Brave or just stupid?

Polly Peptide, BSN, MSN, RN, APRN · Apr 25, 2017

I so appreciate all of the responses. I do take exception to one, however - I don't feel that I have an attitude of being better than an RN without an advanced degree (or will be). At all. That was the very point of my post - whether or not I would even be capable of performing in an NP role (at least initially) without the valuable experience I would be lacking. I am already dreading the experience of fending off attitudes directed towards ME...the whole "who does she thing she is" stuff. I just want to keep my head down and learn...from more experienced nurses, fellow NPs, PAs, docs, CNAs, whoever is willing to offer me some direction. I feel you have to have the right combination of characteristics to approach this - humility, most certainly; willingness to learn; perhaps even an appropriate level of fear. But I think if you lack confidence (totally different than arrogance, mind you), you are going to have some issues. One poster mentioned inexperienced MSN participants running from procedures and fumbling with answers with attendings. You have to be willing to put yourself out there, too.

The comments about familiarity with patients and observations of pain levels, etc., just being aware of those subtle changes in condition and what they mean...I respect that. I most certainly have not 'been there' like experienced RNs have.

I've been accepted into the ACNP specialty, and as someone said, the program must believe they have ways to overcome the lack of experience in non-nurses...but I wonder what types of responses I would get if I was considering primary care? That's no cake walk either. As the gatekeepers of health care, they have to be able to recognize a very wide variety of disease processes, and differentiate between the everyday stuff and those things that need a referral.

Thoughts about this? I can potentially change my specialty after the first year. Although my interest does lie with the higher acuity or at least more complex stuff.

Polly Peptide, BSN, MSN, RN, APRN · Apr 25, 2017

I think your salary wish for your region is unrealistic. Salaries are rarely that high here except maybe for CRNA's.
Now, I want your previous job. How do i get a non-medical job with that kind of pay?

Sell your soul to the devil. Sales. For the big health insurance companies.

Really, I'm grateful to them though. It's been a great career.

Polly Peptide, BSN, MSN, RN, APRN · Apr 25, 2017

Excellent question and there are a couple of articles out there indicating there isn't an issue, "nursing research" of course, however I believe it is too early in this new initiative to have enough data. Unfortunately the trend is now to admit anyone who can fog up a mirror held under their nose and pay the tuition so my guess is the next 5-10 years is where we will see the problems although I consider negative outcomes, short of death or extreme disability, difficult to quantify. And patients LOVE their NPs because they hold their hands, and mop their brows with little concern of their actual skill set.
I've posted about this in the past but how would one discern if a patient saw NP with c/o ear pain, received antibiotics and actually didn't have an ear infection? Or a patient who comes in with a rash that gets treated for eczema without effect, then tinea corpus, then finally scabies which they had from the onset. The patient didn't die or likely suffer disabling harm so would this even be documented or monitored? Would the insurance companies pick up on this eventually? In psych I frequently see egregious regimens for people with substance use disorder and bipolar disorder. Bipolar is a common train wreck that inexperienced clinicians seem to favor for people with SUD, personality disorders and most concerning children who have trauma hx and horrible home lives NOT bipolar disorder. Do your first intake on a NP's patient who is 9yo with a bipolar disorder diagnosis on a stimulant, alpha blocker and lithium, which has blown out their thyroid, minimal therapy and living in an unsafe home and get back to me on how dangerous inexperienced prescribers can be.
My opinion and one that clearly isn't shared by the universities who are interested in retaining students and therefore tuition is overall the odds of being a better clinician would be more favorable if the person actually had nursing experience which if anyone cares to remember is why our short nurse practitioner education was originally approved. PAs and of course physicians have significantly more clinical hours.
Overall I think its too early in the new trend of everyone and their poodle becoming a NP for us to tell exactly how things will go but one thing is certain, our wages are going to continue to tank as the supply exceeds the demand and those with zero business sense accept lame offers. Like you and others have said there are certainly outliers however I would disagree that NP clinical requirements of 500-1000 hours is sufficient to take a person from zero medication knowledge to competently diagnosing and prescribing regardless of how well regarded the university is so imvho you will need to be the exception rather than the rule.

If nursing organizations are the ones publishing the articles, then there is a conflict of interest.

It would be particularly helpful to see research done for the very purpose of determining the best education model for "midlevels" (still don't know what to think about that term, but whatever works) - outcomes for PAs (requiring patient hours for admission to schools and much higher clinical hours) and NPs (differentiating amongst those who had prior RN experience and those who did not). And they will have to delineate by years of experience in the field as well.

