Direct Entry NP Programs: Anti-Intellectualism/Bullying

Polly Peptide, BSN, MSN, RN, APRN · Oct 25, 2018

I will let others answer the majority of your questions. I am one that actually turned down one of the programs you mentioned and chose to pursue the second-degree BSN. I don't think it's impossible to be a competent NP without RN experience. However, considering your age and the fact that you are currently an undergraduate student (for the first time, I assume), why wouldn't you just go ahead and get your BSN? That's the only thing I'm not grasping. While many will make the argument that you'll be "fine," you will absolutely never suffer for gaining experience in the field, right? Especially if you are on the younger side and could use the experience...any experience.

Just my thoughts. If I misunderstood your post, please forgive.

Jules A, MSN · Oct 25, 2018

I already know I'm gonna get bombarded with the "you need bedside experience first" on this post, but my question is, why do established universities like UCSF, Johns Hopkins, Yale, Columbia, Vanderbilt, Emory, (the list goes on) offer these programs if they didn't produce well-rounded, competent individuals?

Unfortunate that you are already mentioning bullying.

While I can't speak about these particular institutions the first thought that comes to my mind is money. If they are charging graduate level tuition for undergraduate courses its a brilliant strategy. It would be interesting to know the increase in universities with nursing programs gross income over the past 5 years after adjusting for inflation of course.

aswiz · Oct 25, 2018

I understand that aspect, but if you look at rate of employment post-graduation for many of these programs, 98%+ of them go on to find jobs without a problem within a year.

Perhaps another reason they are successful is because level of rigor from institutions is so vastly different and # of clinical hours required for graduation varies as well. I think whenever someone hears that I want to pursue a DE program, they assume I want to get my MSN online from some obscure university that barely has accreditation? I'm not sure at this point.

Jules A, MSN · Oct 25, 2018

Up until recently most probably had hiring rates that high but does that actually mean someone is successful? There are many duds out there who are able to get and keep jobs. I would agree programs with good reputations hopefully have more rigor but I would research to see how many of the faculty, even at the prestigious universities, have actually practiced more than a few hours a month in the 30 years they've been employed there. In general nursing is very heavy on book smarts and light on skill especially in recent years.

pro-student · Oct 25, 2018

I'm one of the outliers in the nursing field in that I don't see RN experience as essential to becoming an excellent APP. I would like to point out that there is absolutely no empirical evidence to suggest that RN experience has any impact on performance as an APRN. The roles are often very different and experience in one does not necessarily translate into increased competency in another. We, unfortunately, have more than a few things in nursing like this that people hold onto despite lack of evidence (or evidence to the contrary). We are slow to change sometimes and I think there is an idea that people who try to do things outside the traditional path have disdain for the profession or see themselves as better.

The term "advanced practice nurse" gives some people the wrong idea - that you have to do X amount of basic before you can move up to advanced (as if this was ballet class or something). "Advanced" references the increased scope of practice which, while it is based on mastering basic nursing competencies, does not necessarily require having worked a certain amount of time. (If we extend the ballet metaphor, some people are ready for advanced ballet after a few classes learning the basic, some people need years of practice to barely get the basics down.) Someone will inevitably bring up Patricia Benner and her "Novice to Expert" theory while failing to realize that she never applied to own theory to APRNs (nor was she an APRN) and taught DE students herself.

To answer your question, there are a number of people out there (and in here) that will have made up their mind about you because you didn't do things the "right" way. Let me just point out that this is the very definition of close-mindedness. Many will claim to have anecdotes about people who did it the "wrong" way and how awful they were. The fact remains that hundreds of APRNs have been produced without a day of RN experience and the sky is not falling. I wonder how these individuals preconception about the "right" way shades their observation of people they have already decided couldn't possibly be competent. There are also a number of RNs who aren't nuts about APRNs in general for various reasons.

That being said, there is value in experience for several reasons. Basic nursing is increasingly complex and requires a wide variety of knowledge and skills as well as the ability to seamlessly integrate and act upon this information. This is no small feat and it is nearly impossible to tell who will be able to do with well and who will struggle. It's unlike academics in any other area and even people who are excellent students sometimes struggle immensely with this. Attrition can be high for students in DE programs for this reason and they way they are structured can leave you high and dry if you are unable to complete the whole program for any reason.

