Nursing Model vs Medical Model (again!)

[jjjoy, LPN]

I went back to read previous posts on this topic but I think there's always more to say.

One thought goes that the medical model is about diagnosing disease processes/injuries and to treat that disease/injury whereas the nursing model is about helping a patient deal both physically and emotionally with the illness process. Since both medicine and nursing currently take part in preventative health care, perhaps we should develop a whole other discipline for that, and, in fact, that may happen eventually....

Anyway, the NP role, by those definitions, IS medical in most cases. They may be more aware of the nursing needs of the patient (assistance with ADLs, preventing skin breakdown, psychosocial support, etc), but their main practice would be medical (diagnosing and prescribing treatment).

Just tossing thoughts around...

[traumaRUs, MSN, APRN]

I definitely think the NP theory is based on the medical model of care. When you consider what you did as a staff nurse versus what you do as an NP, they are different. However, as a nurse, you do bring some added points to the care of the patient:

1. When I'm in the hospital, I know what it takes to give the care I'm ordering. I try to be concise and leave some room for a staff nurse to make some decisions themselves.

2. I always strive to educate the nurses I work with - by doing so, I'm showing them that I respect their knowledge.

3. I am never ever too busy or too "medical" to help with basic care of the patient. If I'm examining a pt and they need a bedpan or urinal or they vomit, I always get the care started. I don't always have time to finish it, but I never say "I'll get your nurse." I AM their nurse.

4. Finally, I am not a doctor wannabe. If I had wanted to go to med school, I would have. However, I do like the "care" of the patient.

Hope this helps.

[core0]

I definitely think the NP theory is based on the medical model of care. When you consider what you did as a staff nurse versus what you do as an NP, they are different. However, as a nurse, you do bring some added points to the care of the patient:

1. When I'm in the hospital, I know what it takes to give the care I'm ordering. I try to be concise and leave some room for a staff nurse to make some decisions themselves.

2. I always strive to educate the nurses I work with - by doing so, I'm showing them that I respect their knowledge.

3. I am never ever too busy or too "medical" to help with basic care of the patient. If I'm examining a pt and they need a bedpan or urinal or they vomit, I always get the care started. I don't always have time to finish it, but I never say "I'll get your nurse." I AM their nurse.

4. Finally, I am not a doctor wannabe. If I had wanted to go to med school, I would have. However, I do like the "care" of the patient.

Hope this helps.

This is similar to what I do. The thing that bugs me is that hospitals are increasingly taking any decision making away from bedside nurses. If I write and order for Percocent 5/325 1-2 Q4-6 PRN PO then I trust the nurse has enough decision making capacity to decide based on their pain assessment how to give the med. But now they have to give one wait 1/2 an hour then give another. Nurses are professionals and they have a good understanding of what the patient needs. My understanding is that this is based on Joint Commission guidelines. More like based on flawed interpretation of these guidelines.

I agree on the orders also. I like to check with the nurse on what they want. If you are going to write for an IV are there enough lines? Do they think the patient needs a picc? This is one of the things that I see people who haven't worked on the floor miss.

Another thing you can do if you are seeing a lot of the same type of questions is offer to do a class. Get a drug rep to pony up some lunch and put together a 1/2 hour power point. These are always well attended.

I think that most NPs really work in the medical model in the diagnose test treat mode. I see very little difference in daily function.

David Carpenter, PA-C

[traumaRUs, MSN, APRN]

David - we need to work together - lol. In my practice, we have 4 PAs, 3 NPs and me (CNS). We work pretty well together.

[PMFB-RN, RN]

I am neither an NP or a PA. Just a regular RN who works in a very high acuity surgical trauma intensive care unit. Nurses on my unit are expected to (and are trained to) do everything from recover fresh open hearts with ECHMO, IABP, vent, many vaso active drips, PA catheters, ect to taking fresh traumas with every sort of injury, to neuro-surgical patients. We are also on the code and trauma teams and one of us carried the code and trauma beeper all the time. We are also expected to handle the vents on our own, the RTs only come around once a shift.

We have both a PA and an NP on all the time. the PA works days and the NP works nights as well as coverage by surgical residents. I can detect no difference between the job our PA on days does and the job the NP does on nights. We also work with PAs and NPs from the various services from CV surgery, nuero sugery, infectious disease, nephrology and several others. On my unit when an RN needs orders the PA is the first call, except on weekends when the surgical residents cover ( I dread calling for orders on weekends for this reason). I have learned that I can call the the PAs and NPs with problems and they will help me, but when I have to call the MD residents I need to know exactly what I want and in what dosage becuase the first thing the resident is going to ask is "what should we do about it?" or "what do you want?" and they seldom know the dosage needed.

