Quality of Online NP Programs and Providers

ProgressiveThinking, MSN, CRNA · Jan 26, 2020

@FullGlass I don't mean to offend you, and I'm sorry if it comes off that way.

allnurses Guide · Jan 26, 2020

11 hours ago, FullGlass said:
We need better schools and education, not barriers.
So why is there is so much complaining about NPs not have RN experience? They do have RN experience if they are working in the hospital!
With an acute shortage of primary care providers, the last thing we need now is to throw up more barriers to producing primary care providers. 90% of NPs are educated in primary care, and 75% of them work in primary care.

To be clear, better schools and education is also a barrier to entry for some/many.

I would suspect its because of some of the threads we see right here on AN. I just read one last week about a new-grad FNP with no RN experience that took a job on an Intensivist consult service. That should be scary to everyone. The consensus model has tried to address this but there are still a fair amount of new-grad FNPs going to work either in-patient or on specialist services.

I think the more time you spend in your NP career (as the naivety starts to fade) you start to think about what happens when there is no longer primary care provider shortage?

Tegridy · Jan 26, 2020

I’ve been through both medical school and FNP school. The online or in person part doesn’t matter. I never went to class in either. As long as the hands on skills part are adequate. The problems are the following with NP edu.
1. Some don’t have closed book tests. Open book online quizzes don’t test knowledge.
2. Lack of clinical education. 500 hours isn’t enough. Not even close.
3. Board exam too easy.
4. No residency

some schools are good. Some are bad but no NP comes out fully prepared from FNP school as they should. 500 hours for such a broad job is not enough. Especially the low amount of ped and GYN hours. 120 each? Sheesh

Advanced Practice Columnist / Guide · Jan 26, 2020

I think there should be a push for standardization of training across all programs with close oversight by the accreditation board. I can only go by what I see in the acute care side. I've been an Adult ACNP since 2004 and in Critical Care since 2005. I've seen new ACNP's and AGACNP's come and go.

Our group hires grads from top tier (source being US News and World Report) and mid tier (state schools from other states, lesser known but established NP programs), and we never hire grads of for-profit programs by choice. We have NP fellows and new grads from schools like Penn, Yale, Columbia, Vanderbilt, UCSF, UCLA. Even with those grads, there's so much variability with what they know straight out of school. There are gaps that need to be remediated and it's never the same for each individual. It's not fair to rely on bedside nursing background because that is not at the level of a provider.

There will always be that exceptional person who can pick up on things and will be super smart regardless of where they went to school but not all students are like that. We need to tailor our training to make things more consistent for everyone. We need to make schools accountable for making sure resources are indeed available for training and yes, we need more than just 500 hours of clinicals.

FullGlass, BSN, MSN, NP · Jan 26, 2020

14 hours ago, ProgressiveThinking said:
1) Yes and no. We do need better education, but not having any barriers will just saturate the market and result in lower salaries. In my area there are a ton of FNP new grads who work at the bedside for one reason or another (area saturation, lower salary, etc). None of them are flocking to these shortage areas. I don't think that having less barriers would suddenly make graduates want to relocate to these areas. Incentives have to be provided to recruit people into these areas. Increasing access to programs for people who are from these areas who wish to stay in the area and practice might be a good idea as long as standards and quality are maintained.
2) I think that this was already established earlier on in the thread.
3) I'm not sure what your point is. I was providing my frame of reference in order to convey my thought process as to why I thought the way I initially did. This thread was specifically posted in this section because I'm considering pursuing a post master's FNP, but I'm somewhat on the fence and was looking for insight from practicing NPs on issues that may affect me in the future if I do choose pursue the field.
4) I can see how this frustrates you. In those people's defense, I can see how one could jump to this conclusion. In my ICU, the NP students worked full-time, had families, and still managed to go out on the weekend. To me, this was just a reflection of the schools they attended. A buddy of mine went to a different program and received phenomenal training, and was stuck studying most of the time. The program piggybacked off his RN experience and he graduated feeling prepared to be a solid provider. He actually had to cut hours at work. If I didn't know that the more rigorous program existed, I probably would have jumped to the conclusion that NP training is < as well. Again, this is just a reflection of the NP schools in my area. One of them actually recruited a friend of mine who had a 2.5 GPA and said his experience would make up for his lack of GPA since the school didn't really have enough applicants. They basically rolled out the red carpet for him. Couldn't even make this up.