Additionally, many people enter and leave nursing school with radically different ideas about what direction they want their nursing career to go. Not having experience in nursing and/or healthcare can leave students without a clear and realistic picture of their desired specialty. All the DE programs I know of require students to select and apply for their specialty before they even begin the program and many or may not permit someone to move to a different specialty. For that reason, it is especially important to do your research and get some first hand exposure to the specialty your interested in. Volunteer at a hospital if you can. Shadow anyone who will let you and make sure you have spend at least some time shadowing a provider in the specialty you're considering. For instance, you might love kids and want to be a PNP but until you have some exposure to sick kids (and their parents), you have no idea what you're getting yourself into.

Some clinical sites and employers will be reluctant to work with DE nurses. Do some research about the demand for your specialty and the job market where you would like to end up after graduation. Primary care and psych are probably much more receptive to DE students/grads than acute care.

The best advice I can give is just you do you. Yes, there are nurses who will turn up their noses at you but that's their problem. Most people will be collegial and will give you the opportunity to demonstrate your skill level without too much bias. Eventually people will judge you based on your own performance especially after a few years as an APRN. Opinions tend to get amplified in places like this especially the extremes. Most people you encounter in your education and professional experience will treat you will respect and keep their biases to themselves. If it makes sense for you and you've done your due diligence, go for it and let the naysayers worry about themselves.

Oldmahubbard · Oct 25, 2018

There will be advantages and disadvantages either way you go. If direct entry MSN programs had existed 30 years ago and I had the financial resources, I would have probably gone that route. Instead I struggled all the way through, getting a cheap ADN, then working as an RN for 13 fairly miserable years as I got my BSN and MSN. However, I supported myself, learned a ton, and came out of my MSN with only modest debt. I also discovered my passion for psych.

The biggest disadvantage I see is that without work experience, you won't know what specialty to pursue. And you won't have any of the "big picture" of that specialty.

A good DE program will be very expensive, and there is no guarantee of the income when you graduate. There are NPs who make 80k.

I went to a mediocre private B and M school where they absolutely did not teach me to be a Psych NP. Our department chair believed in Freud. It was a joke. My work experience as an RN at a mental health clinic was indispensable. I could not have gotten it out of a book.

Nursing is a very catty and judgemental field, no matter the area. You will be deemed incompetent until you prove otherwise. That is the nature of the beast.

On the other hand, a degree from a place like Johns Hopkins or Yale will mean something. If you can get in to a place like that, I would consider it.

If you go to some crappy school where you have to arrange your own clinicals (which is a nightmare), your odds of success are very low.

Trauma Columnist · Oct 25, 2018

Lots of different opinions on this hot subject for sure.

We will all comment on what our own experience is. Hard to make a decision based on what others have done. We all have different circumstances.

I work and live in an area where if you interviewed at our practice, no one would understand DE because its just not here yet. That said, whether you can be a good and competent provider as a DE grad - ? I've never worked with one. I will say that the new grad APRNs that go straight thru from BSN to MSN have done fine.

That said, I think there is something to be said for more experience. If I had done DE (which like OldMaHubbard didn't exist when I went to school) am unsure I would have chosen the path I did as far as specialty. I learned a ton of stuff in my 14 years as an RN - some of which I still use today. Now, that I've been an APRN for 12+ years I truly do feel my RN experience was worthwhile.

To each his own though...

Polly Peptide, BSN, MSN, RN, APRN · Oct 25, 2018

I understand that aspect, but if you look at rate of employment post-graduation for many of these programs, 98%+ of them go on to find jobs without a problem within a year.
Perhaps another reason they are successful is because level of rigor from institutions is so vastly different and # of clinical hours required for graduation varies as well. I think whenever someone hears that I want to pursue a DE program, they assume I want to get my MSN online from some obscure university that barely has accreditation? I'm not sure at this point.

Where have you seen that DE programs provide a greater number of clinical hours than other programs?

