I'm an NP student - How did you choose your specialty?

AnnieNP, MSN, NP · Mar 29, 2018

I think I actually "stumbled" into all of the positions I had in the hospital over the years. My first year out of school I worked on a Cardiac Step down unit (this was in 1989 when there was a real nursing shortage). I was terrified the first 6 months and prayed every day I wouldn't kill anyone. From there I went to CCU for another 2 years. Then I moved to the ER and loved it. I was part time, and then I was asked to cover a maternity leave in Endoscopy (for a former CCU nurse I used to work with). Remember this is when there was a real shortage and they were willing to train me on my days off from the ER just to have the coverage. When my youngest started college a friend asked me if I wanted to go back to get my NP and we could do it together. I said sure, why not!!!!! I had seen so many sick people over the previous 16 years that I thought it would be a good idea to work in primary care and try to keep the patients out of the hospital. When I started the NP program I knew I wanted to do primary care for adults and I have never looked back. I really do love being an NP and I also enjoy teaching, so I precept every semester.

allnurses Guide · Mar 29, 2018

Those who had at least 5 years of nursing experience prior to doing their NP typically did quite well in their NP programs. Those who went straight through the BSN-MN-NP stream didn't pass their preceptorships in most cases.

What program were you precepting for? If "most" aren't passing their preceptorships then there is a fundamental flaw with either the program or the preceptors. I would think we could all agree on that.

The_Salty_Cat · Mar 29, 2018

No kidding, your criticism on my post is the exact point I was making to the post I quoted. I'm merely conveying to this student that they were being oxymoronic. Critiquing someone's opinion with no facts is exactly the problem. We all have our opinions, but we all know that every individual is different. I would be interested in a study on this. Honestly, if there were several studies with results tending to find no significant difference I would be more open to it. If stduies even showed that non RN experienced NPs were better, I would be in support of it. Thinking like a true scientist would mean exploring new avenues, and trying to find what works the best. However, until this arguement actually has facts, I have my opinion.
The original question the OP asked was about finding your specialty. Most individuals think that experience helps guide you, I am one of those people. Does that need to be the answer for everyone? No, it does not.

Columbia University recently received a couple million dollars to study your specific complaint. I'll be sure to send you the most updated facts when the papers are published (:

allnurses Guide · Mar 29, 2018

No. I would argue that's simply not true in most cases. There is a significant difference between the "novice" NP who has more than a year or two of previous work experience in emergency, L&D, outpost hospitals, public health, etc, versus the "novice" NP who has never done any clinical practice outside of a practicum. The former is an established RN, who has a wealth of knowledge and experience to rely on in order to accurately assess, diagnose, and treat/manage the patient's problem. The latter is a new grad, who has mostly book-learning to offer with limited experience to back it up. Don't tell me there's no difference between the two, because I assure you, there is.

If you can assure us, then cite your sources. If anyone can show me data that shows, in aggregate, prior RN experience makes any significant difference in NP role socialization, I will change sides and argue for it being a requirement (and perhaps in some specialty settings it should be)! My professional experience has been different (with the caveat that clearly this could also be grossly affected by my location, practice area and the programs I have worked with) and while I have had excellent SNPs with years of RN experience and poor SNPs with no RN experience, the reverse is also true, and I have never found that prior RN experience predicted if a student would excel or fail or be average. Same is true of my experience with prior healthcare experience for medical students.

The problem with a blanket requirement for RN experience, as I see it (and aside from a total lack of evidence it would be statistically beneficial) is that the quality and type of RN experience is so variable it is difficult to assess the contribution of that experience. There is one clear place in my experience that RN experience helps novice NPs: dealing with other nurses. We can see evidence of that here on this thread in the assumption of nurses that an novice NP with any type of RN experience is better than a novice NP without any experience regardless of how talented the individual is. Can ED experience as an RN help an novice NP working in the ED? Absolutely. Does that mean is is necessary? How much of it? Does the novice NP in the ED get the same kind of help from RN experience in a different setting like a dermatology clinic?

I've been both the "novice" outpost nurse, who worked the equivalent of a NP position, almost immediately after graduating with my BSN, and the very experienced NP. I look back at my early days of outpost nursing and shudder to think of all I didn't know. Some nights and weekends, I was the only medical person available in the community I lived in. I'm sure it was only the grace of God that kept my patients safe in some cases.

Isn't the moral to that story that you were challenged and succeeded? Or are you arguing you should have been help back from that career until you had more experience?

allnurses Guide · Mar 29, 2018

Columbia University recently received a couple million dollars to study your specific complaint. I'll be sure to send you the most updated facts when the papers are published (:

There are already a number of published studies, though most of them are small.