I get your point that it might be difficult to actually evaluate - antibiotics prescribed for a viral infection will "appear" to work eventually. But many outcomes actually are measured by insurance companies. If a patient keeps returning to the doc because their scabies aren't improving and the NP keeps prescribing the wrong thing, that will be documented. If someone is admitted to the ER because a condition wasn't appropriately managed or caught, that will be documented. Re-admission rates are watched like a hawk. Using episode of care and shared-savings type reimbursement models encourage providers to use "best practices", and that is all managed by insurance companies. I know it makes the providers crazy, but for the purposes of running a study...maybe it could be useful.

I imagine psych is far more difficult to evaluate in this way.

Anyway...I am curious. For myself and all of the providers coming out of these institutions and the patients we will end up serving. I have an interest in not diluting the market with over-supply and keeping quality high too.

michaelg510 · Apr 25, 2017

I'm in the same boat! I think either way you'll do fine but there's probably benefit to being an rn first.

la_chica_suerte85, BSN, RN · Apr 25, 2017

Serious question, because I think you are right - do you know if there have been any studies done on the safety and/or efficacy of NPs both with RN experience and without?

Yes, and the results have been conflicting. This may be largely due to the type of experience RNs had prior to enrolling in a graduate program. Another variable to consider is what happens after school. For example, though I'm a BSN, I work with people who are entry-level Master's-prepared and, though I went to a relatively, um, "less rigorous" program than they did (though, I did a ton of independent learning and made my own strong knowledge base), I feel that my prior experience working as a nursing assistant on the same unit helped me take more advantage of my orientation during residency. There were little details I didn't have to worry about because I already knew these ins and outs and the learning curve was much different though, overall, the residency program was key to me not feeling like I'm going to die every night I go into work. My transition into the role of RN was much more fluid and my foundation is strong. With that in mind, many hospitals are looking into orientation programs similar to the entry-level RN residency programs because these seem to help with transitioning into the role of NP after graduation. That is something you will want to look into during school so that you can find a hospital that is forward-thinking enough to support its NPs in a way similar to an RN residency.

Barnes, H. (2015). Exploring the factors that influence nurse practitioner role transition. The Journal for Nurse Practitioners, 11(2), 178-183.

Also, info on the job outlook and salary expectations:

Nurse Practitioners

If I were you, I would go aBSN, get some experience and then go DNP. But, since you're already accepted into an MSN program that is well-regarded (which, really doesn't mean much -- it's up to you to get what you want out of it), you'll probably be fine. The biggest obstacle is what people think which is more from the outside of things. When you're actually working, it's as long as the RNs can get what they need from you that counts. If you're not responsive and don't eventually learn to anticipate what they need to get the job done (especially if you end up in a 9-5 kind of role, your noc shift RNs need support, too!), then that may be a reflection of a lack of experience as an RN but, again, it's really actually just a bit of a learning curve. It's ultimately how well you work with the physicians that will matter. Good luck! You won't regret either path!

CCU BSN RN · Apr 25, 2017

Your school is a business. They are interested in getting as much money as possible from you and maybe to have you pass your boards at the end to pad their statistics. They will tell you anything to get your tuition.

We have no vested interest in your future. If you feel like blowing a few miserable years in school and paying dearly for it, just to get chewed up and spit out at your job regularly for not knowing things that most other NPs would know...that's cool. It's a free country. Academically you may be prepared, and that's great, and your patients might like you, because you might be personable and they're healthcare illiterate. But to earn the salaries you want, you're not talking about holding hands and writing colace orders at long term care. You're talking about ICU or ER hospital jobs, where there is very little margin for error. I don't want you to go through experiences where you cry every day on the way home from work because your actions directly contributed to someone's death.

Extreme? Yeah. That toughening up thing needs to start right now if you have ANY chance of achieving this dream career without putting in the blood, sweat, and tears that got many of the rest of us here.

wyld~heart · Apr 25, 2017

Personally, I feel my 10+ years of experience as a RN in the ED and ICU were a most valued asset and the foundation for my NP studies and success..

This being said, I do not think someone needs that long but , I do feel it would be difficult to become a NP without at least some RN experience..

3ringnursing, BSN · Apr 26, 2017

I look at it this way: Do MD's start out as a PA, or RN routinely first? Probably not.

