Does RN experience improve NP competency?

[FullGlass, BSN, MSN, NP]

This has been a topic of much debate among nursing professionals on this forum.  The answer is:  it depends.  Until relatively recently, RN experience was required for admission to NP programs.  However, several years ago, that changed. While most acute care NP programs still require RN work experience, most primary care NP programs do not. This post discusses the reasons for that change and reviews the existing evidence supporting the change.

Some Background

Unlike ADN, BSN, or MSN RN programs, prospective NP students must select one of the following specialties when applying for an NP Program:

Primary Care Roles

• Family Nurse Practitioner (FNP) - FNPs make up the majority of nurse practitioners – 70% of NPs are FNPs (AANP, 2024).
• Pediatric Primary Care NP
• Adult and Geriatric Primary Care NP
• Psychiatric and Mental Health NP (PMHNP) – some inpatient jobs, but the majority are outpatient
• Women's Health NP

Acute Care Roles

• Pediatric Acute Care NP
• Adult and Geriatric Acute Care NP
• There are now some programs for Emergency Department NP

Other Advanced Practice roles not generally categorized as NPs:

• Nurse Anesthetist
• Nurse Midwife

RN Work Experience Likely Benefits Acute Care NPs

For NPs that work in an acute care (inpatient or hospital) setting, RN experience is required for most NP programs in these specialties and RN experience is helpful.  It is intuitive that an RN with med/surg experience who decides to become an Acute Care NP is going to benefit from their RN experience, because it is directly related to their new NP role.  An ER RN will have valuable knowledge and experience for a future Emergency NP.  Likewise, L&D experience will benefit a future Nurse Midwife, and so on.  In other words, RN experience in a similar specialty and care setting will likely be of benefit to an NPs or other APRNs in that specialty and setting (Barnes, 2015; Taylor, et al., 2021).

RN Work Experience Does NOT Appear to Benefit Primary Care NPs

While the vast majority of RNs, about 91%, work in in-patient settings, in contrast, the vast majority of NPs work in a primary care setting (Flinter, et al., 2017).  According to the American Association of Nurse Practitioners (AANP) (2024), 88% of NPs are certified in a primary care specialty, and 70.3% work delivering primary care.

For NPs that work in ambulatory (outpatient) care, RN experience is not required and does not appear to improve NP competency.  This is likely because very few RNs work in primary care in the U.S.  Only 9% of U.S. RNs work in an ambulatory care setting (Flinter, et al., 2017).  Therefore, working as an RN generally does not provide experience directly relevant to primary care NPs.  Working in an outpatient setting is very different than working in a hospital – different conditions seen, different patient acuity level, different protocols, different equipment, different work hours, etc. (Barnes, 2015; Lavoie & Clarke, 2022; Taylor, et al., 2021).

Taylor, et al. (2021), in a study of Norwegian NPs, found that among primary care NP students, "Previous work experience in primary healthcare was a statistically significant, yet minor, predictor of the development of clinical competence.” 

However:

Neither work experience as an RN overall, work experience within specialist health care or previous education, were significant predictors of clinical competence . . . According to the ICN, entry requirements for NP programmes in terms of work experience differ markedly between countries [from 0 to 5 years of experience] . . . in the present authors' previous study we did not find evidence to recommend having work experience as an entry requirement. Due to the findings in the present study, that are significant yet minor, we remain inconclusive to a recommendation for having working experience as an entry requirement. (Taylor, et al., 2021). 

Given that only 9% of U.S. RNs work in an outpatient setting, only a small minority of RN applicants to U.S. primary care NP programs would have relevant work experience.

Barnes (2015), in a U.S. study with mostly FNP participants, found that there was no significant correlation between RN work experience and NP role transition.  Instead, a formal orientation program was significantly positively correlated with NP role transition.  Barnes (2015) hypothesized that " . . . the relationship between prior RN experience and NP role transition may not be solely explained by the amount of RN experience but also the type of RN experience gained. NP role transition may be influenced by similarities or differences between the practice settings of an individual's RN role and subsequent NP role, such as transitioning from an inpatient RN role to an outpatient vs. an inpatient NP role.”  Again, this is likely because only a small minority of US RNs have primary care experience.

