Brave or just stupid?

Polly Peptide, BSN, MSN, RN, APRN · May 1, 2017

I'm in nursing school now, and I would argue that the quality of clinical hours in RN school IS NOT the same as in PA/NP school. It's hardly experience, more like required exposure or job shadows into different nursing settings. It also doesn't help that our clinical experience is inundated with busy-work assignments that eat up all our time. I am learning and practicing my nursing skills more when working as a CNA/nurse tech than as a student in clinical rotations.
The sad truth is that the number of NP required clinical hours average at about 600 compared to 2,000 in PA programs. That said, I would think that newly graduated PAs enter the workforce better prepared and practiced than direct-entry NPs. I hope you can be the outlier.
Before nursing school, I was looking into ABSN, entry-level MSN-RN and entry-level MSN/DNP-NP programs. I ultimately chose a community college program because it was about 1/7 of the cost of the others. I think you may be getting a lot criticism because you are jumping straight to the top of the nursing career ladder as quickly as you can. For generations, nursing had been a field in which experience granted you opportunities to step up in the job ladder. Start as an LPN or floor RN (med/surg), then gain critical care experience, then charge, then the opportunities really open up: unit manager, assistant nurse manager, nurse manager, clinical educator, house supervisor; or going back to school for a PhD or advanced practice: nurse practitioner, clinical nurse specialist, nurse anesthetist or nurse midwife.
Direct-entry programs are still relatively new, and they've shook the foundation of the nursing career ladder - a non-nurse, in 2-4 years, can now head straight to the top.

I do totally understand this, and I expected the criticism when I posted here. I've reach MUCH criticism on this board of DE programs and NPs without RN experience and was beginning to question my methods...and rightfully so, I think. I understand the intention behind the original creation of the "Advanced Practice Nurse" role. The issue is, over time, the nursing field has made it possible to 'jump straight to the top', as you say, without requiring all of these stepping stones. At my age, it doesn't make sense for me to go through a two year ADN program, work a couple of years; get them to pay for my RN to BSN; work for a few more years; move to charge nurse or nurse manager and work some more years; as I would be into my 60s by the time I accomplish my goal.

My point in all of this is: if it's possible for me to attain competency - not just baseline, but to really be able to do a good job - then I would like to take advantage of the opportunities offered to me. But if it's truly a disaster waiting to happen, then I wanted to know. As I should have expected, I've gotten a mixed bag of responses, some saying I'm likely to kill people and others saying I will be fine with hard work.

I do appreciate your comments on the RN clinicals and how they compare to PA or even the MSN portion. I do believe that, straight out of school and all other things being equal, I would probably feel better prepared as a PA. I would have been exposed to more provider-type clinical hours in a condensed period of time. That SHOULD make me feel more prepared. However I pointed out in an earlier comment on this thread that it makes sense that PAs get more hours, sense they are trained as generalists vs NPs being required to pick a specialty. The disparity being ~600-800 vs ~2000...that's a bit hard to swallow. But let's just take my local PA program for instance.

They do eight 6 week rotations in the following: Family Med I and II, Peds, Behavioral Health, Emergency Med, Internal Med, and General Surgery. There is one elective rotation. That equates to about 250 hours per rotation.

I am pursuing the ACNP specialty in my NP program. When I consider the above rotations, 4 of them would not be included in my program. Family Med would be for the FNPs; Behavioral Health for the PMHNPs; Emergency Med for the dual ACNP/FNP program; and Peds for the obvious.

Two of the rotations (IM and surgery) would be included and I don't see any critical care. So if I am comparing, that's at least three rotations on the PA side to my ACNP side, which is 750 hours and about right. BUT...I have to say, when I think about the broadness of critical care...I sure as heck would like more clinical hours. Lots more.

FNP...when I compare it to PA, you could include Family Med I and II, maybe ER, maybe Peds. NP falls short there.

PMHNP...NP wins. But I do wonder what sort of training is mixed in so that co-morbidities are recognized, etc.

Peds...NP wins, sort of. But I would think general rotations would help, no matter what.

So I think we should consider the fact that NPs are specializing, but I do agree...PAs have the advantage in clinical hours. However, I would think (and I've been told this anecdotally as well), that even if initial disparities exist, there appears to be no real difference in practice abilities between the two roles over a fairly short period of time.

SopranoKris, MSN, RN, NP · May 1, 2017

Unfortuately, you have never yet even set foot on a critical care unit. You have NO IDEA what it's really like and just how much knowledge you need to have in order to keep these unstable patients alive. I went from a step-down unit to the ICU thinking it was going to be a few more drips to titrate and participating on the code team. Boy, was I wrong. You have to have extensive knowledge of pathophysiology and how your interventions will affect this patient and what could possibly go wrong. Not only that, but you need to know what you'll SEE in the patient when complications arise. You can't wait until late signs appear to take action.