1. Having barriers does nothing to improve access or quality. The way to improve access is to have MORE providers, not less. The way to improve quality is to improve the quality of education and training, not throw up arbitrary barriers WITHOUT ANY EVIDENCE to back them up. The high quality schools do not throw up random barriers - they are selective on admissions because there is fierce competition to get into those schools. The admissions requirements for the best schools are actually pretty reasonable. Reputable public universities also have reasonable admissions requirements. These programs have proven curricula, rigorous classes and progression requirements, good instructors, and provide good clinical rotations. These schools truly want to produce good providers.

Most for-profit schools will accept anyone, do not find clinical rotations, and are only doing this to make money. They often charge a lot more than a good school, including private schools like Hopkins or Yale. If a student has trouble, they get no support. That's why these schools suck. An easy way to get rid of these schools would be to require NP schools to find clinical placements for students. If a student can find their own placement, fine. Even the best schools are happy if students can assist in locating clinical rotations.

In addition, for-profit schools often exploit disadvantaged students. They aggressively recruit these students and tell them they can get loans for everything. Then, the student either can't make it through school or they graduate, unable to find a job. School doesn't care, because they've got their money. Sadly, many of these students would have been admitted to reputable schools for far less money and would have received much more support. Often, these students are too intimidated to apply to better schools due to ignorance of their options.

There is no evidence that increasing the number of NPs drives down salaries. I am so sick of this argument. What state has the most NPs? California. What state pays NPs the most? California. Which cities have the most doctors in California? LA, Bay Area, San Diego. Where do doctors make the most money? LA, Bay Area, San Diego. Which areas have the most high tech workers? Silicon Valley, Washington DC, Seattle, Austin TX. Which areas pay high tech workers the most? The same areas. Which cities have the most high-powered attorneys? NYC, Washington DC, Chicago, Los Angeles, SF Bay Area. Which firms (AmLaw 100) pay the big bucks? The ones in those cities. Which cities have the most actors? LA and NYC. Where do actors go to make the big bucks? LA or NYC.

Yes, certain areas may have an oversaturation and/or pay poorly. Guess what? People can move!!! That's what doctors do - they have to go to wherever their internship/residency is, like it or not. The same with other professionals - most successful professionals move multiple times to maximize their career advancement and earnings. I certainly did, from Wash DC to SF to LA then to the San Joaquin Valley. I will likely move to a full practice authority state with lower taxes and more affordable housing in the future. My goodness, the news is full of articles about people moving to/from different states for job opportunities and cost of living. If an FNP can't get a good job for decent pay in City X, they can move to City Y!

EVERY SINGLE STUDY AND ANALYSIS indicates there is a shortage of primary care providers, including doctors, in this country. Yes, providers could be distributed better, but that is no reason to reduce the supply of providers.

3. If you don't care for the way NPs are educated and trained, then become a PA.

4. I went to Hopkins. Many NP students worked as RNs. Some started out working full-time, then cut back to part-time as the program progressed. That is great. It allows some students to become NPs that otherwise would not be able to afford it.

Personally, I greatly admire NPs that "bootstrap" themselves up. I don't think I could do it. I have met many NPs that literally started as MAs or CNAs, then LPN, then RN, then NP. PA school does not allow for this.

If you only want to go to a school that requires full-time attendance, will educate and train you in everything from ER, ICU, L&D, to primary care, then go to PA school or med school. Anyone can apply to PA school or med school. Yes, I get frustrated by people who basically complain that NP school is not PA school. No, it isn't, and that is by design.

NP residencies would do a lot to rectify the shortcomings of NP school. More and more of these residencies are becoming available. Obtaining funding is a big issue.