Thompson (2019), also found that there was no significant correlation between RN work experience and NP role transition.  Interestingly, this study found a positive correlation between age of the participant and NP role transition.  "This is the first study to demonstrate that there are possibly age-related differences in NP role transition, indicating perhaps more life experience equates to improved coping skills and in general enhances NP role adjustment (Thompson, 2019).”  So, it may be the additional years of life experience that NPs with RN experience have that provides benefit, as opposed to the actual RN experience.  This may also be why highly-motivated new NP graduates without RN experience, for whom becoming an NP is a career change, can become competent NPs.

Furthermore, RN work experience has not been found to translate into improved NP clinical skills.  Rich (2005) found the opposite to be true:

. . . there was a significant negative [emphasis added] correlation between years of experience as a RN and NP clinical practice skills as assessed by the NPs' collaborating physicians. Longer experience as a RN was associated with lower rankings of NP skills competency by the physicians. This information can lead us to question longstanding biases that claim that those with little or no experience as RNs are poorly prepared for advanced NP practice.

The lower ranking of clinical practice skills by NPs with RN work experience may be because such students "would often rely on basic assessment techniques and struggle to integrate more advanced ones:  'They think it's enough to just listen to the lungs.  They forget that you can also percuss, check for pectoriloquy, and so forth.  They've just been doing certain things for the physical exam for so long.’ "  These students may have bad habits of improper assessment techniques that must be unlearned, and this may be difficult for some (Lavoie & Clarke, 2022).

Finally, a recent qualitative descriptive study by Lavoie & Clarke (2022), based on interviews of 27 NP faculty experienced in teaching both traditional (with RN work experience) and direct-entry NP students concluded that requiring RN experience for admission to NP programs is not supported by their experience.   (Direct-entry NP students are defined as NP students without RN work experience).  This is a very interesting study.  Many of the NP educators admitted they were skeptical about allowing direct-entry NP students into their school's programs, but found that the direct-entry students ended up doing just as well as the traditional students.  The faculty agreed that their experience, and current research, has failed to demonstrate that RN work experience is required to become a successful NP (Lavoie & Clarke, 2022). 

The purpose of the Lavoie & Clarke study was to describe NP faculty perceptions of the role of prior RN work experience in developing NP clinical judgment and decision-making.  Clinical judgement was defined as "the NP's ability to harness his or her knowledge, skills, and intuition together with the details of a patient situation to make an assessment and decide on a course of action in partnership with the patient.”  All study participants believed "that prior nursing experience only mattered during education and that it was impossible to distinguish traditional from direct-entry students by the end of their programs.”  Basically, the NP students with RN work experience had a leg up at the beginning of the NP Program, but by the end of the program the direct-entry NP students had "caught up" (Lavoie & Clarke, 2022). 

Interestingly, most of the educators agreed that students with RN experience may have detrimental "baggage.”  Traditional students may " . . . think of one or two things that [the diagnosis] can be, and they can be very rigid.”  They may also be quick to jump to a conclusion without further consideration.  The traditional students often have "hospital-centric" habits, as demonstrated by a tendency to rely on hospital technology, stat labs and consults.”  Such students may need to "unlearn" these habits, which can be difficult.  Traditional students may also have difficulty adjusting to the provider role, because "they must 'break free of the idea that they are going to be implementing orders; instead, they are going to be making orders' (Lavoie & Clarke, 2022).“ 

Participants also pointed out that all RN experience is not created equal.  "There's a limited amount of information you can take from the hospital and apply to outpatient (care) . . .”  Some felt that some traditional students "have just so many entrenched years of experience at the lower skill set . . . (Lavoie & Clarke, 2022).“

Direct-entry students may also have to unlearn habits developed during their previous professional roles.  This includes direct-entry students with non-nursing healthcare experience, such as EMTs.  EMTs "know what to do to save your life, "but this is very different from the typical primary care NP role.  Such students, including internationally-educated physicians, also need to learn the nursing model's more holistic, humanistic approach to health (Lavoie & Clarke, 2022). 

While direct-entry NP students without a healthcare background have a steeper learning curve at the beginning of the NP Program, they also bring valuable knowledge, skills, and insights to the program, that "enriches class discussions (Lavoie & Clarke, 2022).”

Direct-entry NP students usually have an easier time adjusting to the provider role because they don't have the RN frame of reference.  They are very clear on being an NP provider and "own it (Lavoie & Clarke, 2022).”

