great, but it made it more difficult for me to go back to school. I was the bread-winner.

Then we had children, making it nearly impossible to go back at that time. Sure, I could go, but it seemed extraordinarily selfish. Yet again, I put it off.

By this time, we had moved back home, to an area with a couple of very good nursing programs. In addition, there was a PA program and a very good B&M NP program, which included an option for those without nursing experience. That became very appealing to me, as the years flew by.

To make a very long story a little shorter, now that my children are a little older, I finally got it together and applied to that MSN program. I also applied to an Accelerated BSN program. I quit my job and started taking pre-requisites. Ultimately, I got into both programs. I was torn: the MSN program was my dream (highly-ranked and I could start doing what I really wanted sooner); but I had heard that having a BSN could be more flexible and perhaps better for me as it relates to getting RN experience first. As of now, I plan to attend the MSN B&M school this fall.

Here comes the BIG BUT – I read this board and it scares me. Am I being completely irresponsible by becoming a nurse practitioner when I have not been a nurse? I recognize my lack of experience as a nurse, believe me. I am, however, not green.” I have been a working business professional for 17+ years. While I absolutely do not have clinical experience, I do have something of value, in both life experience and business acumen, to bring to the table. As well, my work was in healthcare and I've acquired a fair amount of knowledge along the way.

I have a lot of confidence in the school that I've chosen. They are one of the top-ranked institutions, as well as my specialty being extremely highly-ranked. My preceptors are selected for me; the clinical hours are high; I have the option to specialize further (which adds to my clinical hours); I believe if any school is going to prepare me, considering my lack of experience in this area, they are one of the best. I also fully expect there to be a large learning curve. But am I being completely naïve?

This is something I have always wanted to do. I am no longer in my 20s or 30s. I don't want to spend years and years starting over with a BSN, and then going back later for another degree. It seems to be not only additional time but additional money. Is it reasonable to think that I can gain experience as an NP and become competent, even without RN experience first? I am more than willing to work hard, ask questions, know what I don't know, seek help from peers, and put forth diligent effort. In fact, I look forward to it.

The last thing that I think about is: I see so much written on this board about salary. I am actually in a position where I do not have to work. However, I will say it again – this is something that I WANT to do. And even though I don't have to work, I am not looking to do this for charity. I would like to be paid what I'm worth. I recognize that I will initially be an inexperienced NP, but that won't be the case for long. Am I crazy to think I can make $150K at some point? I see $80-90K and it bums me out. It seems ridiculous for the work NPs do. I am in the Southeast. I can go back to my old profession and make $150K easy. I just don't want to.

Sorry for the length. Would appreciate your advice.

[Jules A, MSN]

It is easy to be respectful and professional in the workplace, Jules. I have no problem doing so. I am not surprised at the reaction here, though. It is funny, however, that you would react this way, but when RNs are insulting all of our colleagues and speaking as to how fantastic they are, you seem to find no problem with it. I was speaking to the FACT that I have constantly had to keep RNs from seriously hurting patients, and when covering floors, feel like half my job is keeping those nurses from killing their patients. I educate and correct, with respect, but it does not mean that I do not remember what happened. Unfortunately, I entirely understand where RNs would and do lose autonomy. Since becoming an NP, I have been thoroughly disappointed at the lack of critical thinking skills. When those calls are not being directed my way, but going to physician who are seeing that on a more massive scale, it hurts the nursing profession as a whole and is utterly embarrassing. It then is no wonder they seek to limit NPs. Call me what you like, but I will not sugar coat this outside the workplace to make people feel better. Call me a coward for doing it here. That is okay, as well. I have a thick skin. I also habe the guys to call things as I see them...at least in an arena where I won't be fired.

My experience has been different and I am forever thankful for both my years as a floor RN and the nurses who now care for my patients 24/7. Although being a NP in psych is different in the tasks I perform my mindset and thought process are exactly the same. I always considered s/s of their diagnosis and what medications I'd like to see ordered or which of the available meds I would need to select for prn administration based on their presentation.

I think it is beyond smug that people think they can step into this specialty without solid experience and identify the subtleties if they haven't ever seen and compared multiple presentations of psychosis vs delirium vs SUD vs personality disorder vs trauma vs TBI etc.

As for my beloved RNs, they keep me abreast of what is actually happening, the many things I might not detect in the mere 15 minutes I spend face to face with my patients. They alert me to errors or omissions I might have made. They continually make me look good by ensuring everyone is alive each morning. I'm not saying there isn't the occasional mistake, as well all have made, or silly after hours call but I'd much rather they feel comfortable to contact me with anything than to let one major sign go unreported. I attempt to let them know how thankful I am for their vigilance and treat them to goodies regularly as a small gesture of my appreciation.