FullGlass, BSN, MSN, NP · Jan 26, 2020

22 minutes ago, FullGlass said:
1. Having barriers does nothing to improve access or quality. The way to improve access is to have MORE providers, not less. The way to improve quality is to improve the quality of education and training, not throw up arbitrary barriers WITHOUT ANY EVIDENCE to back them up. The high quality schools do not throw up random barriers - they are selective on admissions because there is fierce competition to get into those schools. The admissions requirements for the best schools are actually pretty reasonable. Reputable public universities also have reasonable admissions requirements. These programs have proven curricula, rigorous classes and progression requirements, good instructors, and provide good clinical rotations. These schools truly want to produce good providers.
Most for-profit schools will accept anyone, do not find clinical rotations, and are only doing this to make money. They often charge a lot more than a good school, including private schools like Hopkins or Yale. If a student has trouble, they get no support. That's why these schools suck. An easy way to get rid of these schools would be to require NP schools to find clinical placements for students. If a student can find their own placement, fine. Even the best schools are happy if students can assist in locating clinical rotations.
In addition, for-profit schools often exploit disadvantaged students. They aggressively recruit these students and tell them they can get loans for everything. Then, the student either can't make it through school or they graduate, unable to find a job. School doesn't care, because they've got their money. Sadly, many of these students would have been admitted to reputable schools for far less money and would have received much more support. Often, these students are too intimidated to apply to better schools due to ignorance of their options.
There is no evidence that increasing the number of NPs drives down salaries. I am so sick of this argument. What state has the most NPs? California. What state pays NPs the most? California. Which cities have the most doctors in California? LA, Bay Area, San Diego. Where do doctors make the most money? LA, Bay Area, San Diego. Which areas have the most high tech workers? Silicon Valley, Washington DC, Seattle, Austin TX. Which areas pay high tech workers the most? The same areas. Which cities have the most high-powered attorneys? NYC, Washington DC, Chicago, Los Angeles, SF Bay Area. Which firms (AmLaw 100) pay the big bucks? The ones in those cities. Which cities have the most actors? LA and NYC. Where do actors go to make the big bucks? LA or NYC.
Yes, certain areas may have an oversaturation and/or pay poorly. Guess what? People can move!!! That's what doctors do - they have to go to wherever their internship/residency is, like it or not. The same with other professionals - most successful professionals move multiple times to maximize their career advancement and earnings. I certainly did, from Wash DC to SF to LA then to the San Joaquin Valley. I will likely move to a full practice authority state with lower taxes and more affordable housing in the future. My goodness, the news is full of articles about people moving to/from different states for job opportunities and cost of living. If an FNP can't get a good job for decent pay in City X, they can move to City Y!
EVERY SINGLE STUDY AND ANALYSIS indicates there is a shortage of primary care providers, including doctors, in this country. Yes, providers could be distributed better, but that is no reason to reduce the supply of providers.
3. If you don't care for the way NPs are educated and trained, then become a PA.
4. I went to Hopkins. Many NP students worked as RNs. Some started out working full-time, then cut back to part-time as the program progressed. That is great. It allows some students to become NPs that otherwise would not be able to afford it.
Personally, I greatly admire NPs that "bootstrap" themselves up. I don't think I could do it. I have met many NPs that literally started as MAs or CNAs, then LPN, then RN, then NP. PA school does not allow for this.
If you only want to go to a school that requires full-time attendance, will educate and train you in everything from ER, ICU, L&D, to primary care, then go to PA school or med school. If you think PA school is more rigorous and provides more clinical training, then apply to one! Anyone can apply to PA school or med school or osteopathic school. Yes, I get frustrated by people who basically complain that NP school is not PA school. No, it isn't, and that is by design.
Finally, NP residencies would do a lot to rectify the shortcomings of NP school. More and more of these residencies are becoming available. Obtaining funding is a big issue.

ProgressiveThinking, MSN, CRNA · Jan 26, 2020

Respectfully, it doesn't matter to me either way, but it sounds like you have a chip on your shoulder since you didn't have any prior RN experience to be honest. I get it, and I'd probably be making the same arguments if I were you. I'm just trying to view things objectively. Hats off to you, you're doing it. Good for you. Maybe you're right, but to call RN experience an arbitrary barrier is absurd, especially when you've never worked a day as a RN.