Other personal or professional experiences of direct-entry NP students can also facilitate development of clinical judgment.  The faculty participants " . . . believed that any experience involving problem-solving and analytical thinking can provide exposure to advanced decision-making" that will help develop clinical judgment.  Taking care of a sick relative or friend can also be beneficial (Lavoie & Clarke, 2022). 

Another factor that may help direct-entry NP students is that, in the literature, they are often described as "academically gifted.”  Their academic abilities may offset their lack of RN experience and allow them to "catch up" to the students with RN work experience by the end of the program (Lavoie & Clarke, 2022).

Lavoie & Clarke (2022) concluded that while differences between traditional and direct-entry NP students were most apparent during the first few months of the programs, " . . . eventually, students could not be distinguished based on their previous experience.  These findings align with prior studies that showed equivalent outcomes for NP students with and without RN experience in terms of academic success and successful entry to practice.”

Conclusion

While some initial research indicated RN work experience was helpful to prospective NPs, additional research has not supported that conclusion.  The consensus of current research on this topic is that prior RN work experience is not required to become a successful primary care NP.  This was a limited review, but other studies referenced in the reviewed literature came to the same conclusion. 

A couple of additional findings merit discussion.  RN work experience that was directly related to the NP specialty was found to have a small, but significant, positive benefit (Taylor, et al., 2021).  However, given that only 9% of U.S. RNs work in primary care, while 88% of NPs are certified in primary care, the number of RNs with relevant work experience for a primary care NP is quite small.

An additional interesting finding by Thompson (2019) was that age at start of an NP Program was positively correlated with NP role transition.  The educators in the Lavoie & Clarke (2022) study also agreed that various types of professional and life experience can facilitate becoming an NP. 

References

American Association of Nurse Practitioners (AANP).  (2024, February).  NP fact sheet.  https://www.AANP.org/about/all-about-nps/NP-fact-sheet

Barnes H. (2015). Exploring the factors that influence nurse practitioner role transition. The Journal for Nurse Practitioners, 11(2), 178–183. https://doi.org/10.1016/j.nurpra.2014.11.004

Flinter, M., Hsu, C., Cromp, D., Ladden, M. D., & Wagner, E. H. (2017). Registered nurses in primary care: Emerging new roles and contributions to team-based care in high-performing practices. The Journal of Ambulatory Care Management, 40(4), 287–296. https://doi.org/10.1097/JAC.0000000000000193

Lavoie, P., & Clarke, S.P.  (2022).  Educators' perceptions of the development of clinical judgment of direct-entry students and experienced RNs enrolled in NP programs.  Journal of Nursing Regulation,

12(4), 4-1.  https://doi.org/10.1016/S2155-8256(22)00011-4.

Rich, Ellen R.  (2005, December).  Does RN Experience Relate to NP Clinical Skills?  The Nurse Practitioner 30(12), 53-56.

Taylor, I., Bing-Jonsson, P.C., Finnbakk, E., Wangensteen, S., Sandvik, L., & Fagerstrom, L.  (2021).  Development of clinical competence – a longitudinal survey of nurse practitioner students. BMC Nursing, 20(130). https://doi.org/10.1186/s12912-021-00627-x

[subee, MSN, CRNA]

FullGlass said:

This has been a topic of much debate among nursing professionals on this forum.  The answer is:  it depends.  Until relatively recently, RN experience was required for admission to NP programs.  However, several years ago, that changed. While most acute care NP programs still require RN work experience, most primary care NP programs do not. This post discusses the reasons for that change and reviews the existing evidence supporting the change.

Some Background

Unlike ADN, BSN, or MSN RN programs, prospective NP students must select one of the following specialties when applying for an NP Program:

Primary Care Roles

• Family Nurse Practitioner (FNP) - FNPs make up the majority of nurse practitioners – 70% of NPs are FNPs (AANP, 2024).
• Pediatric Primary Care NP
• Adult and Geriatric Primary Care NP
• Psychiatric and Mental Health NP (PMHNP) – some inpatient jobs, but the majority are outpatient
• Women's Health NP

Acute Care Roles

• Pediatric Acute Care NP
• Adult and Geriatric Acute Care NP
• There are now some programs for Emergency Department NP

Other Advanced Practice roles not generally categorized as NPs:

• Nurse Anesthetist
• Nurse Midwife

RN Work Experience Likely Benefits Acute Care NPs

For NPs that work in an acute care (inpatient or hospital) setting, RN experience is required for most NP programs in these specialties and RN experience is helpful.  It is intuitive that an RN with med/surg experience who decides to become an Acute Care NP is going to benefit from their RN experience, because it is directly related to their new NP role.  An ER RN will have valuable knowledge and experience for a future Emergency NP.  Likewise, L&D experience will benefit a future Nurse Midwife, and so on.  In other words, RN experience in a similar specialty and care setting will likely be of benefit to an NPs or other APRNs in that specialty and setting (Barnes, 2015; Taylor, et al., 2021).