You make an interesting point about our reputation and my loyalty. I consider my psych nurses to be more my colleagues than the newly minted NPs with zero experience who were not properly prepared by our quickie NP education to practice competently after becoming certified. In my opinion they are the ones who are embarrassing us to physicians not RNs and LPNs.

[bnw6385]

I do fully believe admission standards are becoming more of a joke for NP school by the day, and we are overestimating the market which drives down our wages. The physicians talk about enrollment needing to increase while simultaneously lobbying against it to protect their incomes. I do think we should go to that extent, but the assembly line of NPs has to slow dowm, and admission standards must go up.

As for the thought processes between RNs and NPs, generally speaking, RNs are reactionary by training. Sure, they can and do see some disasters on the horizon and notify the provider, but they do not have to run down the differential and treat for the multitude of possibilities. That is not a knock on them. That is what the training of the RN is, and many are good at it. However, many should not even be licensed. I do not make my nurses feel their calls are unwelcome. That is simple customer service, and I want to be available the times they get it right. As for them being more my colleague than new NPs, that is still the "eating your young" mentality that runs rampant in this profession. Lobby the schools to make changes to admission requirements if you think they should change, but until then, treat the new NPs well and teach them what is necessary. Like it or not, you can try to separate your practice from theirs as much as you want, but you will be judged by their practice and the practice of poor NPs in general. Again, I will probably take a ton of heat on another statement, but I will make it anyway. Nurses should not be allowed into NP school, of any kind (except L&D nurses going to Midwifery), without at least one year in an ED or ICU. As others have stated, there is a level of assumption of knowledge base of the newly minted NP student. It is not insurmountable to make up for this as one goes, but I want the best as my colleagues and a limited number of graduates, not someone who just barely managed. Those shortcomings do become evident in the clinical arena. I acknowledged my shortcomings coming out of school despite my ICU experience and worked internal medicine for two years before going to work with Intensivists. The vast majority of students bypassing the bedside work will have to acknowledge some considerable limitations on graduation. I know I went over a couple things in this post, but it needed to be pulled back to the OP's inquiry.

[Ruby Vee, BSN]

Somewhat off topic, but someone has to say it. To the bedside RNs here, your work is much appreciated. I got out of that as soon as I could. I have been a critical care NP for 3 years now and an ACNP for nearly 6 years total. New grad NPs should be watched pretty closely, agreed. However, that is up to the NP, PA, M.D., or DO, the NP is collaborating with. It is your job to clarify orsers. There may even be things you can teach an NP because no one knows everything. All that being said, the things I habe seen and been asked by critical care nurses are truly horrifying and downright dangerous. These were the same CCRNs walking around acting like their you know what was top notch. When corrected, they got defensive as opposed to learning from errors, even though it was done respectfully. Granted, the floor nurses are leaps and bounds scarier and likely kill people on the regular, but for RNs to come in the NP section and act like they know it all and how to do our jobs better than many of us is...frustrating...to put it lightly. The job is totally different, barely even nursing anymore. The thought processes are entirely reversed. The knowledge base is miles beyond RN teaching. Sure, it takes APPs time to get there, but until you're there, the RNs like the one who called the OP a sellout (paraphrasing) just need to keep quiet.

I'm sure your attitude at work is extremely respectful to those CCRNs you've corrected and to the floor nurses who are likely to "kill people on the regular." Of course it was. Why, you sound like an paragon of tact and respect.

NOT.

[bnw6385]

Burn! I did not expect bedside nurses to take that for what it was, criticism of their lack of critical thinking and a call to improve. Nursing is not known for its thick skin and professionalism. My statements obviously do not apply to all, but they apply to enough.

[Wuzzie]

Bnw6385 do you realize you are contradicting yourself all over the place? You say that the work of the bedside nurses is "much appreciated" by you and then turn around and say that but for your presence those same nurses would be killing patients "on the regular" and that you are "constantly keeping RN s from hurting patients". What exactly ARE you "appreciating"? If you think the NP and nursing roles are "totally different" and "barely even nursing anymore" that the "thought processes are entirely reversed" and the the "knowledge base is miles beyond RN teaching" then why do you think there should be a requirement for an RN to have "at least one year in an ED or ICU" because, according to you, even the CCRNs are one millisecond away from killing patients if you weren't there to intervene. On one hand you sneer at RNs then on the other you say RN experience should be an absolute requirement for entry into NP practice. It makes no sense and honestly isn't reflecting well on you. But I don't think you give a crap about that so...