Also, I think you lack a basic understanding of supply and demand. I actually live in California (where NPs are paid the most), and I've worked with multiple FNP graduates who still work at the bedside because they can't find quality jobs (oversaturation) and/or end up not wanting to shoulder more responsibility for equal pay (or perhaps slightly more, but it equalizes with equal hours worked at the bedside). Oversaturation may not acutely affect immediate salaries, but it can affect pay raises that go hand in hand with inflation and cost of living.

Also, the only studies that I could find were somewhat convoluted and performed by NPs. I could see this as a conflict of interest (do they have an axe to grind, interests/incentives, etc)..

If anything, in one of the studies I found: "The third theme identified was “It is very different as a provider, but I am so glad I was a nurse with experience first.” There were varying ranges of prior RN experience. Those with more prior experience relied on their prior nursing experience to care for these patients. The participants perceived that prior experience helped fill gaps in the NP education."

FullGlass, BSN, MSN, NP · Jan 26, 2020

6 hours ago, BostonFNP said:
To be clear, better schools and education is also a barrier to entry for some/many.
I would suspect its because of some of the threads we see right here on AN. I just read one last week about a new-grad FNP with no RN experience that took a job on an Intensivist consult service. That should be scary to everyone. The consensus model has tried to address this but there are still a fair amount of new-grad FNPs going to work either in-patient or on specialist services.
I think the more time you spend in your NP career (as the naivety starts to fade) you start to think about what happens when there is no longer primary care provider shortage?

That's not going to happen anytime soon. What bothers me is this mindset. Coming from the corporate world, and high tech, we had enough confidence not to be worried by more people going into STEM or business. We welcomed it. In fact, if there is more competition, the bad NPs will not get hired. Problem solved.

ProgressiveThinking, MSN, CRNA · Jan 26, 2020

Oh, and I completely agree that a residency or fellowship would solve most of this. NP residency >> RN experience.

FullGlass, BSN, MSN, NP · Jan 26, 2020

48 minutes ago, ProgressiveThinking said:
Respectfully, I don't care either way, but it sounds like you have a chip on your shoulder since you didn't have any prior RN experience to be honest. I get it, and I'd probably be making the same arguments if I were you. I'm just trying to view things objectively. Hats off to you, you're doing it. Good for you. Maybe you're right, but to call RN experience an arbitrary barrier is absurd, especially when you've never worked a day as a RN.
Also, I think you lack a basic understanding of supply and demand. I actually live in California (where NPs are paid the most), and I've worked with multiple FNP graduates who still work at the bedside because they can't find quality jobs (oversaturation) and/or end up not wanting to shoulder more responsibility for equal pay (or perhaps slightly more, but it equalizes with equal hours worked at the bedside. Oversaturation may not acutely affect immediate salaries, but it can affect pay raises that go hand in hand with inflation and cost of living.
Also, the only studies that I could find were somewhat convoluted and performed by NPs. I could see this as a conflict of interest (do they have an axe to grind, interests/incentives, etc)..
If anything, in one of the studies I found: "The third theme identified was “It is very different as a provider, but I am so glad I was a nurse with experience first.” There were varying ranges of prior RN experience. Those with more prior experience relied on their prior nursing experience to care for these patients. The participants perceived that prior experience helped fill gaps in the NP education."

What have I said? To repeat, yet again, there is no evidence that RN experience is helpful in PRIMARY CARE. The vast majority of RNs DO NOT HAVE PRIMARY CARE EXPERIENCE. In primary care, we do not hang IVs, pass meds, and so forth. As a CRNA, you are working in acute care, not primary care, so I fail to see how you can be so sure of what it takes to be a primary care provider. The brutal truth is the NP schools are not going to change their admissions policies to suit your personal beliefs. While more studies could be done, the existing studies support their policies, including a blinded study in which MDs evaluated NP physical exam skills and found the NPs WITHOUT RN experience performed better.

Here are some other reasons, based on my participation on this forum, of why RN experience may be a disadvantage to an NP in primary care:

1. Having to transition from implementing orders to writing them. This can be very hard for some RNs. As you stated, some RNs don't want that increased responsibility when they may not make more money right off the bat. Direct entry NPs don't have these issues.