RN Work Experience Does NOT Appear to Benefit Primary Care NPs

While the vast majority of RNs, about 91%, work in in-patient settings, in contrast, the vast majority of NPs work in a primary care setting (Flinter, et al., 2017).  According to the American Association of Nurse Practitioners (AANP) (2024), 88% of NPs are certified in a primary care specialty, and 70.3% work delivering primary care.

For NPs that work in ambulatory (outpatient) care, RN experience is not required and does not appear to improve NP competency.  This is likely because very few RNs work in primary care in the U.S.  Only 9% of U.S. RNs work in an ambulatory care setting (Flinter, et al., 2017).  Therefore, working as an RN generally does not provide experience directly relevant to primary care NPs.  Working in an outpatient setting is very different than working in a hospital – different conditions seen, different patient acuity level, different protocols, different equipment, different work hours, etc. (Barnes, 2015; Lavoie & Clarke, 2022; Taylor, et al., 2021).

Taylor, et al. (2021), in a study of Norwegian NPs, found that among primary care NP students, "Previous work experience in primary healthcare was a statistically significant, yet minor, predictor of the development of clinical competence.” 

However:

Neither work experience as an RN overall, work experience within specialist health care or previous education, were significant predictors of clinical competence . . . According to the ICN, entry requirements for NP programmes in terms of work experience differ markedly between countries [from 0 to 5 years of experience] . . . in the present authors' previous study we did not find evidence to recommend having work experience as an entry requirement. Due to the findings in the present study, that are significant yet minor, we remain inconclusive to a recommendation for having working experience as an entry requirement. (Taylor, et al., 2021). 

Given that only 9% of U.S. RNs work in an outpatient setting, only a small minority of RN applicants to U.S. primary care NP programs would have relevant work experience.

Barnes (2015), in a U.S. study with mostly FNP participants, found that there was no significant correlation between RN work experience and NP role transition.  Instead, a formal orientation program was significantly positively correlated with NP role transition.  Barnes (2015) hypothesized that " . . . the relationship between prior RN experience and NP role transition may not be solely explained by the amount of RN experience but also the type of RN experience gained. NP role transition may be influenced by similarities or differences between the practice settings of an individual's RN role and subsequent NP role, such as transitioning from an inpatient RN role to an outpatient vs. an inpatient NP role.”  Again, this is likely because only a small minority of US RNs have primary care experience.

Thompson (2019), also found that there was no significant correlation between RN work experience and NP role transition.  Interestingly, this study found a positive correlation between age of the participant and NP role transition.  "This is the first study to demonstrate that there are possibly age-related differences in NP role transition, indicating perhaps more life experience equates to improved coping skills and in general enhances NP role adjustment (Thompson, 2019).”  So, it may be the additional years of life experience that NPs with RN experience have that provides benefit, as opposed to the actual RN experience.  This may also be why highly-motivated new NP graduates without RN experience, for whom becoming an NP is a career change, can become competent NPs.

Furthermore, RN work experience has not been found to translate into improved NP clinical skills.  Rich (2005) found the opposite to be true:

. . . there was a significant negative [emphasis added] correlation between years of experience as a RN and NP clinical practice skills as assessed by the NPs' collaborating physicians. Longer experience as a RN was associated with lower rankings of NP skills competency by the physicians. This information can lead us to question longstanding biases that claim that those with little or no experience as RNs are poorly prepared for advanced NP practice.

The lower ranking of clinical practice skills by NPs with RN work experience may be because such students "would often rely on basic assessment techniques and struggle to integrate more advanced ones:  'They think it's enough to just listen to the lungs.  They forget that you can also percuss, check for pectoriloquy, and so forth.  They've just been doing certain things for the physical exam for so long.’ "  These students may have bad habits of improper assessment techniques that must be unlearned, and this may be difficult for some (Lavoie & Clarke, 2022).

