Direct entry graduate nursing school advice -NP

WestCoastSunRN, MSN, CNS · Jun 2, 2017

I'm going to be straight with you. RN experience is a must for advanced practice nursing. I know there are short cuts now, but it isn't right and it's not about "paying your dues". I'm also going to be even more specific and say that only nursing experience with direct patient care -- inpatient bedside nursing, to be specific -- should qualify as appropriate experience. Nurses at the bedside hone the skills they learned in nursing school of physical assessment, triage, patient management, lab/test interpretation, problem solving, collaboration, care-planning (an important and unique contribution of nursing), and more. I had cursory introduction to these things in school. I learned and mastered them on-the-job. After years at the bedside, and I'm still learning.

Advanced Practice Nursing is based off the model that a nurse enters into a graduate program AFTER obtaining this experience. This is why the clinical requirements are less for student NPs than for PAs, for instance. People who argue that prior RN experience doesn't matter because the job of a bedside RN is vastly different than the job of an NP, miss the point completely of how skills build upon other skills. The muscles of a basic nursing education need to be worked and strengthened before taking on the very daunting and heavy responsibility of becoming a provider. Furthermore, being a provider should in no way be romanticized -- which I feel is what many many nursing schools are doing these days -- most especially these schools that make it easy to become one. As for direct entry grads being successful? If those programs were modeled after PA programs I would be much more encouraged -- but they aren't. They are science-lite and clinical-lite compared to PA programs. The idea of APN programs is that they could get away with that because of the years of experience their students had (and yes, even though it's not diagnosing and prescribing experience -it is VERY valuable experience especially in ICU/ED/home health settings where the nurse needs to be able to function with quick thinking and autonomy).

Bedside nursing is a great gig. I encourage you to think long and hard about becoming a nurse -- and doing that for awhile to test the waters and yourself. Aside from that, you could look into PA programs that will prepare you to be a mid-level provider who will always have the support and supervision of a medical colleague. That makes way more sense to me, than going into a direct entry advanced nursing program.

Best of luck to you!

JTravelsTheWorld, RN · Jun 2, 2017

Bump!

MierKat · Jun 3, 2017

J - there was another recent thread with lots of different opinions on the DE NP route. https://allnurses.com/nurse-practitioners-np/brave-or-just-1100340.html You might find it interesting.

JTravelsTheWorld, RN · Jun 6, 2017

That is very helpful. Thank you.!

ForensicPMHNP, MSN, NP · Jun 6, 2017

Do what makes financial sense to you. Gaining experience as a bedside RN is great but if the direct entry program makes more sense financially and time wise then that is where you should go. As long as you put in the effort to become the best provider you can be and continue to learn you will be ok, in the end this is a decision that you have to make, not anyone on this board and remember that NP's and RN's do not do the same thing, do not let anyone guilt trip you into doing it just because they think that is how things should be.

allnurses Guide · Jun 7, 2017

RN experience is a must for advanced practice nursing. Nurses at the bedside hone the skills they learned in nursing school of physical assessment, triage, patient management, lab/test interpretation, problem solving, collaboration, care-planning (an important and unique contribution of nursing), and more. I had cursory introduction to these things in school. I learned and mastered them on-the-job. After years at the bedside, and I'm still learning.

Respectfully, I disagree with this as an absolute.

You are absolutely right that this is career of lifetime learning, in fact it really requires a commitment to lifetime learning. Just like RN practice, APNs demonstrate a basic competence by board exam but entry to practice signifies the beginning of the development of that practice. All novice providers whether they are NPs or PAs or physicians require years of on-the-job development. As such, and as you give credit to, much of practice is developed in the year or two following entry to practice, working on-the-job (really it is the only way to see the amount of patients that need to be seen to be competent independently.

Nursing experience often helps student and novice NPs, depending on the quality of their experience and it's relation to their NP role. There are some skills that RNs have that make them excellent providers, but they are not tangible skills from my experience, rather they are things like being comfortable talking to patients, having a "6th sense" about a patient before they tank, a familiarity with the system in general.

