Op-ED: Practicing Medicine vs Practicing Advanced Nursing

myoglobin, ASN, BSN, MSN · Dec 13, 2020

Just because someone works IP doesn’t mean that cannot ask for help. For example my wife has five years as a Psych NP and I will sometimes ask for input. Sometimes I have conversed with other psychiatrists and NP’s for input even though I’m IP. Conversely, even when I was a student in a supervised non IP state I was expected to see about 25 patients per day on my own and maybe received input from my supervising MD once per week at most. Even when I received input it was usually along the lines of “why did you advise Omega’s, morning light, exercise vitamins and SAMe rather than starting them on Lexapro or adding a benzo” in other words my approach was incongruent (and I believe vastly superior most of the time). However, the reality is that in practice most practice even in non IP states is effectively IP since MD’s are too busy seeing their own clients to worry much about yours. Bottom line NP’s are growing and the laws as well as political and economic forces are largely on our side. This is a very good thing both for nurses and the American public.

myoglobin, ASN, BSN, MSN · Dec 13, 2020

I would also point out that I doubt that in most cases you would find "very much" difference between the courses and texts utilized at say Johns Hopkins (their online program where I was accepted), The University of Southern Indiana (where I went) and say Walden (a for profit school where I applied). However, the Walden and University of Southern Indiana options are radically less expensive (Hopkins would have run me about 25K per year, and I would have had to move there during my final year for local preceptors, which would have essentially made it impossible). All schools essentially use similar texts (Stahl, Sadock), and all graduates must pass the same national board certification exam. True, Hopkins required a year's experience and USI preferred it (I had over seven years at the time of application in neuro ICU, trauma ICU, med surg, and taking care of inpatient Baker Act in an acute care facility). However, I'm not sure that the experience really made me any better as a practitioner given that the jobs are so different. I will say that there "used" to be a few programs like the University of North Dakota that did some things different like requiring an additional one semester strictly focused on counseling which was worthwhile (not sure if they still do).

TheMoonisMyLantern, ADN, LPN, RN · Dec 14, 2020

Curriculum may be the same but what about content delivery? Are all online programs essentially self learning now? People I've spoken to and from what I've read of people's experiences with Walden and other similar schools is that you read the book, do a case study or test, write a paper, possibly have a discussion group depending on the school and bam that's your education. There's no recorded lectures, no required in person skills check off etc. While that method of content delivery may be acceptable for a non-clinical degree. I think a clinical degree should have more teeth. The college professors I had referenced the textbook of course, but most of their lectures would be based off of other resources peppered with examples of their own experiences. How can just reading the textbook be enough to prepare someone to be a provider? Am I crazy for thinking this way? Is being a provider easy enough to simply be prepared by reading a textbook and writing some papers? I'm not being sarcastic, I simply just don't understand how we can demand IP in all states and yet have such loose standards for education.

myoglobin, ASN, BSN, MSN · Dec 14, 2020

We had recorded head to toe exams and psychiatric interviews along with real time discussion groups Zoom meetings in addition to textbook and journal assignments. This was how The University of Southern Indiana did things, and it was essentially how Johns Hopkins and Walden advertised their programs. So what makes my program and Hopkins “okay” but Walden s bad? Again they are abiding by the laws and regulations that exist. Also as NP’s we are not “asking” for anything we have had IP for decades in some states like Washington and Arizona and we are utilizing the political process to gain it elsewhere. We will not be stopped but will rather use the greater numbers and political strength that we can muster (aligning with institutions of higher learning, insurance companies and hospitals, along with governmental agencies where possible where interests such as cost savings align) to further our goals. At the same time improving the educational quality is an optimal and worthwhile goal that I support, but not denigration of my fellow nurses who largely just want to serve our clients to the best of our abilities.

TheMoonisMyLantern, ADN, LPN, RN · Dec 14, 2020

Did you have lectures and onsite skill validations throughout the program in addition to the constant read the textbook write a paper content? You keep missing my point I'm trying to make about NP's and IP, yes IP is present in quite a few states but NP's want IP nationwide and wish to continue independently in the future they better make sure that the next generation of NP's that are being churned out in mass numbers are going to be worthy of IP and safely treat patients. The big business of college degrees has convinced people that guided self study is the standard for online education and worth charging thousands of dollars in tuition for mediocre education. I'm not "denigrating" NP's I'm simply pointing out the massive problems that graduate nursing education faces. Do a search on here for Walden and other similar schools and look at the feedback from former students and clinicians who have trained students from these programs and found them lacking the ability to function. You can't just rationalize away the problems of the profession just because you're billing numbers look good.

myoglobin, ASN, BSN, MSN · Dec 14, 2020

There was nothing onsite. I did not visit the campus even once (didn't go to my graduation) nor did my significant other who graduated four years before me at the same institution. Not that I believe they were necessary. I felt the delivery and modality were appropriate. Indeed, now that I practice essentially 100% via tele video I feel that way even more. They have started adding onsite visits once or twice per semester I believe this year, but I don't know that there is any additional learning inherent in that process. Show me studies that demonstrate that onsite validation is superior and perhaps I will reconsider. However, there are also trade offs. For example traveling from Florida to Indiana would have involved several thousand dollars (especially when you consider lost ICU shifts from my night shift job that's another thing I lived a "night shift schedule" during school until the last two semesters). Thus, any gain from onsite would have to out weight the study hours lost from the travel and the expense (conservatively at least 20 to 30 hours per trip with planning and packing, transit ect). Sure it "looks good", but is it really superior for education?

