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

Oldmahubbard · 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.

Thank you

allnurses Guide · Mar 30, 2018

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.

I am not sure I follow that argument here, it seems to be that because you struggled with advanced concepts even though you had extensive experience then naturally people with less experience would have a much larger struggle?

If your experience in the ED didn't fully prepare you and ICU experience would have helped with concepts like hemodynamics then wouldn't cardiology experience have helped with cardiac and case management experience helped with navigating the system and VNA experience helped with transitions of care, etc. Should NP require extensive experience in all these different areas?

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.

I don't disagree with this but my argument would be that it is provider experience not prior experience that contributes to the "medical" competency of experienced NPs.

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.

Can you cite some sources on this; I am fairly plugged into the national NP advocacy and I have never seen this written about or even discussed at national conferences.

NHGN · Mar 31, 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 (:

I imagine that may be quite biased.

allnurses Guide · Mar 31, 2018

I imagine that may be quite biased.

Wow this is what we have devolved to.

allnurses Guide · Mar 31, 2018

I imagine that may be quite biased.

I guess a study by a renowned and well respected university is now reduced to "fake news".

Dodongo, APRN, NP · Mar 31, 2018

I think that there is an unfortunate culture in nursing that implies the requirement of "putting your time in." Nurses are really one of the only professions that does so. PTs and PAs don't require each other to work in the profession prior to continuing on in their professions.

My biggest worry with no longer requiring RN experience is our push for independent practice. This was the one thing that NPs could cite when distinguishing ourselves from PAs, when addressing our low clinical hour requirements, and when opposing supervisory requirements. Without RN experience, I think PAs will see they easily have the upper hand in their education, and physicians and legislators will also make our education an easy target.

All of this remains to be seen, of course. But I just think we are opening ourselves up to scrutiny far too much by removing every single barrier to entry for our profession. We have no prior RN experience requirements, low credit hour requirements, bare minimum clinical hour requirements, our science preparation is hardly defensible - the 3 P's.

And, hopefully we all can agree that studies funded by nursing organizations, for nursing organizations, are not high yield evidence. Anyone can immediately dismiss them simply for that fact.

We need to do better for ourselves. PAs are adding on more education - see the PA doctorate at Lynchburg and the DMS at LMU - while we are lessening ours?

staphylococci, NP · Mar 31, 2018

After working adult critical care for a few years, I wanted to focus on keeping folks out of the hospital due to unmanaged or poorly managed chronic conditions. So, I enrolled in an FNP program and continued working in critical care until I landed my first and current NP job in pediatric primary care (with a little family medicine).

I have never worked as an RN in peds even though I had the opportunity to transfer to the Peds ER while in FNP school (my boss at the time was very flexible with my schedule, and it was something I could not give up). Pediatrics was my favorite rotation in FNP school and nursing school as well! I love taking care of the kiddos and doing my best to keep them healthy in hopes that they'll continue to be healthy adults as well. Plus, it's amazing to watch kids grow over time and getting to know them and their families very well. Peds has been very rewarding for me, and it's where I want to stay for the rest of my career. :)

NHGN · Apr 1, 2018

Well, consider it. Columbia has a well-known DE program, right? Why wouldn't we be as scrutinizing of their results as we are of studies funded by drug companies?

There's no need to sensationalize my comment with a "fake news" follow-up.

The_Salty_Cat · Apr 1, 2018

I imagine that may be quite biased.

Already assuming the worst, are you? I can assure you Columbia is never going to tarnish their name by publishing mediocre research papers. Some of the faculty I personally met and spoke to have 10+ years of nursing experience in being providers and researchers. They are advocating for us, and are highly regarded in the nursing profession and thus, take their position and research seriously. Please respect that.

