Clarification on NP Curriculum?

[DO_question]

Hello allnurses,

I'm a DO student dating a RN who is looking into obtaining her DNP in the near future. Currently, she's interested in FNP due to the flexibility and her interests. We try to support each other as best we can, so she has asked me my thoughts on pros & cons of various programs. I feel woefully inadequate for this task just due to unfamiliarity with graduate nursing education and I hope some of you can help me out. So now to the questions...

1. I note the courses at several institutions cover stats, leadership, roll transition, and research but I don't see courses in anatomy, microbiology, immunology, or biochemistry. Are these integrated into other courses? Or is this varied enough that it would be on a school by school basis? I ask this specifically wondering if the undergraduate courses in these subjects are considered adequate for FNP practice or if they are covered at the advanced level. Keep in mind, I'm familiar with her undergrad courses, I took most of them.

2. Is there a general expectation of established clinical sites? To what level does this vary? I'm not finding much on school websites about clinical sites.

3. For those of you in practice, can you offer any resources that would benefit her in making the most of her education? Anything you wish you had done prior to enrollment?

4. Any pitfalls that might not be so obvious to a significant other? Any pitfalls you see that a medical student or resident might need to understand specifically?

I appreciate your time and forgive me if this is some beaten horse, I did try to some rudimentary searches on the site and did not see these questions addressed. Please, if I seem ignorant, just know I'm trying to understand to the best of my ability and support her in her career moves.

[BostonFNP, APRN]

it's only ever FNPs practicing in areas they weren't trained for - specialty trained NPs generally don't try and practice outside of their training. You see it on this forum all the time. FNPs saying they went FNP to "have more options" and "to be able to practice wherever they want". It's unfortunate that schools promulgate this idea. The specialty NPs understand the difference.

Statistically this isn't true; a larger percentage of ACNPs work in nontraditional settings compared to FNPs (not really even close). We may here more "talk" of it here but that's typically because there doesn't tend to be the same type of "outrage" when ACNPs are working in non-traditional settings and/or there are less tradition jobs for the number of ACNPs.

(Keough V.A., Stevenson A., Martinovich Z., Young R., Tanabe P. (2011). Nurse practitioner certification and practice settings: Implications for education and practice. Journal of Nursing Scholarship, 43(2), 195–202.)

A matter of semantic perhaps, but remember FNP is a specialty just like ACAGNP or PNP is. All NPs are trained as specialists.

I don't think the state boards of nursing will ever be specific (about anything) and say where a certain NP can and can not practice.

Based on NCBSN data (though a bit old): "Results indicated that 18 states and the District of Columbia (37%) had specific regulations defining NP SOP by certification and/or educational preparation while 23 (45%) did not. The remaining nine states (18%) had SOP regulations that were interpreted as being ambiguous in relation to certification and/or educational preparation.

(Blackwell, C. W., & Neff, D. F. (2015). Certification and education as determinants of nurse practitioner scope of practice: An investigation of the rules and regulations defining NP scope of practice in the United States. Journal of the American Association of Nurse Practitioners, 27(10), 552-557.)

[Corey Narry, MSN, RN, NP]

Wondering, do you diagnose or do you present your findings to the MD? Meaning are you allowed to in your scope of care?

Thanks and btw your avatar is awesome! It makes me want to go to the beach maybe even all the way to California.

Edit~~~May as well add an awesome video here...

We do diagnose on a lot of cases. We are part of a larger Adult Critical Care Medicine service and rotate on all the adult ICU's - Med/Surg, Cardiac, and Neuro. In some cases, diagnosis is already established, like in the case of a patient coming from the OR after an open heart surgery or craniotomy for a brain bleed. In those cases, while the diagnosis is established, there are physiologic changes that the ICU provider looks out for and treats accordingly such as hemodynamics in the case of the open heart patient and ICP changes in the neuro patient. We would do those as expected of us.

The more challenging case for me are when I'm dealing with medical ICU patients coming in with a puzzling constellation of symptoms. It's easy enough to detect septic shock and determine source and hopefully treat and do source control. I could also be concerned about a pulmonary embolus and do the work-up and confirm. Those are bread and butter cases that we don't always need an attending to start the diagnostic process. Because hospitals are mandated to have a physician in charge of each patient, we call or inform the attending of what we're doing and what the diagnosis we made on a patient.

As an academic medical center, we are the last destination for patients that most other hospitals can't handle. Diagnoses such as hemophagocytic lymphohistiocytosis, posterior reversible encephalopathy syndrome, botulism, creutzfeldt jakob disease are examples of cases I've seen but required a collective effort from an entire ICU provider team + consults to confirm.

