Question from a doc on NP education

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Hello, I am coming here to see if I can pick some information off of you all. I will state that I appreciate ahead of time the responses I will hopefully receive and hope to put them to good practice.

I am an ER physician in the southeast-ish area of the US, and usually do much travelling around. I work for various staffing agencies, usually just taking the most needed bids and such. I tend to work with many different nurse practitioners and physician assistants in the various locations, mostly in the bigger ERs. The smaller ones usually it is just me since the volume is low.

The reason I come here is because I am looking or some info on the education of nurse practitioners. Sine I occasionally lecture on ER topics at one of the local PA schools in front of medical students and Pas I have been able to get a thorough glimpse at the PA ED model, which really is not too much different than a condensed version of ours it seems. I did go to a med school here in the US which also has a PA program close by so I understand this aspect.

I have noticed at many of the facilities I work at, a higher than average (in comparison to PA and other docs) the nurse practitioners often (not a total majority) seem to be oblivious to many aspects of ER level care. Some are unable to understand the interpretation of a basic set of lab panels, X-rays, and some are unable to suture well, if at all. There are a few that are Excellent at what we do (the term we used because we are a team and I dislike the dichotomy many use separating physician practice from other types of providers since it just stems unneeded conflict and perpetuates social gaps).

I have not noticed such a large gap in practice from the physician assistants that I work with though. Nearly all of them are able to suture, interpret labs, splint, suture, read most X-rays (abdominal X-rays can be very difficult to read at times, often we physicians consult rads on these). (I am also referring to flat plate x rays not CT/MRI and the such when providing the term Xray).

The gap is narrowed it seems between the PA/NP when it comes to diagnosing illness in the fast track though, I do notice it seems the PA do edge out slightly on better diagnosis (but my time is limited in the fast track, I am only there when they have a question about something, if something gets miss-triaged, or if family requests to see me, etc etc.)

But the whole point of me coming here is to ask if they teach nurse practitioners during their educational adventure how to read X-ray, suture, splint, read basic lab panels, intubate, and what not. I have looked through curriculums but course names often do not tell accurate stories in any aspect of education.

I would feel rather rude asking my coworkers these questions, since they may take it as demeaning and I like to maintain great relationships with the other providers. So again, here I am looking for a bit of info on what type of education they provide nurse practitioners in school (we use mostly FNPs in er) to see what you all thought of the situation.

Hope I am not stepping on toes with this,,,, just looking to gather some information in an objective manner.

Best wishes

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Specializes in NICU.

It will vary between schools and also the NP's prior RN background. I can tell you my experience, as someone with 6 years of RN experience in a Level IV NICU (highest level, I know that for trauma it's the opposite) and went to school in the northeast, now working as a neonatal NP.

In school we were taught how to place a chest tube, intubate, do a lumbar puncture, among other things. Reading xrays came more from on-the-job training. As a RN, I could tell you if the ETT & NG was in good position and if there was a collapsed lung, but that was about it. The bulk of my learning came from that aspect was on the job, listening to radiologists in morning report. I felt like I had a rudimentary understanding of how to interpret basic labs as a RN (keeping in mind that the neonate population has several electrolyte shifts in the first couple of days of life) and got a much better understanding in school. I did not learn how to suture (unless you count suturing in an umbilical line), but the pediatric intensive care NP class did. I'm not sure what the adult class did.

Out of the gate, my guess is that many PAs would do better in certain specialties (not everyone, but many due to the extensive clinical/didactics that PAs have), but not king over everything (like OB, psych, peds, or NICU) and my next guess is that within a few years of experience, everyone would even out for the most part.

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I am presently finishing up my Nurse Practitioner education at one of the best NP schools in the South East, and I had to take a whole semester long class on reading general films (chest and abdominal), suturing (Simple interrupted, vertical/horizontal mattress, running suture, and figure 8 stitch) and interpreting diagnostic lab values. However, it is sad that this is not the general educational curriculum that is set around the country. At this present moment there are online schools where a nurse can get their Masters without ever having to show up on campus more than a few times.... How could they ever educate a competent provider is beyond me. Employers should definitely inquire about school, clinical experience, and RN experience prior to hiring.

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I am presently finishing up my Nurse Practitioner education at one of the best NP schools in the South East, and I had to take a whole semester long class on reading general films (chest and abdominal), suturing (Simple interrupted, vertical/horizontal mattress, running suture, and figure 8 stitch) and interpreting diagnostic lab values. However, it is sad that this is not the general educational curriculum that is set around the country. At this present moment there are online schools where a nurse can get their Masters without ever having to show up on campus more than a few times.... How could they ever educate a competent provider is beyond me. Employers should definitely inquire about school, clinical experience, and RN experience prior to hiring.

