BSN straight to NP or gain work experience

Boomer MS, RN · Jun 29, 2017

My experience? I work in a specialty (NICU) that requires its NNPs to have a minimum of two years of clinical bedside experience prior to clinical practicums. Neonatal NPs were some of the first NPs to emerge from the advanced practice nursing force.
It would be an injustice to the neonates to go into to AP with the bare minimum. Hence why I am now just starting the application process so that, by clinicals, I have more than the minimum.
I also had the interesting opportunity while in undergrad to take classes side-by-side the direct-entry students. They were just a few months away from graduating from the RN portion and entering the NP part of the program. Some of them couldn't take a blood pressure manually. Nor did they seem to have an understanding of basic pharmacology. For example, some didn't know that heroin is consider a "downer" not an "upper" and that heroin and morphine work and metabolize similarly in the system.
That is terrifying.
And make no mistake. This is also a reputable and highly-ranked NP program. That is scary.
If bedside experience isn't so important, then why are many advanced practice schools (NNP, CRNA and, up to a certain point, Acute Care AGNP) requiring their applicants to get that bedside experience? Why aren't MDs being hired without residencies? And more importantly, what is the point of being called an advanced practicing nurse if one doesn't have the BASICS down?
I can also speak from a less specialized field: med-surg. Do you know how many patients and how many different diagnoses a bedside RN can see and learn how to manage on a fundamental level? At my med/surg job, I can have up to seven patients with seven different CCs and multiple comorbidities.
As an NP, one has to know how to prioritize which diagnoses to treat, how to treat them and when to recognize even the slightest variation from a patient's baseline to prevent a patient from going down the tubes. Now I know some direct-entry NPs think that book smarts and a quick wit is all that is needed to be a good NP, but here is something one cannot learn in a classroom: intuition.
So while you think it is "ironic" that a bedside nurse is speaking to greater than thou NP, understand that bedside nursing provides the FOUNDATION from which NPs learn and grow. NP students were expected to already have a strong knowledge. As the bedside nurse, I need to feel confident in the APNs abilities and education because when SHTF, I am calling you (general you, of course).
If NPs feel that bedside nursing experience is no longer needed, then NP training should divorce itself from nursing altogether and just be called "practitioners."

Amen.

allnurses Guide · Jun 29, 2017

I would like to try and respond in generalities as getting personal doesn't really advance the dialogue in an meaningful way.

I work in a specialty (NICU) that requires its NNPs to have a minimum of two years of clinical bedside experience prior to clinical practicums. Neonatal NPs were some of the first NPs to emerge from the advanced practice nursing force.

As I wrote above, student and novice NPs working in specialty practice are certainly benefited by relevant RN experience in that specialty. Spending three years as a NICU RN (I would assume, I don't have any direct experience) would benefit a student/novice NNP much more so than three years as a RN working in another setting.

Hence why I am now just starting the application process so that, by clinicals, I have more than the minimum.

If I understand correctly, you are applying to NNP programs currently? As you pointed out my bias, do you think you have any of your own? I think we can all agree that recognizing your own bias is important.

I also had the interesting opportunity while in undergrad to take classes side-by-side the direct-entry students. They were just a few months away from graduating from the RN portion and entering the NP part of the program. Some of them couldn't take a blood pressure manually. Nor did they seem to have an understanding of basic pharmacology.

The undergraduate level and the graduate level are two completely different things, and in this scenario, neither you nor the pre-licensure DE students had any RN experience?

If bedside experience isn't so important, then why are many advanced practice schools (NNP, CRNA and, up to a certain point, Acute Care AGNP) requiring their applicants to get that bedside experience? Why aren't MDs being hired without residencies? And more importantly, what is the point of being called an advanced practicing nurse if one doesn't have the BASICS down?

Many program require bedside experience, including many DE programs. Just because a program is DE doesn't mean it doesn't require bedside experience. Some specialty programs require specialty experience, as discussed above. FWIW there are now physician pilot programs that don't require residency; and remember, what residents are called: doctor. Residents are practicing physicians in a collaborative practice, many people forget that thinking they are students.

At my med/surg job, I can have up to seven patients with seven different CCs and multiple comorbidities.

True, but the bedside RN job is very different from the hospitalist job. I am not sure you can find many practicing NPs that have worked at the bedside that will tell you they learned nothing in NP school because they already knew it all from the bedside.