I, too, am a career changer in my 40s. I would strongly suggest getting your RN at a community college and then work as an RN while you're doing NP school. That way, you're getting some experience on the actual floor. If you've never seen a patient start crumping, how are you going to recognize it as an NP? It's all fine to try to justify not getting RN experience until something adverse actually happens. I want to keep my patients safe. I want to feel secure that I have a good, solid foundation before embarking on NP. 2 years in the grand scheme of things isn't an insanely long period of time. There are RN to MSN programs out there, so you needn't put off pursuing NP. The only reason why I did the BSN right after the ADN was that it was a requirement of my employer and they paid for it. It only took me a year to complete (I took a 6 month break from school inbetween getting the ADN and starting BSN).

If you were going more on the FNP office setting side, I'd have less concerns. Most reputable ACNP programs require a minimum 1 to 2 years experience in ICU before starting the program. I can't understand why they'd allow DE in to ACNP. For those of us who actually work in the ICU, it's scary to us because we are with these patients every day. We see firsthand what happens when knowledge is lacking. I work at a teaching hopsital for a Big 10 university and do you know how often the nurses catch the residents making incorrect orders or prescribing a drug in the wrong amount? Quite often. If we didn't know what we were doing, those patients could be harmed. They're still "puppies" learning how to be doctors and they've had MANY more clinical hours that you'd ever get in a DE NP program. That's why there are so many people concerned about this route of education. You simply to do not have the baseline knowledge you need never having been an RN on the ICU. You can't learn ICU experience from a book, you simply can't.

Polly Peptide, BSN, MSN, RN, APRN · May 1, 2017

Unfortuately, you have never yet even set foot on a critical care unit. You have NO IDEA what it's really like and just how much knowledge you need to have in order to keep these unstable patients alive. I went from a step-down unit to the ICU thinking it was going to be a few more drips to titrate and participating on the code team. Boy, was I wrong. You have to have extensive knowledge of pathophysiology and how your interventions will affect this patient and what could possibly go wrong. Not only that, but you need to know what you'll SEE in the patient when complications arise. You can't wait until late signs appear to take action.
I, too, am a career changer in my 40s. I would strongly suggest getting your RN at a community college and then work as an RN while you're doing NP school. That way, you're getting some experience on the actual floor. If you've never seen a patient start crumping, how are you going to recognize it as an NP? It's all fine to try to justify not getting RN experience until something adverse actually happens. I want to keep my patients safe. I want to feel secure that I have a good, solid foundation before embarking on NP. 2 years in the grand scheme of things isn't an insanely long period of time. There are RN to MSN programs out there, so you needn't put off pursuing NP. The only reason why I did the BSN right after the ADN was that it was a requirement of my employer and they paid for it. It only took me a year to complete (I took a 6 month break from school inbetween getting the ADN and starting BSN).
If you were going more on the FNP office setting side, I'd have less concerns. Most reputable ACNP programs require a minimum 1 to 2 years experience in ICU before starting the program. I can't understand why they'd allow DE in to ACNP. For those of us who actually work in the ICU, it's scary to us because we are with these patients every day. We see firsthand what happens when knowledge is lacking. I work at a teaching hopsital for a Big 10 university and do you know how often the nurses catch the residents making incorrect orders or prescribing a drug in the wrong amount? Quite often. If we didn't know what we were doing, those patients could be harmed. They're still "puppies" learning how to be doctors and they've had MANY more clinical hours that you'd ever get in a DE NP program. That's why there are so many people concerned about this route of education. You simply to do not have the baseline knowledge you need never having been an RN on the ICU. You can't learn ICU experience from a book, you simply can't.

You're right, I've never been an RN in the ICU. But I HAVE been lucky enough to shadow an ACNP in the ICU, who was also on the Rapid Response team for the hospital. So saying I've never "stepped foot" in a critical care until is inaccurate. Don't get me wrong, I know shadowing gives no actual experience.

I can't quite figure out why people are ignoring my comments about working during my MSN year. I'm saying that I'm now considering working during that portion, so that I CAN gain at least some experience.

People are also making the assumption that I want a job in a critical care right when I come out of school. This is faulty. I would like to be trained in this area, but I don't necessarily feel the need to work there. ACNPs are employed in a variety of settings, not just ICUs.

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.

Tacomaboy3 · May 1, 2017

I hope and think you will do well. You seemed well-informed of the roadblocks coming your way. You're likely to get a lot of backlash and criticism for years to come (directly and behind your back), but focus on job performance and patient outcomes. Like others of have said, the role of an NP and RN are vastly different, which is the primary defense of some NP programs no longer requiring RN experience! It would be interesting to see studies on this. Research consistently shows that BSN-prepared nurses have better patient outcomes than ADN-prepared nurses; I'd love to see studies that compare patient outcomes between direct-entry NPs and those with previous RN experience.