I've been searching for one of these schools! What school is this?

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Specializes in GI/GU surg,Pacu, ct surg, home care, NH.

I went to FNP school in NYC. We didn't learn to read Xrays and suturing. However I took initiative and took a suturing class and Xray class. I work in a hospital in general surgery department so my Xray reading skills have gotten even better, and I have gotgten used to looking at CT scans. However I have not had the chance to do any suturing. If I were ever to decide to switch to an ICU setting or to an ER setting I would def take a refresher course on suturing as well as courses on Central line insertion, arterial line and on an other invasive procedures that I may encounter.

Unfortunately NP education is not standardized across the country. Ideally in my opinion all those skills you mentioned should be taught across the board to any one in NP school.

As far as reading and interpreting labs that's something I would think every NP school teaches that.

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Specializes in Family Practice.

I think there are many aspects to this particular issue. Most NP programs are FNP programs and I know my program forbade us from any in hospital practice which I found to be ludicrous.

We had one eight hour session on the items you mentioned- suture, interpreting X-ray, and splinting. I found it to be quite pitiful. One of my clinical rotations was in urgent care so I insisted on suturing every laceration so I could practice. Now I have not sutured in almost two years so I'd need a refresher.

Many schools now are pushing BSN straight to DNP and I think it is contributing to this issue. I had eight years of ER and ICU experience as a RN so I was already comfortable with interpreting labs, reading x-rays, and splinting. If schools are going to try and fast track people through, they need to beef up their curiculum. My two pennies.

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Specializes in Pediatric Critical Care.

If you are mostly coming across FNPs, that may explain some of it. FNPs are more trained towards primary care. Not so much suturing and the like. ACNPs might be better trained in the ER procedure stuff.

NPs chose a specialty to study upfront, as opposed to a PAs education which is as a generalist. If the NP specialized in primary care their education is going to be different than those who specialized in acute care.

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Specializes in Outpatient Psychiatry.

Nurse practitioners as a whole don't get a lot of training at the graduate level and the required hours in clinical rotations usually cap around 700-750. Graduate nursing, even NP, is largely theoretical and research driven. Of my 44 semester hour program, 13 hours had no clinical bearing. There were very few -ology courses, and little time given to practical skills. The focus of NP training is largely base, i.e. here's sinusitis, here are the typical symptoms and meds. Very little scientific underpinnings are provided. Time and experience are unfortunately required for most to learn rudimentary skills, e.g. suturing, I&D, splinting, and insufficient science is provided to really "understand" the labs. I think thorough dedication to learning is the only way to mount the learning curve if you will. If I didn't spend much of my free time reading about psychiatry, psychology, neurobiology, neurology, and endocrinology I would attest that I would not be adequately prepared to run my shop as there isn't another clinician beyond master's level therapist there. I do try to remain aware of "the rest of medicine" with other readings, Journal Watch General Medicine, and some others.

I've cried for more clinical training and more book science in murse practitioner programs as well as program standardization for a long time.

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This is a hot button, multifaceted issue, doc. The simple answer stems from the fact that NPs school quality wildly varies. It may come as a shock to you but most RNs holding a BSN can get into at LEAST one NP school which is a stark contrast to medical school where competition is fierce.

There are a myriad of for-profit and online schools with one or even less campus visits and very little face time and evaluation. Granted, there are still a number of schools that do it the right way (teach x-ray interpretation, suturing, I&D etc.) and probably still produce those excellent NPs you work with in the ED.

To summarize and add:

1. Admission standards are way too low and thus there is a "boom" of RNs leaving the bedside to go to NP school.

2. Regulation of NP schools by national credentialing organizations is poor.

3. NP curriculum varies wildly from to school to school and specialty to specialty other than the basic classes. Some teach literally nothing while others teach chest tube insertion, CVC insertion, intubation etc.

4. Online and for-profit, while convenient, have led to overall a poorer education model for NPs. How man for-profit MD/PAs schools are there? Very very few.

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These are some great responses. I do appreciate the help. Not having a centralized curriculum (if that is what is occurring) could be a concern. I am surprised they have not touched on such important topics such as the basic physical skills as presented above. I think we learned that in our first year of school and continued to do practice for the next 8 years until we could practice on our own.