[bnw6385]

I don't care. You are correct. I appreciate that there are people willing to stay at the bedside, but I expect RNs to provide the standard of care. Many do. I am responding to the fact there are RNs on here who have no idea what it is to be an NP, dog all of the NP profession, and act like they walk on water. A dose of reality doesn't hurt. Concrete examples of poor RN practice:

1. Nurse had no idea WHY her pts were in the ICU at rounds. Had to go get her shift report.

2. ICU nurse had no idea what a CVP was or why we monitor it.

3. ICU nurse not monitoring urine output on a pt with AKI following cardiac tamponade.

4. Pt with elevated CK, multiple fasciotomies, acutely low CVP and Hgb, with falling BP. RN starts pressors and doesn't report to providers.

5. Floor nurse calls at 0300 to report acutely low BP of 110/45. Np BP change in days.

6. Could go on and on.

The point is that while bedside nurses may be able to bash NPs on an NP forum, it is time for a reality check. Your work is appreciated, but the providers are saving your tails and educating you sometimes without your realizing it. That goes both ways, unlike how some bedside nurses are making it sound. As for being respectful in the workplace, there is no excuse for any other attitude, despite the fact that I can empathize with the physicians now unlike any time before in my practice. This forum is the kind of place to bypass formalities and get down to the bottom line.

[bnw6385]

Many of these nurses criticizing me are the ones "sneering" at the lack of competence of their colleagues when they're taking report on transfers. You know you do it.

As for contradicting myself, working as an RN does not teach one to be an NP. It DOES give one exposure to duseases, patients, treatment modalities, and the workings of an Acute facility. These are important to starting advanced practice. That was the point.

My statements are not just me by the way. I have spoken to MANY high performing NPs who think the same. I just happen to be the one on here talking about it.

[Wuzzie]

Many of these nurses criticizing me are the ones "sneering" at the lack of competence of their colleagues when they're taking report on transfers. You know you do it.

I most certainly do not. And I have never sneered at an NP here or anywhere else. You are making a very large, inaccurate assumption about me without having a clue what my experience is. Just to be clear I started functioning at an extremely advanced level of nursing while you were still in elementary school and becoming an NP wasn't fashionable. Everything you've done I've done a thousand times just with kids who, by the way, have a much smaller margin for error.

[Wuzzie]

And for the record. The NPs responding in this thread have done just fine supporting their argument without being rude, inflammatory, obnoxious and denigrating. This allows for open discussion and shows a maturity level necessary for being successful in an APN role.

[Zyprexa]

Somewhat off topic, but someone has to say it. To the bedside RNs here, your work is much appreciated. I got out of that as soon as I could. I have been a critical care NP for 3 years now and an ACNP for nearly 6 years total. New grad NPs should be watched pretty closely, agreed. However, that is up to the NP, PA, M.D., or DO, the NP is collaborating with. It is your job to clarify orsers. There may even be things you can teach an NP because no one knows everything. All that being said, the things I habe seen and been asked by critical care nurses are truly horrifying and downright dangerous. These were the same CCRNs walking around acting like their you know what was top notch. When corrected, they got defensive as opposed to learning from errors, even though it was done respectfully. Granted, the floor nurses are leaps and bounds scarier and likely kill people on the regular, but for RNs to come in the NP section and act like they know it all and how to do our jobs better than many of us is...frustrating...to put it lightly. The job is totally different, barely even nursing anymore. The thought processes are entirely reversed. The knowledge base is miles beyond RN teaching. Sure, it takes APPs time to get there, but until you're there, the RNs like the one who called the OP a sellout (paraphrasing) just need to keep quiet.

Wow, you sound fun.

[Zyprexa]

Last but not least, my school is in the top 3 for ACNP programs. I am trying not to give TMI, though not sure if it matters. So when you say you can't see a top program allowing this...they actually do.

So I'm guessing your program is the MSN PreSpecialty Entry at Vanderbilt University? Three semesters for the RN (70 credits), followed by three semesters (75 credits) for the MSN ACNP - Hospitalist Track. An estimated cost of $197K. 700 clinical hours for the RN, 630 clinical hours for ACNP, 1,330 hours total. No RN experience required. And then you can prescribe, diagnose,and manage the care of acutely ill patients! Yay!!!

For those you who say, "How is this different from PA school, they go in without prior experience?" let me explain. The OP will complete 1,330 hours, but only 630 hours are at the advanced practice level. The other 700 are just for the RN license, which is about average for a basic nursing education. And we all know how prepared new grad RNs are for practice following graduation.

PA schools have over 2,000 clinical hours, all at the advanced practice level (in addition to a more rigorous medical education).

[Cococure]

I just need get some more popcorn ...this formum reminds me of the nursing station drama that happens ....it always gets personal and no one sticks to the topic at hand...smh