You also have a fair point in the difference of PA/NP clinical hours being attributed to the generalist vs specialty role. Regardless, though, 600 hours is not a lot (equivalent to only 15 weeks of full-time work).

MurseJJ · May 1, 2017

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.

From the info you've given I'm pretty sure I know which school this is :).

Anyway, I think it's great that you're considering working through the NP portion as an RN. Depending on your location (not sure if you'd end up staying in the area of the school), RN experience may be required for inpatient NP positions. In the NYC area for example, I've noticed many hospital NP positions will say "new grads welcome" but then also say that "1-3 years nursing experience required", as in bedside RN experience. So, if you work while completing the NP portion of the program, at least you won't be ruled out for such jobs.

As far as salary, it really depends on location and specialty. As a new grad RN in NYC, I make just under 100K, and NPs at my hospital start at around $115K-$120K (not including differentials for certifications, RN experience, night shift, etc).

Good luck!

Polly Peptide, BSN, MSN, RN, APRN · May 1, 2017

From the info you've given I'm pretty sure I know which school this is :).
Anyway, I think it's great that you're considering working through the NP portion as an RN. Depending on your location (not sure if you'd end up staying in the area of the school), RN experience may be required for inpatient NP positions. In the NYC area for example, I've noticed many hospital NP positions will say "new grads welcome" but then also say that "1-3 years nursing experience required", as in bedside RN experience. So, if you work while completing the NP portion of the program, at least you won't be ruled out for such jobs.
As far as salary, it really depends on location and specialty. As a new grad RN in NYC, I make just under 100K, and NPs at my hospital start at around $115K-$120K (not including differentials for certifications, RN experience, night shift, etc).
Good luck!

I'll be staying here, due to kids and husband, unless something crazy happens.

My last post was a bit of a typo-fest. I'm sick and I can tell it, lol.

Ruas61, BSN, RN · May 1, 2017

I can't quite figure out why people are ignoring my comments about working during my MSN year. I'm saying that I'm now considering working during that portion, so that I CAN gain at least some experience.
People are also making the assumption that I want a job in a critical care right when I come out of school. This is faulty. I would like to be trained in this area, but I don't necessarily feel the need to work there. ACNPs are employed in a variety of settings, not just ICUs.
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.

It's going to sound snarky, negative or nasty no matter how it is worded.

These kind of programs may fast track someone and they hopefully will be competent at a bare minimum by graduation/licensure for practice. There will be some learning curve that will get the person experience.

The thing is that there is so much missed with this track to becoming a nurse. A big part of the journey is experience over time. But, one will never miss what they don't know.

Good luck.

Polly Peptide, BSN, MSN, RN, APRN · May 1, 2017

It's going to sound snarky, negative or nasty no matter how it is worded.
These kind of programs may fast track someone and they hopefully will be competent at a bare minimum by graduation/licensure for practice. There will be some learning curve that will get the person experience.
The thing is that there is so much missed with this track to becoming a nurse. A big part of the journey is experience over time. But, one will never miss what they don't know.
Good luck.

So if a tree falls in the forest, and no one is around to hear it...

Let me ask you this: is there not a point at which a practicing with NP with no prior RN work can feel that they, too, are experienced? Let's say you have an NP with 10 years of experience, all as an NP; and another NP with 10 years of experience; 5 as an RN and 5 as an NP: do you believe that the former is less competent than the latter? Or actually, is it vice versa? Or are they equal? At what point does the lack of RN experience no longer matter? Or will you guys argue that it will ALWAYS matter?

I don't believe you can fairly say that having RN experience will always matter. In the beginning, certainly. Over time, these things must level out. Perhaps if you are an RN that happened to gain experience in a variety of settings, and now as an NP you will use that background in a single specialized area, then the advantage may always exist. But what if your RN experience was limited to OP clinics and your NP specialty requires critical care skills? Your NP experience will be the more important of the two.

I honestly think this is a gap that may be able to be closed in a relatively short period of time. Even those programs that require experience before going on to advanced degrees (MSNs and CRNA programs) only need a year or two.

I am playing devil's advocate, because I still believe experience is better. Which is why I think I will work after getting my RN, and do the MSN portion part-time. The program does not let me take time off in-between, though. I have to plow through.