I have decided I want to be one of these highly competent mid-level providers. I have been asking many questions about the schooling required for both. I had about written off PA school because of the pre-reqs required means I would have to go to college for 1-2 years before I could even apply to PA school. However the though of going to graduate nursing school makes me sick. I work with lots of RNs who are getting their masters to be educators or NPs. I see what they have to do. It seems it's (like my RN-BSN program) mostly paper writing and projects. I am under the impression, from talking to many PAs and looking at PA school web sites, that PA school is more competency based. More this is the material you need to learn and there will be an exam type learning. This is MUCH more my style. I have discovered a PA school that only accepts RNs and just about any ADN RN would already have the pre-reqs done (A&P, chem, pharm) for this particular school. I am leaning to PA vs NP for this reason.

If I have arrived at completely incorrect conclusions please enlighten me.

[PMFB-RN, RN]

I agree on the orders also. I like to check with the nurse on what they want. If you are going to write for an IV are there enough lines? Do they think the patient needs a picc? This is one of the things that I see people who haven't worked on the floor miss.

*** You are right, it's a difference I have noticed between working with the PAs and NPs vs the surgical residents. However on my unit we have standing orders for nurse initiated IV and even a flow sheet for PICCs. We can insert any IV we feel is needed and not contraindicated, even put in a PICC if we need it and if the patient meets the criteria we can install a PICC without any involvement of MDs or mid-level providers. We do need to PA or NP to install a central line or PA catheter. However I have never heard of the PA or NP refusing to install a sub-clavian tipple lumen central line on the nurses request.

[core0]

I am neither an NP or a PA. Just a regular RN who works in a very high acuity surgical trauma intensive care unit. Nurses on my unit are expected to (and are trained to) do everything from recover fresh open hearts with ECHMO, IABP, vent, many vaso active drips, PA catheters, ect to taking fresh traumas with every sort of injury, to neuro-surgical patients. We are also on the code and trauma teams and one of us carried the code and trauma beeper all the time. We are also expected to handle the vents on our own, the RTs only come around once a shift.

We have both a PA and an NP on all the time. the PA works days and the NP works nights as well as coverage by surgical residents. I can detect no difference between the job our PA on days does and the job the NP does on nights. We also work with PAs and NPs from the various services from CV surgery, nuero sugery, infectious disease, nephrology and several others. On my unit when an RN needs orders the PA is the first call, except on weekends when the surgical residents cover ( I dread calling for orders on weekends for this reason). I have learned that I can call the the PAs and NPs with problems and they will help me, but when I have to call the MD residents I need to know exactly what I want and in what dosage becuase the first thing the resident is going to ask is "what should we do about it?" or "what do you want?" and they seldom know the dosage needed.

I have decided I want to be one of these highly competent mid-level providers. I have been asking many questions about the schooling required for both. I had about written off PA school because of the pre-reqs required means I would have to go to college for 1-2 years before I could even apply to PA school. However the though of going to graduate nursing school makes me sick. I work with lots of RNs who are getting their masters to be educators or NPs. I see what they have to do. It seems it's (like my RN-BSN program) mostly paper writing and projects. I am under the impression, from talking to many PAs and looking at PA school web sites, that PA school is more competency based. More this is the material you need to learn and there will be an exam type learning. This is MUCH more my style. I have discovered a PA school that only accepts RNs and just about any ADN RN would already have the pre-reqs done (A&P, chem, pharm) for this particular school. I am leaning to PA vs NP for this reason.

If I have arrived at completely incorrect conclusions please enlighten me.

There are a lot of nurses that feel the way you do. We had four RN's in our class. One of the areas of medical experience that any PA school will accept is nursing. Ultimately the decision between NP and PA is multi factorial. There are certain areas that are dominated by on side or the other. For example there are many more PAs working in surgery than NPs. On the other hand there are more PNPs or NNPs covering pediatrics or neonatology than PAs. There are also regional variation. In my city two of the NICUs are PA only and the others are NNP only.

You also have to consider your environment. If I wanted to work at Vanderbilt I would not consider PA. If I wanted to work at Duke I would not consider NP. You have to assess the local market and see what that will support.

Another factor is lifestyle and learning style. Many NP programs can be done part time by working. Almost all PA programs prohibit working while in the program. I can't speak for the educational style of NP programs, but there was very little information that wasn't clinically relevant. Of the 1700 clock hours in my didactic program, about 50 were not directly related to clinical medicine. Even this was related to billing, coding, the history of the PA profession etc.

I can't speak for NP education but PA education is incredibly focused on clinical competency. The guidelines published are derived from surveys of what PAs actually do in practice. The testing done is based on that same data.

The only caveat I would warn you about the school that you are considering is that this is the only PA school that wants you to fine your own clinical sites. In theory they will provide sites, but because of this they are not well thought of in the community. On the other hand I have never worked with one of their graduates and they have a decent first time pass rate. I would urge you to look around at some of the other programs. If you have your BSN you should be within 2-3 classes of most programs.