700 hours does seem like a pretty quick route to be a provider also. I think by the time we graduated medical school we had around 5000-6000 hours of clinical experience, maybe a little less. But it was 50 or so + hour weeks for most of the year. We really did not count. Nonetheless much of our training was excessive, most of us could probably handle an ER (especially the non-trauma ERs) after our first year of residency.

I do not know much about profit organizations besides they probably, as other for profits, seek the approval of shareholders over all else.

I do not much much control over who we employ, I travel around too much, would rather not get involved, and also do not hold any administrative privileges.

The big dichotomy I notice though is the personality factor, which is present across all providers. I have met MD/DO/PA/NP that all seem to think they know it all, and then the ones who are more eager to learn… the latter always succeed much more and get less lawsuits (at least our attendings told us that). I do enjoy working with nurse practitioners that like to learn, I let them do all the stuff they need to beef up their skills, especially on slow nights/days, because we were all new once. The ones that I work with that worry me are the ones that do not seem to want to bounce anything off of other providers or take constructive criticism. and this has a few times almost gotten me into trouble since my name is on all the charts. I did have to complain on one or two (which I do not like doing, and after multiple offences) and put my foot down stating I did not want them on my shift or I would go elsewhere/not resign my contract at that facility.

You all seem to have answered my question pretty thoroughly, but I am not sure how to adjust the problem though. As I said, it is not super-commonplace, but I have had a couple occurrences in the past year and I have only been out of residency a year also.

Again though, not to step on toes, most providers I work with are competent across all spectrums, but as you all said they may not do as good of a job sieging NP's brains (in all programs) with the needed information to provide safe care as they do pas or MD/DO. At least this is what I am hearing from the responses.

To those who are able to pull off being a provider in 700 hours that is an amazing hat-trick, btw.

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Specializes in Nephrology, Cardiology, ER, ICU.

Hi and welcome.

Appreciate the questions. I'm an advanced practice nurse with 10 years nephrology exp. I have also moonlighted in the ER as an APN. My nursing background is 10 years level one trauma center background at an ER with 100+k visits/year (with an ER residency program).

In my spare time, I volunteer on my rural fire/EMS squad at the ALS level where I intubate, run codes, etc..(and we are rural with 20 minute + transport time - 17 years exp).

Thats just to give you background on where I'm coming from with my opinion.

In my nephrology job - my knowledge in pretty solid. The docs in my practice trust my judgement and consider my assessment skills on par with theirs. If I have questions/concerns I have them as back up but we they are not in the building nor in the same town that I am in so I am expected to be able to give decent report and know what I want when I call them.

When I work ER - since I work just very part time, I take the easy (no procedure) pts as I don't keep up my suturing skills. Since I am usually the lone female, I do most of the gyn exams, peds stuff and if any dialysis pts come in, well they are always slid my way! lol

As to my education background, like you I'm sure, not everything is taught in school - taking initiative and continuing to learn as the years roll on is very important. It is also important to know your limitations. No one likes a cowboy except the lawyers...

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Specializes in Urology.

As others have pointed out the education will vary wildly from institution to institution. It seems as of late a lot of RN's are wanting to do NP school for the sheer fact they don't like the RN job. We are seeing an influx of nurses with 1-2 years experience leave the bedside to become providers because they don't like it. I'm not sure which coconut hit them on the head because if you don't like bedside, what makes you think you'll like being a provider (you're still seeing patients, just writing the orders instead of doing the orders).

I will say this, a lot of your good NP's are learners and most likely had a robust career as an RN. I know a lot of people say the job is different and I agree it is, but just having a solid career in nursing can provide you with so much more knowledge. You think a nurse with 1-2 years experience has ever dealt with ludwig's angina or had a patient with meralgia paresthetica (lateral femoral cutaneous nerve entrapment)? Maybe, but most likely not. Thankfully those were things I saw in my career in the ER, and they are cemented in my brain now. Having a robust career has provided me with the situational awareness of what do to when things go wrong, anticipate whats next and even offer suggestion to the attending (gasp!). Much of how I nurse is part nursing, part provider (minus the provider). I'm currently in school to become an FNP. I go to a very well known state university. Pur course does not include reading x-rays, though through my RN experience I've looked at thousands and have picked enough ER docs brains to understand what we are looking at. We do have a suture lab and basic labs should just be par for the course of taking care of patients. I'm not certain as to why or how this is happening.

I'm sorry for your experience with NP's and I hope it doesnt change your judgment about them. Its going to come down to the person and their abilities to make themselves a better provider. Some will come out the gate lightyears ahead of others. Like I mentioned before, those that have limited exposure might struggle where others might flourish.

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