If it was a deal breaker not being an RN first you never would have been accepted into the NP program.

It's your life my friend - live it the way you want to. After all, there is no do-overs if you discover at the end of your life you didn't live it to your full potential.

I say go for it.

Kooky Korky, BSN, RN · Apr 26, 2017

Sell your soul to the devil. Sales. For the big health insurance companies.
Really, I'm grateful to them though. It's been a great career.

OP, have you considered going to Medical school? Just because your father discouraged you before does not mean you couldn't achieve becoming a doctor now.

What area do you see yourself working in if you do go the NP route? ICU? ER? drug store clinic? Medical? Surgical? Other?

I wish you well however you choose to proceed.

Neuro Guy NP, DNP, PhD, APRN · Apr 26, 2017

You make a good point. I'd like to say that I agree that it isn't impossible to be a good NP without RN experience because at the end of the day the NP role is NOTHING like being an RN. However, I do think there is some benefit to having that experience first because of the graduate nursing paradigm and the amount of assumption built into graduate programs.

You make a great point though. I actually advocate the creation of intensive fellowship programs for NPs, something I'd like to discuss in another post.

Neuro Guy NP, DNP, PhD, APRN · Apr 26, 2017

No need to tell them anything. Don't say anything about NP aspirations in the initial interview or resume. That's the solution

SopranoKris, MSN, RN, NP · Apr 26, 2017

Thanks for your reply. I see that you now have your BSN...so did you first get your ADN and then your BSN? I wondered about that, because many hospitals won't hire RNs unless they are BSN-prepared, to work in the ICU. If that is the path you took...ADN, to BSN...are you happy you went that route? If you were going to be a PA, did you already have a bachelors degree in something else? At my age, it just concerns me to get all these additional degrees.
I should confirm with our hospitals...I THINK they have relaxed on the BSN requirement, that if you have a bachelors degree and an RN, you are okay. But some still might be hanging on to the BSN, no matter your other bachelors degrees. Ironically, I will be sitting here with a BA, RN, and an MSN...so for some hospitals both over- and under-qualified.
I do not necessarily want to be an ACNP in the ICU. My program has an intensivist specialty in which I can get even more clinical hours, but I don't think that's where I want to work. I certainly agree that I would need RN experience in the ICU first. I got to shadow an ACNP in the ICU who was also the Rapid Response team for the hospital. I loved the fast pace, but I don't necessarily need to be in critical care. I am interested potentially in a hospitalist role or perhaps working in surgery. But I also know I may not walk out of school with my dream job. I am willing to do the work. I just want to make sure I CAN.

Yes, I obtained my ADN and then got hired in to a nurse residency program. The condition of the program was that I had to complete the BSN within 2 years of hire date. However, my employer reimbursed me for the tuition for my BSN. I was able to work full time and take BSN courses full time. When I finished the residency program, I was hired on in the ICU after working on the progressive care respiratory unit with trach/vent patients. I had to get my ACLS certification to work on that unit and that helped me to get my foot in the door in ICU.

I know you say you're not as interested in ICU, but I know our hospital only uses ACNPs for ICU/trauma & ER. FNPs are hospitalists. You can also work in the ER as an FNP if you already have experience as an ICU or ER RN. The "intensivist" certification is more applicable to the ICU, so if that's not what you want to do, I don't think it would be the right route to go. If you're interested in the ER, also know that many require dual FNP/ACNP certification so you can see patients of all ages. ACNPs can only treat patients age 13 & up.

As far as age goes, I was 45 when I finished my ADN. I just finished my BSN in December. I'll be 49 when I finish my FNP program. I wouldn't let age be your defining guide to your career path. I was initially interested in being done as quickly as possible. However, now that I'm an RN, I see the value in having RN experience before embarking on a career as an NP. By the time I graduate, I will have a little over 4 years of experience as an RN, 3 of those in the ICU. If you have the opportunity to work as an RN, I would definitely consider doing so.

I know someone said in a previous reply that MDs aren't required to be PAs or RNs first. True, but the schooling for an MD is not the same as an NP. We are expected to have baseline knowledge gained from being an RN. MDs are schooled as a blank slate. It's comparing apples to oranges. While the NP role is definitely very different from being an RN, the background knowledge you gain, especially if you're going the ACNP route, it certainly a solid foundation. I just know the ACNP curriculum is going to expect that baseline ICU/ER acute care knowledge.