2. Working 4 10 hour shifts or 5 8 hour shifts. This forum is full of complaints by former RNs that they don't like the normal primary care working hours.

3. An experienced RN has a lot of skills and expertise that do not carry over to primary care. This forum is full of such NPs wanting to continue working at the bedside or go back to the bedside. It is psychologically very difficult to go from being an expert (RN) to a novice (NP).

4. Some RNs are glad they had that experience before becoming an NP. Great. I don't know what that one quote from one person proves. Personally, it didn't matter to me not having RN experience. What I would have greatly benefited from is an NP residency.

If you are in California, I don't know how you can claim that there is an oversaturation of FNPs. Yes, in certain area, but most of the state has a shortage of PCPs. Why is this concept so difficult for you to grasp? In addition, even in more affluent areas, there are underserved populations served by FQHCs, Native American Health Centers, and free clinics. When I graduated from NP school, despite my terrible handicap of no RN experience, I had NINE (9) job offers! And you are worried about finding an FNP job?! I recently had to find a new NP job and despite having no RN experience, I found a good job in ONE WEEK!!! (Sacramento). I beat out more experienced NPs to get that job. I'm not saying this to toot my horn, just to illustrate that an NP must know how to do a good interview and close the deal to get the job and not everyone knows how to do that. The only really bad job market in California is the San Diego area, which even doctors complain about.

Just because some FNPs have trouble finding jobs does not mean there is oversaturation:

1. One must have a good resume

2. One must know how to interview

3. One must be willing to relocate

4. One must be flexible - some NPs are too picky and don't want to ever be on call, never want to cover Saturday clinic, only want to work certain hours, blah, blah

5. Be willing to consider a specialty - these also often pay more. I am very interested in psych as well as pain management and there is a high demand for such specialists, and the pay is much better than primary care. Ultimately I chose psych, and will be starting my post-master's PMHNP certificate program this fall. There is definitely a HUGE shortage of psych providers in California, and it pays very well.

6. One must know how to find a job. Job search is a skill and some people do not have this skill. Fortunately, it can be learned.

Finally, UC Davis has a program for a dual PA/MSN degree that you might want to consider.

As for me having a chip on my shoulder, right - I get job offers at the drop of a hat while your friends can't get jobs. I get frustrated going over the same thing ad nauseum. The main reason I post on this topic is that there are an increasing number of direct entry NP students and I don't want them to be discouraged or suffer needless anxiety from the many negative posts on this forum.

Forecasts of California's PCP supply predict a WORSENING shortage:

California Future Health Workforce Commission. (2019, February). Meeting the demand for health: Final report of the California Future Health Workforce Commission. Retrieved from https://futurehealthworkforce.org/wp-content/uploads/2019/03/MeetingDemandForHealthFinalReportCFHWC.pdf

https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage

https://calmatters.org/projects/californias-worsening-physician-shortage-doctors/

https://www.ucsf.edu/news/2017/08/408046/california-demand-primary-care-providers-exceed-supply-2030