Finally, a recent qualitative descriptive study by Lavoie & Clarke (2022), based on interviews of 27 NP faculty experienced in teaching both traditional (with RN work experience) and direct-entry NP students concluded that requiring RN experience for admission to NP programs is not supported by their experience.   (Direct-entry NP students are defined as NP students without RN work experience).  This is a very interesting study.  Many of the NP educators admitted they were skeptical about allowing direct-entry NP students into their school's programs, but found that the direct-entry students ended up doing just as well as the traditional students.  The faculty agreed that their experience, and current research, has failed to demonstrate that RN work experience is required to become a successful NP (Lavoie & Clarke, 2022). 

The purpose of the Lavoie & Clarke study was to describe NP faculty perceptions of the role of prior RN work experience in developing NP clinical judgment and decision-making.  Clinical judgement was defined as "the NP's ability to harness his or her knowledge, skills, and intuition together with the details of a patient situation to make an assessment and decide on a course of action in partnership with the patient.”  All study participants believed "that prior nursing experience only mattered during education and that it was impossible to distinguish traditional from direct-entry students by the end of their programs.”  Basically, the NP students with RN work experience had a leg up at the beginning of the NP Program, but by the end of the program the direct-entry NP students had "caught up" (Lavoie & Clarke, 2022). 

Interestingly, most of the educators agreed that students with RN experience may have detrimental "baggage.”  Traditional students may " . . . think of one or two things that [the diagnosis] can be, and they can be very rigid.”  They may also be quick to jump to a conclusion without further consideration.  The traditional students often have "hospital-centric" habits, as demonstrated by a tendency to rely on hospital technology, stat labs and consults.”  Such students may need to "unlearn" these habits, which can be difficult.  Traditional students may also have difficulty adjusting to the provider role, because "they must 'break free of the idea that they are going to be implementing orders; instead, they are going to be making orders' (Lavoie & Clarke, 2022).“ 

Participants also pointed out that all RN experience is not created equal.  "There's a limited amount of information you can take from the hospital and apply to outpatient (care) . . .”  Some felt that some traditional students "have just so many entrenched years of experience at the lower skill set . . . (Lavoie & Clarke, 2022).“

Direct-entry students may also have to unlearn habits developed during their previous professional roles.  This includes direct-entry students with non-nursing healthcare experience, such as EMTs.  EMTs "know what to do to save your life, "but this is very different from the typical primary care NP role.  Such students, including internationally-educated physicians, also need to learn the nursing model's more holistic, humanistic approach to health (Lavoie & Clarke, 2022). 

While direct-entry NP students without a healthcare background have a steeper learning curve at the beginning of the NP Program, they also bring valuable knowledge, skills, and insights to the program, that "enriches class discussions (Lavoie & Clarke, 2022).”

Direct-entry NP students usually have an easier time adjusting to the provider role because they don't have the RN frame of reference.  They are very clear on being an NP provider and "own it (Lavoie & Clarke, 2022).”

Other personal or professional experiences of direct-entry NP students can also facilitate development of clinical judgment.  The faculty participants " . . . believed that any experience involving problem-solving and analytical thinking can provide exposure to advanced decision-making" that will help develop clinical judgment.  Taking care of a sick relative or friend can also be beneficial (Lavoie & Clarke, 2022). 

Another factor that may help direct-entry NP students is that, in the literature, they are often described as "academically gifted.”  Their academic abilities may offset their lack of RN experience and allow them to "catch up" to the students with RN work experience by the end of the program (Lavoie & Clarke, 2022).

Lavoie & Clarke (2022) concluded that while differences between traditional and direct-entry NP students were most apparent during the first few months of the programs, " . . . eventually, students could not be distinguished based on their previous experience.  These findings align with prior studies that showed equivalent outcomes for NP students with and without RN experience in terms of academic success and successful entry to practice.”

Conclusion

While some initial research indicated RN work experience was helpful to prospective NPs, additional research has not supported that conclusion.  The consensus of current research on this topic is that prior RN work experience is not required to become a successful primary care NP.  This was a limited review, but other studies referenced in the reviewed literature came to the same conclusion. 