As you mention, nursing school gives a cursory introduction to skills and they are developed through experience: this means that, at times, they are developed incorrectly/poorly, or not developed at all depending on the type of RN experience. At times there can be difficulty with role transition/confusion with long-time RNs moving to the APN role. At times there can be over-confidence, which is one of the most dangerous things to a novice provider.

In my experience, there are great student NPs with no nursing (or very limited) experience and terrible students with lots of nursing experience and vice-versa. It would be wonderful if we had large studies that looked at this to remove individual variability, but there are only a few (and they suggest RN experience is not an important predictor of NP role transition or skills). I can say, having educated a pretty decent number of student NPs, is that the variability between individuals is greater then the variability of their prior RN experience. The thing I dislike the most is student NPs that are going to NP school, doing NP clinicals while trying to also learn the RN role in the first 1-2 years as an RN, and I feel the end up doing poorly at both.

WestCoastSunRN, MSN, CNS · Jun 7, 2017

Nursing experience often helps student and novice NPs, depending on the quality of their experience and it's relation to their NP role. There are some skills that RNs have that make them excellent providers, but they are not tangible skills from my experience, rather they are things like being comfortable talking to patients, having a "6th sense" about a patient before they tank, a familiarity with the system in general.
.

Boston, you do make some great points. I sure would be hesitant about anyone who came into an advanced practiced role with too much confidence. I also agree that it's NOT good to be working as a new nurse and going to NP school simultaneously. My solution to that would be to require at least 2 years of bedside experience (maybe more -- but I see 2 years seems typical) as a prerequisite for entry into a program. And that is because of what I quoted from you above: perhaps you're right -- the experience that can make the difference between and experienced RN and direct entry may in large part be intangible. But I would suggest it is experience earned on-the-job nonetheless.

Another poster mentioned that NPs and RNs do not do the same things. Of course this is an obvious truth and one I, myself, pointed out in my answer to the OP. But the real world work you have done with patients -- especially the varied work that comes from inpatient, acute care bedside nursing --- real world pharmacology, wound care, assessment -- exposure to these things and more (yes --- talking to real patients everyday!) add up to what is, in my mind, an immeasurable advantage to the bedside nurse advancing his/her practice to NP.

The OP asked the question --- she wants to know she will be well prepared for practice. I gave her my input --- and without even going into the questions that many have about the lack of rigor in NP programs to begin with (aside from whether they are direct entry or not --- another thread). And a reason I suggested she look into a PA program -- which is based off the medical model and requires no patient care background.

But obviously it is a point up for debate and so we'll just have to agree to disagree. :)

ForensicPMHNP, MSN, NP · Jun 7, 2017

Most PA programs require prior direct patient care experience before you can gain admission, it is true that they are based on the allopathic model but entry into those programs is quite strict. Also, requiring 2 years of bedside experience as an RN for an NP programs seems a bit unrealistic especially since the two roles are focused on very different things. I do agree that prior experience in direct pt care is helpful but that is not always the case, would bedside nursing experience be that helpful for a prospective PMHNP? NP scope of practice is varied and a good RN does not always equal a good NP (and vice versa). But I think you made a lot of good points.

Jules A, MSN · Jun 7, 2017

I do agree that prior experience in direct pt care is helpful but that is not always the case, would bedside nursing experience be that helpful for a prospective PMHNP? .

My opinion is that having inpatient acute unit psychiatric experience is absolutely crucial prior to becoming a PMHNP although its obvious the majority of schools disagree. Hmmmm I wonder if they have an ulterior motive? Money perhaps?

allnurses Guide · Jun 7, 2017

Another poster mentioned that NPs and RNs do not do the same things. But the real world work you have done with patients -- especially the varied work that comes from inpatient, acute care bedside nursing --- real world pharmacology, wound care, assessment -- exposure to these things and more (yes --- talking to real patients everyday!) add up to what is, in my mind, an immeasurable advantage to the bedside nurse advancing his/her practice to NP.