Rnis, BSN, DNP, APRN, NP · Dec 14, 2020

On 12/11/2020 at 1:25 AM, TheMoonisMyLantern said:

Have there been any fresh studies on NP efficacy since the rise of online only for profit schools with the only admission standard of having a pulse?

I don't think there is a rise in these programs, they have been in place they are just expanding their programs to more areas. I know it is popular to bash these programs. I purposefully did not consider online programs such as Chamberlain, Kaplan or frontier because I didn't want judgement. However, I have taken students from all of these programs ..........mostly because I was curious. Honestly? They were some of the best students I have worked with (compared to local programs) and even one of the doctors commented how well prepared my students seem to be. I haven't seen the concerns expressed on this website play out in the students I have worked with. Full disclosure...I do screen my students and don't precept students unless they work at my affiliated hospital or have a strong clinical background (I want to learn from them too!). However, most people that ask me to precept them have a solid clinical background.

myoglobin, ASN, BSN, MSN · Dec 14, 2020

I believe that your experience in students probably in part reflects the fact that students at places like Walden may be a bit older and more serious than say ones from the local state university. I remember being absolutely dumbstruck at how much more serious the students were at the technical school where I obtained my ASN verses the four year school I had previously attended. The people were 100 percent “all in” verses being concerned about dates, football games or parties.

TheMoonisMyLantern, ADN, LPN, RN · Dec 15, 2020

14 hours ago, myoglobin said:

There was nothing onsite. I did not visit the campus even once (didn't go to my graduation) nor did my significant other who graduated four years before me at the same institution. Not that I believe they were necessary. I felt the delivery and modality were appropriate. Indeed, now that I practice essentially 100% via tele video I feel that way even more. They have started adding onsite visits once or twice per semester I believe this year, but I don't know that there is any additional learning inherent in that process. Show me studies that demonstrate that onsite validation is superior and perhaps I will reconsider. However, there are also trade offs. For example traveling from Florida to Indiana would have involved several thousand dollars (especially when you consider lost ICU shifts from my night shift job that's another thing I lived a "night shift schedule" during school until the last two semesters). Thus, any gain from onsite would have to out weight the study hours lost from the travel and the expense (conservatively at least 20 to 30 hours per trip with planning and packing, transit ect). Sure it "looks good", but is it really superior for education?

You say you felt the content delivery and modality were appropriate, can you give some examples? I'm geninunely curious because people I've spoken with in some online programs were told to read the textbook, write a paper, and analyze a case study for each chapter they completed, no lectures, no interactive activities, no discussions, no guidance insight or interactions with the professor. That just seems like a very hollow education. One of my colleagues literally read a chapter on chest x-ray interpretation, had a case study to analyze, and bam just like that move on to the next chapter, congratulations she can read chest x-rays now. It just seems we should be demanding more bang for our buck from academic institutions or they need to drastically reduce tuition prices.

TheMoonisMyLantern, ADN, LPN, RN · Dec 15, 2020

9 hours ago, Rnis said:

I don't think there is a rise in these programs, they have been in place they are just expanding their programs to more areas. I know it is popular to bash these programs. I purposefully did not consider online programs such as Chamberlain, Kaplan or frontier because I didn't want judgement. However, I have taken students from all of these programs ..........mostly because I was curious. Honestly? They were some of the best students I have worked with (compared to local programs) and even one of the doctors commented how well prepared my students seem to be. I haven't seen the concerns expressed on this website play out in the students I have worked with. Full disclosure...I do screen my students and don't precept students unless they work at my affiliated hospital or have a strong clinical background (I want to learn from them too!). However, most people that ask me to precept them have a solid clinical background.

I appreciate your experience and am actually glad to hear it. I would love to be wrong about these programs, all I can go by is what I hear from my colleagues and what I read online, thus my original reply where I asked if recent studies had been done on NP efficacy from these programs.

I do want to note however that you mentioned you chose preceptees who had strong clinical backgrounds. I think that fact may explain why you had such a positive experience. I wonder if you were to precept a student without that strong clinical background if you would have to seem experience. Perhaps but I can't help but doubt it.

FullGlass, BSN, MSN, NP · Dec 15, 2020

23 hours ago, Rnis said:

I purposefully did not consider online programs such as Chamberlain, Kaplan or frontier because I didn't want judgement.

Frontier is a very reputable school with an excellent reputation. It has been around for a long time.

myoglobin, ASN, BSN, MSN · Dec 15, 2020

14 hours ago, TheMoonisMyLantern said:

You say you felt the content delivery and modality were appropriate, can you give some examples? I'm geninunely curious because people I've spoken with in some online programs were told to read the textbook, write a paper, and analyze a case study for each chapter they completed, no lectures, no interactive activities, no discussions, no guidance insight or interactions with the professor. That just seems like a very hollow education. One of my colleagues literally read a chapter on chest x-ray interpretation, had a case study to analyze, and bam just like that move on to the next chapter, congratulations she can read chest x-rays now. It just seems we should be demanding more bang for our buck from academic institutions or they need to drastically reduce tuition prices.

We would submit weekly case studies based on actual patients that we were seeing in clinical along with plans of care and followup progressively over the semesters (with these patients). We would also have live lectures and recorded lectures along with readings from the text books and journal articles. We had to submit monthly evaluations and daily log books from our clinical experiences. All of these parameters are specified by centralized educational organizations and the variation is fairly minimal. My point is that the schools that exist are "playing by the rules". I do believe there is room to improve, but I don't believe the current system is horrible.