A couple of additional findings merit discussion.  RN work experience that was directly related to the NP specialty was found to have a small, but significant, positive benefit (Taylor, et al., 2021).  However, given that only 9% of U.S. RNs work in primary care, while 88% of NPs are certified in primary care, the number of RNs with relevant work experience for a primary care NP is quite small.

An additional interesting finding by Thompson (2019) was that age at start of an NP Program was positively correlated with NP role transition.  The educators in the Lavoie & Clarke (2022) study also agreed that various types of professional and life experience can facilitate becoming an NP. 

References

American Association of Nurse Practitioners (AANP).  (2024, February).  NP fact sheet.  https://www.AANP.org/about/all-about-nps/NP-fact-sheet

Barnes H. (2015). Exploring the factors that influence nurse practitioner role transition. The Journal for Nurse Practitioners, 11(2), 178–183. https://doi.org/10.1016/j.nurpra.2014.11.004

Flinter, M., Hsu, C., Cromp, D., Ladden, M. D., & Wagner, E. H. (2017). Registered nurses in primary care: Emerging new roles and contributions to team-based care in high-performing practices. The Journal of Ambulatory Care Management, 40(4), 287–296. https://doi.org/10.1097/JAC.0000000000000193

Lavoie, P., & Clarke, S.P.  (2022).  Educators' perceptions of the development of clinical judgment of direct-entry students and experienced RNs enrolled in NP programs.  Journal of Nursing Regulation,

12(4), 4-1.  https://doi.org/10.1016/S2155-8256(22)00011-4.

Rich, Ellen R.  (2005, December).  Does RN Experience Relate to NP Clinical Skills?  The Nurse Practitioner 30(12), 53-56.

Taylor, I., Bing-Jonsson, P.C., Finnbakk, E., Wangensteen, S., Sandvik, L., & Fagerstrom, L.  (2021).  Development of clinical competence – a longitudinal survey of nurse practitioner students. BMC Nursing, 20(130). https://doi.org/10.1186/s12912-021-00627-x

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I have  a problem with advanced practitioners with no previous nursing experience.   But they need to change their title since they can't magically earn the title "advanced practice " if they haven't ever experienced basic practice.  Perhaps they should just become PA's so they can avoid the whole lie of advanced practice nurse.  

[FullGlass, BSN, MSN, NP]

subee said:

I have  a problem with advanced practitioners with no previous nursing experience.   But they need to change their title since they can't magically earn the title "advanced practice " if they haven't ever experienced basic practice.  Perhaps they should just become PA's so they can avoid the whole lie of advanced practice nurse.  

I'm sorry you have a problem, but the evidence does not support your view.  In addition, it is highly unreasonable to demand that NPs that do not have the background you prefer have a different title.  Good luck with that.

[subee, MSN, CRNA]

FullGlass said:

I'm sorry you have a problem, but the evidence does not support your view.  In addition, it is highly unreasonable to demand that NPs that do not have the background you prefer have a different title.  Good luck with that.

I haven't seen any evidence yet that I would call scientific with the one exception (but only one study) that NP's do not over-order tests as compared to MD's.  It's hard to devise a study design to measure what doesn't exist - a cadre of experienced practitioners who become NP's.   It defies logic that someone who never saw a sick patient can recognize who shows up in an office or a clinic.  I don't believe that patient satisfaction scores count as scientific proof.  Patients judge us on a variety of non-clinical traits.  It would take a layman only five minutes to see the advertising of NP programs that promise cheap, quick and no classroom attendance required.  The physicians certainly see it.  

[FullGlass, BSN, MSN, NP]

subee said:

I haven't seen any evidence yet that I would call scientific with the one exception (but only one study) that NP's do not over-order tests as compared to MD's.  It's hard to devise a study design to measure what doesn't exist - a cadre of experienced practitioners who become NP's.   It defies logic that someone who never saw a sick patient can recognize who shows up in an office or a clinic.  I don't believe that patient satisfaction scores count as scientific proof.  Patients judge us on a variety of non-clinical traits.  It would take a layman only five minutes to see the advertising of NP programs that promise cheap, quick and no classroom attendance required.  The physicians certainly see it.  

I essentially wrote a paper reviewing the evidence, and it concluded that RN experience is not required to be a good NP.   There was not one single study to the contrary.  Your anecdotal opinion does not contribute to a scholarly discussion.