As an NP, one has to know how to prioritize which diagnoses to treat, how to treat them and when to recognize even the slightest variation from a patient's baseline to prevent a patient from going down the tubes. Now I know some direct-entry NPs think that book smarts and a quick wit is all that is needed to be a good NP, but here is something one cannot learn in a classroom: intuition.

Book smarts and a quick wit isn't a bad start, to be honest. Most physicians fit that mold don't they? Intuition is fine if you have it, some RNs do and some don't, some providers do and some don't. The more time you spend in a role the better that gets. The intuition at the RN level isn't enough to make you a good provider. It needs to be pared with knowledge and experience in the provider role.

As the bedside nurse, I need to feel confident in the APNs abilities and education because when SHTF, I am calling you (general you, of course).

Something to consider as you move forward with your RN and APN career: do you think you have the relevant expertise to accurately judge a provider competence, regardless of the degree, and when you are a novice in the APN role how will you respond to a RN who doesn't want to follow your orders simply because they don't think you are good enough?

Simplistic · Jun 29, 2017

I would like to try and respond in generalities as getting personal doesn't really advance the dialogue in an meaningful way.
As I wrote above, student and novice NPs working in specialty practice are certainly benefited by relevant RN experience in that specialty. Spending three years as a NICU RN (I would assume, I don't have any direct experience) would benefit a student/novice NNP much more so than three years as a RN working in another setting.
If I understand correctly, you are applying to NNP programs currently? As you pointed out my bias, do you think you have any of your own? I think we can all agree that recognizing your own bias is important.
The undergraduate level and the graduate level are two completely different things, and in this scenario, neither you nor the pre-licensure DE students had any RN experience?
Many program require bedside experience, including many DE programs. Just because a program is DE doesn't mean it doesn't require bedside experience. Some specialty programs require specialty experience, as discussed above. FWIW there are now physician pilot programs that don't require residency; and remember, what residents are called: doctor. Residents are practicing physicians in a collaborative practice, many people forget that thinking they are students.
True, but the bedside RN job is very different from the hospitalist job. I am not sure you can find many practicing NPs that have worked at the bedside that will tell you they learned nothing in NP school because they already knew it all from the bedside.
Book smarts and a quick wit isn't a bad start, to be honest. Most physicians fit that mold don't they? Intuition is fine if you have it, some RNs do and some don't, some providers do and some don't. The more time you spend in a role the better that gets. The intuition at the RN level isn't enough to make you a good provider. It needs to be pared with knowledge and experience in the provider role.
Something to consider as you move forward with your RN and APN career: do you think you have the relevant expertise to accurately judge a provider competence, regardless of the degree, and when you are a novice in the APN role how will you respond to a RN who doesn't want to follow your orders simply because they don't think you are good enough?

AMEN.

ThePrincessBride, MSN, RN, NP · Jun 29, 2017

As I wrote above, student and novice NPs working in specialty practice are certainly benefited by relevant RN experience in that specialty. Spending three years as a NICU RN (I would assume, I don't have any direct experience) would benefit a student/novice NNP much more so than three years as a RN working in another setting.

As would a couple years of psych experience for Psych NP, pediatrics for PNP, etc. I have many coworkers who have only NICU experience going on to become FNPs having never touched an adult or older child in their career. Since most FNP jobs are geared towards the care of adults, I don't think it would be too much to ask for adult bedside experience.

Not all RN experience is equal. I should have said relevant experience.

If I understand correctly, you are applying to NNP programs currently? As you pointed out my bias, do you think you have any of your own? I think we can all agree that recognizing your own bias is important.

Actually, when I first started out in nursing school, I wanted to go directly to grad school so I could get finished with my formal education before having children. Working at the bedside has taught me the seriousness and level of responsibility and autonomy that comes with being a neonatal NP. Coupled with the fact that so many low-quality NP schools are churning poorly-prepared NPs left and right and I am pretty convinced that even if I did go straight through, I would have regretted not getting the experience.

The undergraduate level and the graduate level are two completely different things, and in this scenario, neither you nor the pre-licensure DE students had any RN experience?

Yet they were taking the same classes as the undergrads and judging from some of the questions they were asking and their level of performance, it was a little scary to believe that many would take the NCLEX and start their NP portion after a handful of months. Even some of the graduate students complained that facilities didn't want to hire them.