[Corey Narry, MSN, RN, NP]

Thanks and btw your avatar is awesome! It makes me want to go to the beach maybe even all the way to California.

Interestingly, that avatar is an Instagram picture I took in Scottsdale, AZ while attending a conference. It reminded me more of Miami Vice a show in the 80's which is certainly dating me. Yes, I'm in California but in the colder north. Yes, there are beaches but they have freezing waters so the surfers are covered neck to ankle with wet suits unlike SoCal where they probably just wear board shorts. It' a cool area here nevertheless with a heyday notable for the "summer of love" but now overcome by techies and the likes of Zuckerbergs and whoever runs twitter or whatever new app kids are into these days. That last part makes the area a bit annoying for old guys like me.

[FullGlass, BSN, MSN, NP]

That being said, it may also be ironic that some on this forum who have no experience in any type of nursing or provider role feel inclined to post as experts on topics they have zero to little experience or expertise in.

Resorting to a snarky comment makes you look weak. I guess you know better than the faculties of Johns Hopkins, UCSF, and U Penn. If it is ok for an FNP w/o acute education or clinical rotations to practice in the acute care environment, then it must be ok for an AGPCNP to practice in psych. After all, 60% of mental health care is provided by primary care practitioners. And I guess they could also work in a hospital. I mean, an AGPCNP does have Adult and Geri training, so it should be ok for them to also provide acute care! Yes, hospitals will hire primary care NPs to work in acute care, but that doesn't make it right. And if anything goes wrong that NP is going to have a very hard time defending him/herself against a malpractice suit. Furthermore, even if a hospital were to hire such a person, they may not get credentialed.

It doesn't matter what the common practice is. The OP had a question and the correct answer is that an NP who wants to practice acute care should study acute care! It is highly irresponsible to suggest otherwise. Not to mention that a lot of hospitals won't hire an NP who has not received appropriate education and training. Given the current consensus model, someone who wants to care for all ages in an ED would be best served by becoming a PA.

[Dodongo, APRN, NP]

A matter of semantic perhaps, but remember FNP is a specialty just like ACAGNP or PNP is. All NPs are trained as specialists.

OH come on now. So the next time I see another one of those silly infographics released during NP week that break down NP work force by practice area, stating that more NPs work in primary care vs specialty practice, I can say that's just not true, all NPs work in a specialty. *wink wink*

You're just splitting hairs there.

And I will admit that outpatient specialty clinics are a grey area for ACNPs (similar to FNPs practicing in the ED or rounding on their hospitalized primary care patients, but there's really no way around that unless you attend an ENP program). However, that study you posted lumped specialty ambulatory care in with primary care for their questionairres. So that's a big limitation. The APPs where I work would technically be practicing in a non traditional setting then as well, as they see patients in the clinic post-operatively (as well as round on inpatients and first assist in the OR). However, who is better prepared for this? An FNP with no surgical training or experience, or an ACNP with that training?

There are a lot of grey areas in the world of NPs. However, I take more umbrage with an FNP trying to practice in the ICU or as a psych provider than I do with an ACNP working in a specialty clinic. The risks are just higher with those populations.

[Oldmahubbard]

I have seen FNPs try to do psych and the results are just sad.

[BostonFNP, APRN]

The OP had a question and the correct answer is that an NP who wants to practice acute care should study acute care! It is highly irresponsible to suggest otherwise.

The particular question was about the ED. The facts here are that the majority of APNs working in that role have FNP training. The majority of ED/UC employers require or prefer it. ENP-certification requires either FNP training plus clinical experience in emergency medicine, completion of an approved fellowship program, or completion of a ENP program (combined FNP and ACAGNP programs): this certification is only two years old. The extant data on the safety of APN in the emergency department is based on APNs which were not certified, the majority of them being FNP trained.

Share with us some of the data you are using to make a determination that ACNPs in this setting have better outcomes or are less prone to malpractice suits. My mind can always be changed by data.

I don't believe that FNPs (or PCAGNPs) should be working in intensivist roles, and unless they have had provider-level experience I also don't believe they should be working in a hospitalist role or psych roles. It happens though, frequently, and thankfully this has traditionally maintained good patient outcomes. In the same vein, should ACNPs be working in specialty clinics? Nothing is clear cut, but in the end, the data is still good on outcomes.

[FullGlass, BSN, MSN, NP]

The particular question was about the ED. The facts here are that the majority of APNs working in that role have FNP training. The majority of ED/UC employers require or prefer it. ENP-certification requires either FNP training plus clinical experience in emergency medicine, completion of an approved fellowship program, or completion of a ENP program (combined FNP and ACAGNP programs): this certification is only two years old. The extant data on the safety of APN in the emergency department is based on APNs which were not certified, the majority of them being FNP trained.