Rocknurse, MSN, APRN, NP · Apr 2, 2018

As far as the Direct Entry NP argument goes, my only input is anecdotal. I'm in the acute NP program and I did a clinical rotation with a Direct Entry FNP student in the ICU. I'm not sure how she got the clinical rotation as she'd never been near an ICU before, let alone worked as a nurse, nor was she planning on entering the ICU on graduation. Whenever there was a procedure to do, such as placing an arterial line or central line, I would jump on it because I love to do procedures and want the experience, but she would visibly shake and literally run away because she feared it, never having even seen a sterile field before. It struck me as odd that she's want to do a rotation in the ICU. She was very book-smart, no doubt, but half the time she didn't know what she was even looking at, whereas I could walk into a room and immediately do a scan that helped me know what was going on with the patient. Ventilators, IABPs, drips.....I'm familiar with it all. Anyway, she's a smart girl and I'm sure she'll do well once she has some experience under her belt. In her defense, she was attending an Ivy League program with a stellar reputation.

With regards to specialties, I have chosen to go the ICU route specifically because most of my 29 years in nursing has been spent in critical care. I want to work inpatient because that's where I feel most comfortable and at home. I would like to experience some other specialties, particularly emergency medicine and surgery, and I may request one of those for my final rotation. By then I will have had two rotations in the ICU. I love the whole critical aspect of medicine...codes, super sick patients, surgeries etc. I could not work in an office and nor do I want to.

djmatte, ADN, MSN, RN, NP · Apr 2, 2018

As far as the Direct Entry NP argument goes, my only input is anecdotal. I'm in the acute NP program and I did a clinical rotation with a Direct Entry FNP student in the ICU. I'm not sure how she got the clinical rotation as she'd never been near an ICU before, let alone worked as a nurse, nor was she planning on entering the ICU on graduation. Whenever there was a procedure to do, such as placing an arterial line or central line, I would jump on it because I love to do procedures and want the experience, but she would visibly shake and literally run away because she feared it, never having even seen a sterile field before. It struck me as odd that she's want to do a rotation in the ICU. She was very book-smart, no doubt, but half the time she didn't know what she was even looking at, whereas I could walk into a room and immediately do a scan that helped me know what was going on with the patient. Ventilators, IABPs, drips.....I'm familiar with it all. Anyway, she's a smart girl and I'm sure she'll do well once she has some experience under her belt. In her defense, she was attending an Ivy League program with a stellar reputation.
With regards to specialties, I have chosen to go the ICU route specifically because most of my 29 years in nursing has been spent in critical care. I want to work inpatient because that's where I feel most comfortable and at home. I would like to experience some other specialties, particularly emergency medicine and surgery, and I may request one of those for my final rotation. By then I will have had two rotations in the ICU. I love the whole critical aspect of medicine...codes, super sick patients, surgeries etc. I could not work in an office and nor do I want to.

Stories like that make me glad places like Frontier mandate you only do clinicals in primary care offices with an NP and only 25% can be in an ED/Urgent care/MD preceptor. While granted FNU does require some experience, the focus on what we train for vs. hitting an hour goal for the sake of hours is important.

allnurses Guide · Apr 2, 2018

Without RN experience, I think PAs will see they easily have the upper hand in their education, and physicians and legislators will also make our education an easy target.

A few things here:

1. The "RN experience" thing is not new; many of these programs have been around since the 1970s-1980s. All the extant data out there on NP outcomes includes graduates with no RN experience. Now if the argument is that there are more of these graduates or that the programs now admitting these graduates are poorer in quality, than that is a topic for discussion, but the solution isn't to mandate RN experience in either case.

2. NPs are educated to be independent providers and PAs are not. The educational structure is very different given one is based on block schedules in the medical generalist model and the other is in the nursing model on semester schedule. I am not sure one is any better than the other overall, having worked with students from both types of programs.

And, hopefully we all can agree that studies funded by nursing organizations, for nursing organizations, are not high yield evidence. Anyone can immediately dismiss them simply for that fact.

That is not the scientific process. The sources of the funding should not matter if there is good scientific rigor.

We need to do better for ourselves. PAs are adding on more education - see the PA doctorate at Lynchburg and the DMS at LMU - while we are lessening ours?

How is APN or nursing as a whole "lessening" itself? At least academically the DNP and consensus push was many years ahead of PA changes towards doctorate degrees.