Many program require bedside experience, including many DE programs. Just because a program is DE doesn't mean it doesn't require bedside experience. Some specialty programs require specialty experience, as discussed above. FWIW there are now physician pilot programs that don't require residency; and remember, what residents are called: doctor. Residents are practicing physicians in a collaborative practice, many people forget that thinking they are students.

And I wonder how many attendings would feel comfortable knowing there are MDs out there without a residency?

Residents may be called "doctor" but being a doctor doesn't automatically make one an attending.

If these "DE" programs require bedside experience, then they aren't truly "DE" as they couldn't go straight to the NP portion without any bedside experience. So that just proves my point even further.

True, but the bedside RN job is very different from the hospitalist job. I am not sure you can find many practicing NPs that have worked at the bedside that will tell you they learned nothing in NP school because they already knew it all from the bedside.

No. But I bet you'll hear many NPs who value their bedside experience and are glad they didn't go straight through either. You seem to want to completely divorce NPs from RNs; you can't. Otherwise, an RN license wouldn't be required.

Book smarts and a quick wit isn't a bad start, to be honest. Most physicians fit that mold don't they? Intuition is fine if you have it, some RNs do and some don't, some providers do and some don't. The more time you spend in a role the better that gets. The intuition at the RN level isn't enough to make you a good provider. It needs to be pared with knowledge and experience in the provider role.

Yes, but I don't want an NP who is starting from ground zero diagnosing patients, and a Nurse Practitioner without any (relevant) RN experience is just that. As a NICU RN going on my second year of practice, I can say for sure that all of what I learned on the floor will help me see the "bigger picture."

And remember, LIVES are at stake.

It isn't about what is best for the NP student's personal life, it is what is best for the patient.

Something to consider as you move forward with your RN and APN career: do you think you have the relevant expertise to accurately judge a provider competence, regardless of the degree, and when you are a novice in the APN role how will you respond to a RN who doesn't want to follow your orders simply because they don't think you are good enough?

Shouldn't you be asking this question to all the NPs without any RN experience?

And hopefully, rather than refusing to follow orders, that RN would ask for more information as to why a certain treatment was ordered, ETC. A competent NP would be able to walk that through with the bedside RN, and believe it or not, many bedside RNs with more than a couple years of experience can tell the incompetent provider from the competent one. We may not be following orders, but after sometime on the bedside, we start to learn to accurately anticipate the next step in the poc.

But I have a feeling that you have it in your mind that bedside RNs are clueless about the NP role and that bedside experience is overrated, so this feels like a waste of a post.

Have a good one.

allnurses Guide · Jun 29, 2017

Not all RN experience is equal.

This is the crux of it. If APN programs want to start making relevant RN experience a requirement than I would support that. The question is for some APN program what should be considered relevant? And how much? There is very little data on this in the extant literature and what data there is suggests that RN experience doesn't seem to make a big impact. Historically, specialty APN tracks have been 2 years of directed RN experience. We should study it and find out what works and what doesn't.

I will say from precepting lots of NP students, trying to do NP school while also trying to be a novice RN at a job (and novice for me is under 2 years) does nobody any favors: patients, the student, managers, etc.

Coupled with the fact that so many low-quality NP schools are churning poorly-prepared NPs left and right and I am pretty convinced that even if I did go straight through, I would have regretted not getting the experience.

We need to do away with the low-quality programs, we agree.

As I have said many times previously, the person themselves (and their direct educators) is often the best judge of what is best for them in transitioning to advanced practice. It has been my experience that most student NPs never "regret" their RN experience.

Yet they were taking the same classes as the undergrads and judging from some of the questions they were asking and their level of performance, it was a little scary to believe that many would take the NCLEX and start their NP portion after a handful of months. Even some of the graduate students complained that facilities didn't want to hire them.

A few things here, for the record if nothing else:

1. Students in pre-licensure RN programs are all the same regardless of the end degree: they all need to pass the same national standard board exams, doesn't matter if they are diploma, ASN, BSN, MSN, or DNP. The national bar is the same.

2. What is the DE program's NCLEX pass rate? This is readily available on the BON website for most states. For instance my state has four programs, the NCLEX pass rate for all four programs is >96%.