Every individual is different, as I said, and I think some gain a great deal from spending years as an RN at the bedside, especially in specialty practice and acute care (psych is one of the most obvious of those as Jules points out). Other's don't; I know no nurses here will want to admit it, but there are some nurses out there that do crap assessments or are forced to do crap assessments by other demands like clicking boxes in the EMR. Also, the pharmacology and assessment as an RN is completely different from that of an APN, something I didn't fully appreciate until I moved to the APN role (and perhaps was a previous poster was alluding to).

For example, does having 30 years of RN experience in wound care nursing really prepare you for the PMHNP role like 5 years of inpatient psych does? Does 30 years of ICU experience really prepare you for the outpatient primary care role? There are translatable skills sure, but some experience is more valuable that others as well.

After I worked as an NP for a few years I started thinking of the question: who would I want taking care of me, an NP with 1 year of NP experience and 9 years of RN experience or an NP with 9 years of NP experience and 1 year of RN experience?

ADDENDUM: I should add, just my two cents.

kadphilly · Jun 11, 2017

Respectfully, I disagree with this as an absolute.
You are absolutely right that this is career of lifetime learning, in fact it really requires a commitment to lifetime learning. Just like RN practice, APNs demonstrate a basic competence by board exam but entry to practice signifies the beginning of the development of that practice. All novice providers whether they are NPs or PAs or physicians require years of on-the-job development. As such, and as you give credit to, much of practice is developed in the year or two following entry to practice, working on-the-job (really it is the only way to see the amount of patients that need to be seen to be competent independently.
Nursing experience often helps student and novice NPs, depending on the quality of their experience and it's relation to their NP role. There are some skills that RNs have that make them excellent providers, but they are not tangible skills from my experience, rather they are things like being comfortable talking to patients, having a "6th sense" about a patient before they tank, a familiarity with the system in general.
As you mention, nursing school gives a cursory introduction to skills and they are developed through experience: this means that, at times, they are developed incorrectly/poorly, or not developed at all depending on the type of RN experience. At times there can be difficulty with role transition/confusion with long-time RNs moving to the APN role. At times there can be over-confidence, which is one of the most dangerous things to a novice provider.
In my experience, there are great student NPs with no nursing (or very limited) experience and terrible students with lots of nursing experience and vice-versa. It would be wonderful if we had large studies that looked at this to remove individual variability, but there are only a few (and they suggest RN experience is not an important predictor of NP role transition or skills). I can say, having educated a pretty decent number of student NPs, is that the variability between individuals is greater then the variability of their prior RN experience. The thing I dislike the most is student NPs that are going to NP school, doing NP clinicals while trying to also learn the RN role in the first 1-2 years as an RN, and I feel the end up doing poorly at both.

I could not agree with this more. I have precepted NP students for many years, and I have not found that years of experience as an RN to be strongly correlated with the skills and effectiveness of the NP student. It's really about thinking autonomously and critically. If anything, I have anecdotally found that more than 10 years or so experience as an RN to be negatively associated with these abilities, in particular for the primary care role. I too would love to study this as I believe the results would not support many years of inpatient experience prior to entering an NP program.

I had one year experience as a visiting Peds RN prior to entering my PNP program 20 years ago. I continued working during my masters as a visiting nurse, which was actually an appropriate experience for primary care. I never worked a day in my life in a hospital or an acute care setting. And you are correct in saying that you develop the skills as an NP in the first year or two of practice. I truly believe that it's the ability of the candidate to think critically and autonomously foremost, and the standard of education at their program secondly. I have found that RN experience may or may not benefit, depending on the speciality. Not every RN is cut out to be an NP. I believe that if anything, NP programs should be more selective about the academic ability of the student rather than the years of RN experience. There are too many NP programs that are accepting inappropriate candidates from an academic standpoint.