Share with us some of the data you are using to make a determination that ACNPs in this setting have better outcomes or are less prone to malpractice suits. My mind can always be changed by data.

I don't believe that FNPs (or PCAGNPs) should be working in intensivist roles, and unless they have had provider-level experience I also don't believe they should be working in a hospitalist role or psych roles. It happens though, frequently, and thankfully this has traditionally maintained good patient outcomes. In the same vein, should ACNPs be working in specialty clinics? Nothing is clear cut, but in the end, the data is still good on outcomes.

It appears you misinterpreted my answers. The OP wanted information for a prospective NP student, not a practicing NP. He indicated this person was interested in working in the ED. My goal was to answer that question. Since FNP programs are now primary care programs, why would I advise such a person that they should become an FNP? The schools themselves state that their FNP curriculums are primary care only. So why would someone determined to go into acute care knowingly enroll in a program that is only going to provide them with primary education and clinical rotations?

Someone who is serious about going into acute care should study acute care, whether it be PA, AGACNP, or Peds Acute Care NP. There are ample programs out there for acute care.

I am not discussing what is the case with NPs currently practicing, nor am I discussing quality of care.

Many hospitals will NOT hire an FNP for an acute care role. While hospitals in rural areas and certain locations may do so, it's not something I would advise someone to count on.

Practicing outside the scope of one's training also carries legal risks.

If a med student said they wanted to be an ED doc, would it be logical to advise them to strive for a primary care internship and residency? No, it would not. So why is it a good idea to advise a prospective NP student who wants to work in the ED to knowingly enroll in a program that will not provide him/her with any acute care training whatsoever? Someone who is contemplating NP school should select the program that will maximize the chances of achieving their career goals.

Being an NP is not for everyone and there is nothing wrong with that. Being a PA is a better choice for some people.

[BostonFNP, APRN]

Since FNP programs are now primary care programs, why would I advise such a person that they should become an FNP? The schools themselves state that their FNP curriculums are primary care only.

To be totally frank, this is where your inexperience shows: you are speaking like FNP programs suddenly changed their didactic and clinical education in response to the consensus model because you had no experience with nursing prior to it. The truth is, by and- large, they have not changed at all; long established programs have existed relatively unswayed for decades. These program are responsible for the quality outcomes that NP practice is based on.

Someone who is serious about going into acute care should study acute care, whether it be PA, AGACNP, or Peds Acute Care NP. There are ample programs out there for acute care.

But PAs do not just study acute care, they study everything, they are generalist educated. If an NP wants to practice exclusively in intensivist or hospitalist roles, they should be certified in AC for their age group.

Many hospitals will NOT hire an FNP for an acute care role. While hospitals in rural areas and certain locations may do so, it's not something I would advise someone to count on.

This, at the moment, is completely and utterly untrue. How much experience do you have in acute care and in hiring/job seeking in this market? Now we could argue that changes should be made, but as it stands, it is blatantly false to say employers are not hiring FNPs for acute care, especially in the ED/UC setting.

Practicing outside the scope of one's training also carries legal risks.

Of course it does, provided there is harm done. Link us to some data that suggests there is an increase in malpractice for non-traditional APNs. This would then also include ACNPs practicing outside of acute care settings, which the data suggests is far more common practice.

If a med student said they wanted to be an ED doc, would it be logical to advise them to strive for a primary care internship and residency? No, it would not.

Obviously it would not, there is no such thing as "primary care internship and residency", though there are "tracks" within medical specialty. If you take the residency programs that do exist (internal medicine, family medicine, ob/gyn) you;ll find that many of these physicians work in both acute care and primary/secondary care settings.

So why is it a good idea to advise a prospective NP student who wants to work in the ED to knowingly enroll in a program that will not provide him/her with any acute care training whatsoever? Someone who is contemplating NP school should select the program that will maximize the chances of achieving their career goals.

If the student wants to be a certified ENP, you tell us what program they should attend. Here are the requirements (Frequently Asked Questions - ENP - AANPCP).

[Jules A, MSN]

Anyone else have the feeling there might have been a $5 bet on how long it would take us to turn on each other like a pack of rabid dogs?

[BostonFNP, APRN]

Anyone else have the feeling there might have been a $5 bet on how long it would take us to turn on each other like a pack of rabid dogs?

It's a good bet I'd take it!

[BCgradnurse, MSN, RN, NP]

Anyone else have the feeling there might have been a $5 bet on how long it would take us to turn on each other like a pack of rabid dogs?

Things usually deteriorate when constructive criticism isn't taken well.