David Carpenter, PA-C

[core0]

David - we need to work together - lol. In my practice, we have 4 PAs, 3 NPs and me (CNS). We work pretty well together.

Could be. I have noticed that some practices tend to go one way or another and some have a mix. In our practice we have four PAs. We have looked at NPs but either they don't have the right skill mix or they self destruct in interviews. The one NP that I thought would have been a good fit couldn't agree on the time commitment. That would be another difference that I see is more part time NPs than PAs (at least in my market).

David Carpenter, PA-C

[jjjoy, LPN]

If you have your BSN you should be within 2-3 classes of most programs.

You give some great advice! Still for many RN-BSNs, they would probably need more than 2-3 courses to meet PA school pre-reqs. For example, the chemistry requirement for nursing school might not meet the PA required chem coursework, and they might need to take another math class to meet the chem class pre-req. Also, nursing students might not have had as many natural science course credits as are required for the PA program. I saw one program which recommended courses like immunology and genetics which aren't a problem if you're a full-time student majoring in biology but a lot more difficult to access if you're just trying to take one or two classes. And these types of courses aren't offered at local community colleges.

[core0]

You give some great advice! Still for many RN-BSNs, they would probably need more than 2-3 courses to meet PA school pre-reqs. For example, the chemistry requirement for nursing school might not meet the PA required chem coursework, and they might need to take another math class to meet the chem class pre-req. Also, nursing students might not have had as many natural science course credits as are required for the PA program. I saw one program which recommended courses like immunology and genetics which aren't a problem if you're a full-time student majoring in biology but a lot more difficult to access if you're just trying to take one or two classes. And these types of courses aren't offered at local community colleges.

Here is a pretty typical list of pre-reqs.

1. College Algebra or higher mathematics, no fewer than 3 semester hours;
   
2. English Electives, no fewer than 6 semester hours;
   
3. Human Anatomy and Physiology, no fewer than 6 semester hours;
   
4. Microbiology, no fewer than 3 semester hours and must be at the 200 level;
   
5. Introduction to Statistics, no fewer than 3 semester hours;
   
6. General College Chemistry, and one semester of either organic chemistry or biochemistry which must be at the 200 level, no fewer than 10 semester hours (however to fulfill this requirement, many applicants have far more credits).
   
7. Psychology and social science electives, no fewer than 6 semester hours

Here is the local BSN program:

Three of the four following science requirements must be completed by the application deadline. Chemistry/Lab

4 SH

Anatomy/Lab

4 SH

(or Anatomy & Physiology I / Lab)

Physiology/Lab

4 SH

(or Anatomy & Physiology II / Lab)

Microbiology/Lab

4 SH

The following courses are required for all pre-licensure BSN options.

General Psychology

3 SH

Development Psychology or Child Psychology

3 SH

Nutrition

3 SH

Sociology

3 SH

Statistics

3 SH

Philosophy

3 SH

Religious Studies

6 SH

Health Care Ethics (upper division)

3 SH

The following courses are not required for the Accelerated BSN option, but are required for the Traditional and CHOICE BSN options

English Composition

3 SH

Literature/Humanities

3 SH

Economics/Business/Social Science

3 SH

General Electives

13 SH

Upper Division Electives

6 SH

So in this case you would need Ochem or Biochem and Micro along with one other chemistry course. Some programs will require genetics or additional chemistry. The other thing that may trip some people up is that some programs require the science classes to be done within 5 years. What I am saying is that all programs have different requirements so don't be turned off if a particular program has difficult requirements. I can think of one program that requires Calculus, physics, and both biochem and organic chemistry (essentially the full premed load).

The other issue is through the magic of the internet almost any non lab class is pretty easily available. So you could take Chem I, II and Micro at the local community college with lab and take Biochem over the internet (tough but doable). Its all about wanting it. The students you will be competing for the slots really want it. The program I highlighted above is a community college program that gets 300 applicants for 28 seats. You will be very competitive with a nursing degree but it is not an automatic entry.

David Carpenter, PA-C

[PMFB-RN, RN]

*** Hey David, thanks for your reply.

There are a lot of nurses that feel the way you do. We had four RN's in our class. One of the areas of medical experience that any PA school will accept is nursing. Ultimately the decision between NP and PA is multi factorial. There are certain areas that are dominated by on side or the other. For example there are many more PAs working in surgery than NPs.

*** This is exactly what I wanted to know. AT my particular medical center this is true as well but there are exceptions. I know I want to work in EM or surgery.

You also have to consider your environment. If I wanted to work at Vanderbilt I would not consider PA. If I wanted to work at Duke I would not consider NP. You have to assess the local market and see what that will support.