SopranoKris, MSN, RN, NP · May 2, 2017

If you're going to be an ACNP it's going to be a MUCH steeper learning curve. I don't think you understand the difference in acuity. As a brand new RN, you will not be able to set foot in the ICU yet. According to you, you can't work while in your ACNP program. How are you going to get ICU experience? You don't understand what you don't know yet. Honestly, you are receiving some non-snarky, well-intentioned advice and are choosing to ignore it and justify the ends to your means. Good luck. :)

Polly Peptide, BSN, MSN, RN, APRN · May 2, 2017

I am not ignoring the advice; I am taking everything in and will have to make a decision on the information I've gathered. The advice has come from multiple points of view.

I said that the school doesn't recommend working during the FT program, but that does not apply if you change to PT after you complete the RN portion.

Jules A, MSN · May 2, 2017

I honestly think this is a gap that may be able to be closed in a relatively short period of time. Even those programs that require experience before going on to advanced degrees (MSNs and CRNA programs) only need a year or two.
I am playing devil's advocate, because I still believe experience is better. Which is why I think I will work after getting my RN, and do the MSN portion part-time. The program does not let me take time off in-between, though. I have to plow through.

I'm hoping those in your specialty will respond because at least in psych it is very possible for a lousy prescriber and diagnostician to remain that way their entire career. I see it all the time with both NPs and MDs. In the cases of outpatient, where most NPs with their desire for Mommy Friendly hours land, they are the sole provider operating in a silo with zero checks and balances until their patients, repeatedly, wind up decompensating and being admitted to my inpatient acute unit. Thankfully its fairly hard to actually kill someone in psych but should the bar be that low for this vulnerable population? Very sad and again just because the schools allow it doesn't mean it is the right or ethical thing to do.

Again while it doesn't sound to me as if you are playing devil's advocate so much as justifying your intent I do appreciate that you continue posting and think working while in school is a solid decision. I'm not sure about the rigors of ACNP program but having been through PMH and FNP I can say it is laughable that schools would assert or anyone would feel they were unable to work at least part-time and complete these relatively easy programs. I'm sure there will be protest and perhaps mine just sucked, despite consistently being rated in the Top 10? :)

Polly Peptide, BSN, MSN, RN, APRN · May 2, 2017

I'm hoping those in your specialty will respond because at least in psych it is very possible for a lousy prescriber and diagnostician to remain that way their entire career. I see it all the time with both NPs and MDs. In the cases of outpatient, where most NPs with their desire for Mommy Friendly hours land, they are the sole provider operating in a silo with zero checks and balances until their patients, repeatedly, wind up decompensating and being admitted to my inpatient acute unit. Thankfully its fairly hard to actually kill someone in psych but should the bar be that low for this vulnerable population? Very sad and again just because the schools allow it doesn't mean it is the right or ethical thing to do.
Again while it doesn't sound to me as if you are playing devil's advocate so much as justifying your intent I do appreciate that you continue posting and think working while in school is a solid decision. I'm not sure about the rigors of ACNP program but having been through PMH and FNP I can say it is laughable that schools would assert or anyone would feel they were unable to work at least part-time and complete these relatively easy programs. I'm sure there will be protest and perhaps mine just sucked, despite consistently being rated in the Top 10? :)

Hi Jules - I just know the MSN portion of my program, when full-time, is 40 hours per week for the didactic part, in addition to the time for clinical hours. I have heard of some people being able to cobble together PRN hours over weekends here and there, but between actual class/lab time, getting in clinical time, and studying, it is really difficult to find time to work as an RN...not to mention working enough to develop and maintain skills to be safe in that kind of scenario.

But this seems to be specific to those who did not have RN experience before coming into the program. My specialty (which is a bit different than the others), if you fall in this category, does not allow any distance learning. So you are required to complete everything on campus and in this area (no clinicals on your own, etc.). Other specialties are a bit more flexible.

If you have prior experience, you can complete the MSN portion on a block schedule format and therefore are more likely to be able to continue to do some work. It is just highly unlikely for those without experience...unless you change to part-time.

Maybe I am justifying...because I am struggling with my options! I actually went online yesterday to look at applying to two accelerated second-degree BSN programs in my area. In fact, I got all the way to the end of the NursingCas application, including writing my personal statement, and hit a wall when it asked me for references. It's not that I can't obtain them, but I've already tapped my references for getting into my MSN program, and they know I'm in. I just feel uncomfortable going back to them and saying, hey, I might be changing my mind here at the last minute. And my most desired program's deadline was yesterday.

I've also thought, I could stop dead in my tracks and get some HCE, take my chem pre-reqs and apply to the PA school. But how crap would that be if I don't get in? Their acceptance rate is lower than our med schools. I mean, I will have wasted another two years of my life, more money in pre-reqs, and turned down this opportunity. I'm just concerned about watching these things walk out of my life....when they could be perfectly fine, even really good.