Tegridy · Jan 26, 2020

1 hour ago, FullGlass said:
What have I said? To repeat, yet again, there is no evidence that RN experience is helpful in PRIMARY CARE. The vast majority of RNs DO NOT HAVE PRIMARY CARE EXPERIENCE. In primary care, we do not hang IVs, pass meds, and so forth. As a CRNA, you are working in acute care, not primary care, so I fail to see how you can be so sure of what it takes to be a primary care provider. The brutal truth is the NP schools are not going to change their admissions policies to suit your personal beliefs. While more studies could be done, the existing studies support their policies, including a blinded study in which MDs evaluated NP physical exam skills and found the NPs WITHOUT RN experience performed better.
Here are some other reasons, based on my participation on this forum, of why RN experience may be a disadvantage to an NP in primary care:
1. Having to transition from implementing orders to writing them. This can be very hard for some RNs. As you stated, some RNs don't want that increased responsibility when they may not make more money right off the bat. Direct entry NPs don't have these issues.
2. Working 4 10 hour shifts or 5 8 hour shifts. This forum is full of complaints by former RNs that they don't like the normal primary care working hours.
3. An experienced RN has a lot of skills and expertise that do not carry over to primary care. This forum is full of such NPs wanting to continue working at the bedside or go back to the bedside. It is psychologically very difficult to go from being an expert (RN) to a novice (NP).
4. Some RNs are glad they had that experience before becoming an NP. Great. I don't know what that one quote from one person proves. Personally, it didn't matter to me not having RN experience. What I would have greatly benefited from is an NP residency.
If you are in California, I don't know how you can claim that there is an oversaturation of FNPs. Yes, in certain area, but most of the state has a shortage of PCPs. Why is this concept so difficult for you to grasp? In addition, even in more affluent areas, there are underserved populations served by FQHCs, Native American Health Centers, and free clinics. When I graduated from NP school, despite my terrible handicap of no RN experience, I had NINE (9) job offers! And you are worried about finding an FNP job?! I recently had to find a new NP job and despite having no RN experience, I found a good job in ONE WEEK!!! (Sacramento). I beat out more experienced NPs to get that job. I'm not saying this to toot my horn, just to illustrate that an NP must know how to do a good interview and close the deal to get the job and not everyone knows how to do that. The only really bad job market in California is the San Diego area, which even doctors complain about.
Just because some FNPs have trouble finding jobs does not mean there is oversaturation:
1. One must have a good resume
2. One must know how to interview
3. One must be willing to relocate
4. One must be flexible - some NPs are too picky and don't want to ever be on call, never want to cover Saturday clinic, only want to work certain hours, blah, blah
5. Be willing to consider a specialty - these also often pay more. I am very interested in psych as well as pain management and there is a high demand for such specialists, and the pay is much better than primary care. Ultimately I chose psych, and will be starting my post-master's PMHNP certificate program this fall. There is definitely a HUGE shortage of psych providers in California, and it pays very well.
6. One must know how to find a job. Job search is a skill and some people do not have this skill. Fortunately, it can be learned.
Finally, UC Davis has a program for a dual PA/MSN degree that you might want to consider.
As for me having a chip on my shoulder, right - I get job offers at the drop of a hat while your friends can't get jobs. I get frustrated going over the same thing ad nauseum. The main reason I post on this topic is that there are an increasing number of direct entry NP students and I don't want them to be discouraged or suffer needless anxiety from the many negative posts on this forum.
Forecasts of California's PCP supply predict a WORSENING shortage:
California Future Health Workforce Commission. (2019, February). Meeting the demand for health: Final report of the California Future Health Workforce Commission. Retrieved from https://futurehealthworkforce.org/wp-content/uploads/2019/03/MeetingDemandForHealthFinalReportCFHWC.pdf
https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage
https://calmatters.org/projects/californias-worsening-physician-shortage-doctors/
https://www.ucsf.edu/news/2017/08/408046/california-demand-primary-care-providers-exceed-supply-2030

Wish they wouldn’t have lumped the cities in with some of the rural areas in those reports. Specifically the third one. If they’ll pay my loans I’d go to rural cali even in light of higher taxes and some meh laws

murseman24, MSN, CRNA · Jan 27, 2020

FullGlass, no offense, but I think the obvious reason you don't have a problem finding a job is because you went to Hopkins. Whether that education was truly better/worth it does not matter. You have a fancy name on your resume that shines above the gajillion other NP applicants and even I would be curious as to the quality of an Ivy league nursing school grad.

There are many hardworking, intelligent, clinically skilled nurses who go to NP school to end up having trouble finding a desirable job when they finish.

It's ludicrous to think RN experience is not applicable in primary care. Say you have a DKA or septic patient come into your office? You take some labs and send them to the ER or hospital to be admitted, fine. You don't have to know how to manage them when they are crashing in front of you or have the hands on skill set to perform the tasks required for stabilization which many critical care nurses understand first hand. But I do think it can give you a perspective on where their disease process can lead, and have a healthy respect for the severity of certain problems.

Experience is valuable, wether or not it is statistically significant in your studies.