3. Facilities don't want to hire DE students.....as RNs. This happens here too, and would you blame them? Students trying to get RN jobs while going to school full-time for a different job? Again, benefits no one.

And I wonder how many attendings would feel comfortable knowing there are MDs out there without a residency?
Residents may be called "doctor" but being a doctor doesn't automatically make one an attending.
If these "DE" programs require bedside experience, then they aren't truly "DE" as they couldn't go straight to the NP portion without any bedside experience. So that just proves my point even further.

And you know why attendings think that? Most often: money. Most resident and fellow physicians practice with very little oversight. The nurses provide most of their real last line of defense. Residents are cheap labor.

In a way this shows your misunderstanding of the NP curriculum, which I don't think is isolated to you by any means. For example, the program I work with requires DE student NPs complete 18 months of part-time RN work prior to graduation as an APN. To be completely honest, I'm not sure that does a whole lot of good, as above.

No. But I bet you'll hear many NPs who value their bedside experience and are glad they didn't go straight through either. You seem to want to completely divorce NPs from RNs; you can't. Otherwise, an RN license wouldn't be required.

Of course they do! No matter what experience an individual has they value it, that's what makes up the people (and as such, the providers) we are. I don't, by any means, want to divorce NPs from RNs, we are educated under the same model, and that is why NPs have fantastic outcomes data. An NP without RN experience does not make them any less a nurse.

Yes, but I don't want an NP who is starting from ground zero diagnosing patients, and a Nurse Practitioner without any (relevant) RN experience is just that. As a NICU RN going on my second year of practice, I can say for sure that all of what I learned on the floor will help me see the "bigger picture."

You don't, based on what, a year of RN experience? You are still learning yourself! I am sure what you have learned on the floor will help you, but at the end of the day, if I had the choice between a APN with two years of APN experience and an APN with no NP experience and two years of RN experience I would take the former. I didn't always think this way but after time in the role and working with students of different levels of experience, I do. If I had the option of RN experience plus APN experience in a specialty then that's ideal. A novice APN is a novice APN regardless of RN experience, at the end of the day, my two cents from having been down this road for many years.

But I have a feeling that you have it in your mind that bedside RNs are clueless about the NP role and that bedside experience is overrated, so this feels like a waste of a post.

That is not the case at all, but I will tell you that, having precepted many experience RNs in the APN role, that most are fairly humbled by the provider role, and the ones that aren't, are dangerous.

In the end, I am very empirical, where is the data that shows how important bedside RN experience is to practice. Again, in my experience with both APN students and MD students, is that the variability between individuals far exceeds the variability in their experience and education, this is why population-level studies are really needed moving forward.

Dranger · Jun 29, 2017

What kind of NP do you want to be? In my acute program I heavily used my RN experience during internal med/hospitalist rotations. I imagine a smart student without RN experience (in another words, a qualified MD applicant) could do just as well as me. It's just going to be like drinking out of a firehouse for the first couple years. I was different as a RN, I always asked why and looked for the rationale behind MD decisions. Many RNs don't and thus their experience would be null and void.

Summary: After going through a program I feel RN experience probably isn't necessary for the right student. (Even after being an a ACNP program that required 2 RN years in the ICU)

kp2016 · Jun 30, 2017

I would suggest it may depend on your previous work experience and military MOS. Going straight from BSN to NP may be just fine if you already have a lot of experience as a medic. If not it may be helpful to work as an RN first. Good luck and thank you for your service.

allnurses Guide · Jun 30, 2017

What kind of NP do you want to be? In my acute program I heavily used my RN experience during internal med/hospitalist rotations. I imagine a smart student without RN experience (in another words, a qualified MD applicant) could do just as well as me. It's just going to be like drinking out of a firehouse for the first couple years. I was different as a RN, I always asked why and looked for the rationale behind MD decisions. Many RNs don't and thus their experience would be null and void.
Summary: After going through a program I feel RN experience probably isn't necessary for the right student. (Even after being an a ACNP program that required 2 RN years in the ICU)

Didn't we argue about this in the past?

Glad to see you are moving on, the role will suit you.

Dranger · Jun 30, 2017

Didn't we argue about this in the past?
Glad to see you are moving on, the role will suit you.

Haha we did, and I will admit that I was wrong.

Thanks, applying for fellowship programs currently to reinforce my knowledge.