*** I don't want environment to wag the dog so to speak. I am planning on returning to my home are of one of the western Mountain states. I am willing to go where the opportunity's are.

Another factor is lifestyle and learning style. Many NP programs can be done part time by working. Almost all PA programs prohibit working while in the program.

*** Not really an issue for me as either way I plan on going full time and devoting myself full time to whatever program. I have the opportunity to do so because of my current family situation.

I can't speak for the educational style of NP programs, but there was very little information that wasn't clinically relevant. Of the 1700 clock hours in my didactic program, about 50 were not directly related to clinical medicine. Even this was related to billing, coding, the history of the PA profession etc.

*** Thanks, that's very encouraging. I dread taking "Nursing Theory" and similar classes.

I can't speak for NP education but PA education is incredibly focused on clinical competency. The guidelines published are derived from surveys of what PAs actually do in practice. The testing done is based on that same data.

*** More good new that jibes with what I have already learned.

The only caveat I would warn you about the school that you are considering is that this is the only PA school that wants you to fine your own clinical sites. In theory they will provide sites, but because of this they are not well thought of in the community.

*** Really? The University of North Dakota is not well thought of? Doesn't the Standford program also require students to find their own clinical sites? That would make at least two that require students to find their own clinicals. The UND program requires the student to find a family practice or IM MD or DO to be their preceptor. This isn't the slightest problem for me. I work for a large and famous medical center in the upper midwest. It has a special office for this exact thing. You just register for the type of preceptor you need and they match you up with one. It's a benefit of employment, with the hope that you will continue to work for them after graduation. In addition to that our own family doctor, who we have known for years has offered to be my preceptor.

On the other hand I have never worked with one of their graduates and they have a decent first time pass rate. I would urge you to look around at some of the other programs. If you have your BSN you should be within 2-3 classes of most programs.

*** Thing is I am not even close. At least not to the programs in the upper midwest, except UND. I am one year into my RN to BSN and to meet the requirements of UW LaCrosse, UW Madison, Marquet, or any of the schools in MN would require a year of college full time or two of part time to even qualify to apply.

Thanks for your advice and help.

[core0]

*** really? the university of north dakota is not well thought of? doesn't the standford program also require students to find their own clinical sites? that would make at least two that require students to find their own clinicals. the und program requires the student to find a family practice or im md or do to be their preceptor. this isn't the slightest problem for me. i work for a large and famous medical center in the upper midwest. it has a special office for this exact thing. you just register for the type of preceptor you need and they match you up with one. it's a benefit of employment, with the hope that you will continue to work for them after graduation. in addition to that our own family doctor, who we have known for years has offered to be my preceptor.

my understanding is that stanford did away with this requirement. i cannot find it on their prerequisites. arc-pa passed a rule this year that pa programs should not force students to find preceptors. the general consensus is that they will change this to may not in the next couple of years. they also passed a rule that programs must offer the same academic support and evaluation services to students at all sites. this has caused a number of programs to cut back on allowing students to arrange their own rotations since they have the same obligation to evaluate preceptors as the ones they select. i think there is some leniency in overseas sites.

don't get me wrong, i benefited from this significantly. i arranged more than half of my rotations in denver where i live. the reality is though is that arc-pa has been cracking down on this since it has been identified as a major weakness in the quality of clinical experience.

on the other hand i have never worked with one of their graduates and they have a decent first time pass rate. i would urge you to look around at some of the other programs. if you have your bsn you should be within 2-3 classes of most programs.

*** thing is i am not even close. at least not to the programs in the upper midwest, except und. i am one year into my rn to bsn and to meet the requirements of uw lacrosse, uw madison, marquet, or any of the schools in mn would require a year of college full time or two of part time to even qualify to apply.

thanks for your advice and help.

you are going to need a bachelors to get into und. the issue will be timing. most programs close their application process in september to november. some will allow you to complete pre-reqs after but some won't. no matter what you are probably looking at a 2009 start date. if you did your pre-reqs then finished your bsn after you turned in your app you should be able to finish it. also look outside the midwest for programs. approximately 1/3 of the pa programs are in pa and ny. it is sometimes easier to get in there than some of the midwest programs. marquet and uw lacrosse can be incredibly competitive at times. you can use the caspa system to apply:https://portal.caspaonline.org/

although i don't see marquet. not saying that und is necessarily bad, but you have to keep your eyes open. i will also say that given the volume of material that you get in pa school it would take a special student to do the didactic portion online. it would also depend on whether you want to do specialty care. you will not have as much opportunity as in other programs. one of the pas that posts on physicianassistantforum.com had decided that he wanted to go into em. he did almost 5 months of his 12 months of rotations in em or related sites. this is the variability that you will have with a more traditional program that you will not have with und (or stanford).

david carpenter, pa-c