Bumex, DNP, NP · Mar 29, 2018

There are already a number of published studies, though most of them are small.

Can you furnish some links? Regardless of the outcome, I love to read newer peer-reviewed research.

allnurses Guide · Mar 30, 2018

Can you furnish some links? Regardless of the outcome, I love to read newer peer-reviewed research.

There is a more comprehensive listed posted in another thread somewhere but here are a few off the top of my mind. I have been thinking for years that I'd make a thread/article that discusses all these sources as a point of reference for future discussion but it hasn't happened. The burden of running an independent practice in the era of dwindling reimbursements.

Rich, E. R. (2005). Does RN experience relate to NP clinical skills?. The Nurse Practitioner, 30(12), 53-56.

Barnes, H. (2015). Exploring the factors that influence nurse practitioner role transition. The Journal for Nurse Practitioners, 11(2), 178-183.

Steiner, S. H., McLaughlin, D. G., Hyde, R. S., Brown, R. H., & Burman, M. E. (2008). Role transition during RN-to-FNP education. Journal of Nursing Education, 47(10), 441-447.

Pellico, L. H., Terrill, E., White, P., & Rico, J. (2012). Integrative review of graduate entry programs in nursing. Journal of Nursing Education, 51(1), 29-37.

Twine, N. (2017). The first year as a nurse practitioner: An integrative literature review of the transition experience. Journal of Nursing Education and Practice, 8(5), 54.

SpankedInPittsburgh, DNP, RN · Mar 30, 2018

Thank u Boston!!! I'll be interested to see what they have to say

SpankedInPittsburgh, DNP, RN · Mar 30, 2018

I'll never run an independent practice but how do you like it? How's it going?

allnurses Guide · Mar 30, 2018

I'll never run an independent practice but how do you like it? How's it going?

All the joys of both medicine and small business held together with copious amounts of red tape.

DayDreamin ER CRNP · Mar 30, 2018

I have not read every single reply but to answer your question...

I chose my specialty based on my nursing experiences. Where did I best fit? Where would my skills be best utilized? I am definitely not a paperwork nurse and could not see myself doing that day in and day out.

I would also discourage anyone from taking the direct entry path. So much of what I do in my job is based on my clinical nursing knowledge and experience and not from what I was told to learn from a book or a theory. I can always tell when I've worked with NPs that never had a day on the floor or "in the trenches." Even with my eight years of ER RN experience before going to NP school, I struggled with some of the more advanced concepts like hemodynamics. I understand the basics but my friends that worked in ICU had a far better understanding than I did. They didn't get that from a book. They got it from years of seeing it and anticipating the treatments and what that patient looked like.

And there is so much more to the medical aspect of being an NP that you will never get from a book or even the 500-600 required clinical hours while in school. It comes from years of sitting at the BS with patients and their families and listening to what they tell you just as much as what they do not tell you. Knowing what questions to ask and knowing when to keep your mouth shut.

And to answer your comment about why programs even offer the DE programs....Well, that's all about the almighty dollar. Butts in seats = income. I am strongly opposed to any program that doesn't require at least three years of experience before applying. It is saturating our market and setting our efforts and value back when schools are producing NPs that have no real clinical experience and knowledge.

Ever wonder why NPs seem to be more and more regulated and our scope is becoming more narrow in some states? It is because there are so many inexperienced NPs out there making mistakes which makes it more difficult for those that have experience.

I would tell you and anyone else thinking about direct entry to PLEASE do yourself, your co-workers and YOUR patients a favor and get some good experience as an RN. As a nurse, I cannot understand why someone would do DE. Our core beliefs are to do what is best for our patients. Experience AND knowledge is what is best for our patients.

wyosamRN · Mar 30, 2018

I'm applying to NP programs now (adult acute care). I have about 6 years RN experience. If I had gone direct entry 6 years ago, I would have said I wanted to work family practice, with my own clinic. If I had done that, I'd have chosen wrong. I believe if I had done that then, I'd be either in, or loooking for another line of work by now. I'm glad most (all?) acute care programs require some degree of experience, but I wish it was more. Yes, the RN role and the provider role are very different. However, working as an RN gives (or should give at least, particularly if you have a long term plan and choose to learn as much as you can) a solid foundation to build on. Assessment skills, clinical judgement, even just being comfortable working with patients. I'm sure there are some great clinicians out there that went DE. But I believe that if you want to go direct entry, the PA route makes more sense. It is a more robust education that is from the ground up designed to create providers out of people without clinical experience.