In my case, I chose not to go DE, but will likely go to the same school for my MSN. I will get the same number of clinical hours regardless. Even if I didn't, there is a pretty standard number of a hours across MSN NP programs.

adventure_rn, MSN, NP · Oct 25, 2018

All of the above posters have presented excellent points. In addition, there are just a few that I don't think others have mentioned in this forum, although they come up frequently on these types of posts.

I would caution against framing the 'experience is necessary' mindset as 'anti-intellectualism,' since it implies that people who favor experience don't also equally value education; it comes across as a bit presumptuous. I absolutely love higher education, and I completely support nurses furthering their education. However, having gone through nursing school, I'd also argue that clinical rotations can't replace RN experience simply because there isn't enough time. Most NP programs require around 600-700 hours of clincials, which is the equivalent of 3-4 months working full-time. I don't think that anybody would argue you could become an expert nurse in only 3-4 months because there is such a steep learning curve. With even a year of full-time bedside RN experience, you add an additional 2,000 hours of assessments, interventions, and skills to your orificenal.

Many other academic specialties require at least a year or two in order to be eligible for graduate education (like MBA programs in business and MPH programs in global health). It isn't necessarily anti-intellectual to recognize the value of on-the-job experience.

In a more practical sense, the main challenge you may face relates to getting your first new grad NP job. After you get some NP experience, nobody will give to flips about whether you did a traditional program or a direct entry program. However, new grad NPs without RN experience are generally far less competitive than their experienced counterparts. This is simply because you all have the same education, took the same boards, got the same license, etc., but you will be at a disadvantage because you don't bring that additional clinical experience to the table. There are posts on this site from time to time by frustrated direct entry new grads who are struggling to find employment, and this is often the reason why. Again, once you have NP experience it will be a non-issue, but until then you may face an uphill battle.

You mention that many of the high-ranking nursing schools have direct-entry programs. I would caution that field of nursing, unlike many other academic fields, places relatively little value on where you went to school. (As a former pre-med student, where university reputation is everything, this was a very hard mindset adjustment for me to make). Even if you graduate with highest honors from a school like Columbia, you may be far less competitive than a new grad NP from a no-name state school with five years of critical care experience (again, because that person brings 10,600 hours of assessment, intervention, and clinical skills to the table, whereas a direct entry NP brings only 600).

Advanced Practice Columnist / Guide · Oct 25, 2018

The question I have for you is what is it about nursing that draws you toward the field? As you know medical school and NP school are not the only options. PA programs are more structured to be consistent and admits students from a variety of both non-health care and health care fields (albeit exposure to health care is required in a volunteer capacity for those who don't have a healthcare background). You come out of the program trained as a generalist provider whose scope of practice requires close relationship with a physician and there is no specialized restrictions such as those in the NP field (i.e, primary care, acute care, mental health).

BassCatchingNurse · Oct 25, 2018

The short answer is....don't worry about what others think. It is your life. It is legal. You can do it.

Long answer...I am one of those that believe there should be a minimum amount of RN experience prior to becoming an NP, much like there is for CRNA. Why? It's not that I think it is impossible to be an excellent NP without RN experience. It's that I see RN experience as part of the NP education. An experienced RN should know what a COPD patient looks like...what a hypoglycemic patient looks like...what an asthmatic looks like...and on and on. They can anticipate what will be ordered because they have "executed the orders" for years. They already know terminology. They have studied lab results. They have learned to think critically and prioritize. Now, even that experienced nurse has a lot to learn, but they do have valuable knowledge before ever taking one MSN class. But, like what was previously stated....nursing is a catty profession. New grad vs experienced... ADN vs BSN...Online schools vs B&M....but what I think really gets nurses upset about DE...is that DE students normally say they have NO DESIRE to be a nurse....and yet NP's are nurses!!! It does not stand for Nano Physician or New Physician or Nearly a Physician. But...like I said....don't worry about others...it is legal....so do what you want!!! I mean it's not just nurses you have to worry about...there are PA's that do not like NP's...there are doctors that don't like NP's...and there are even patients that don't like NP's. Go to school, study hard, give your best, and be professional. You will win the respect of some and never get respect from others. That goes for ANY profession!!