Seeking Advice: Direct Entry Blues

[mk989]

I am a graduate of direct entry accelerated BSN/MSN program for non nurses.

I came into the role of APN, specifically NP as a very green graduate. I did very well in my program, but am finding clinical practice as an APN to be quite challenging. Academic knowledge and clinical expertise are very different. I've been in my present position about a year and have been directed to seek a position elsewhere but permitted to continue working while I search. It was also mentioned I try to seek a specialty area instead of primary care so I can focus my knowledge development.

I'm looking at specialties but wondering about my best options on where to go from here. I am not against applying to bedside RN positions. I've worked so hard but have wondered about leaving nursing altogether for something else.

Any guidance appreciated

[Gentleman_nurse, MSN]

Jules A, I'm confused. Are you saying is it realistic for the average new graduate NP to perform on the same level as a seasoned professional like yourself on day 1? You've probably been around. You've seen places that chew people up and spit them out in a sink or swim environment. If you're saying, it's the business model of medicine deal with it, I respect that. If you're saying this is OK, then we will have to agree to disagree.

[elkpark]

Jules A, I'm confused. Are you saying is it realistic for the average new graduate NP to perform on the same level as a seasoned professional like yourself on day 1?

Not putting words in Jules' mouth but speaking for myself, I don't think "perform(ing) on the same level as a seasoned professional" is a realistic expectation of a new grad, but I think that a minimum level of basic competence is.

If the nursing profession is going to take the position that it's reasonable for new graduate NPs to need extensive, intensive orientation, I think that is going to harm the NP profession over time, employment-wise, against PAs and I also think that it is further enabling the low-quality schools to continue to crank out poorly prepared clinicians with no adverse consequences (for the school, that is).

[Jules A, MSN]

I'm going to poke the dragon. Docs have a minimum of a 3 year residency after school

I think dragon might be the nicest thing you've ever called me. :) Excellent point however the 3 year residency is still their school, they are not considered full vested employees at that stage so if you are suggesting NPs would benefit from a required residency I'd agree 100%.

[Jules A, MSN]

Jules A, I'm confused. Are you saying is it realistic for the average new graduate NP to perform on the same level as a seasoned professional like yourself on day 1? You've probably been around. You've seen places that chew people up and spit them out in a sink or swim environment. If you're saying, it's the business model of medicine deal with it, I respect that. If you're saying this is OK, then we will have to agree to disagree.

I don't believe any new grad should be expected to perform like a seasoned professional although my case load from day one was the same as it is today. What I believe is a minimal orientation to the office and EMR should be sufficient for any new employee who is being paid full wages.

The places that are simply hostile are a different story and unacceptable but I'd leave it up to the individual business to decide how much nurturing they are willing to provide and not feel negatively about those who believe people should come out of school with the ability to practice to the full scope of their licensure and earn their wages from the start.

I guess we are probably in line on a couple of points but agreeing to disagree on others? :)

[babyNP., APRN]

I think dragon might be the nicest thing you've ever called me. :) Excellent point however the 3 year residency is still their school, they are not considered full vested employees at that stage so if you are suggesting NPs would benefit from a required residency I'd agree 100%.

I would argue that you're derisive towards me, not the other way around...but I think a residency would be a godsend for our profession. Some children's hospitals are starting to do this and even build in rotations so that you apply for whatever specialty you'd like after a year. They are paid a lower wage during the year of residency and then given a bonus at the end if they sign on to the hospital.

[traumaRUs, MSN, APRN]

While I agree a generalist NP (FNP or AGNP) in primary care should feel comfortable without an extensive orientation, for specialty practices, I believe a more in-depth orientation is needed.

And certainly at the hospitals I'm credentialed at, no AGACNP goes right into the ICU and starts lines/intubating without the requisite number of procedures with MD to prove competency.

[Richard Wolfe, RN]

I'm going to poke the dragon. Docs have a minimum of a 3 year residency after school

That's because beyond theory, doctors know absolutely zero coming out of school. Everyone knows that, therefore they are very accommodating.

APRNs are expected to have basic experience through bedside nursing. That is the way it is supposed to work.

[BCgradnurse, MSN, RN, NP]

That's because beyond theory, doctors know absolutely zero coming out of school. Everyone knows that, therefore they are very accommodating.

APRNs are expected to have basic experience through bedside nursing. That is the way it is supposed to work.

But what is learned and experienced as a bed side nurse is very often not applicable at all in a clinic or office setting.

[Skippingtowork]

Bedside nursing does not help you in primary practice or even many specialty practices. The problem is that many practices do not have the time or money to provide extensive training for anyone. Also, many of these practices are poor examples of how to run a business. I worked in a practice where the MD owner did not even expect you to see patients on your own for three months (specialty). Myself and my colleague began seeing them in 3 weeks, with the MD support and mentorship. The MDs just out of fellowship also received good orientation and close monitoring. We all felt free to tap each other's brains and the practice did very well. My bedside nursing (extensive) was a hindrance. Even in clinical, my preceptors laughed and told me "you are in the community now, not in the hospital." If you intend to work in the hospital then bedside nursing is very beneficial. You will be approaching care differently.

The OP needs to find a practice which is more mentoring, go to some conferences or find an NP residency where a lot of time is spent with her/him. As far as being ready to be independent on day 1, if you feel so secure, you won't be seeing me. Not even MDs can practice up to speed that quickly. I had one MD tell me it takes MDs years to be comfortable.

No need to go to bedside nursing unless you want a side job.

[guest769224]

But what is learned and experienced as a bed side nurse is very often not applicable at all in a clinic or office setting.

What about emergency room nursing as an RN? That can be very applicable to what's seen in a clinic and office.

[KatieMI, BSN, MSN, RN]

Bedside nursing can play any role at all in preparation of a new grad NP for functioning on a provider level only if the new grad happened to work in the same enviroinment, with the same physicians, same population and was able to practice within a full scope of bedside RN. In other words, if a new grad NP was working in the same hospital, same type of unit, knows most physicians (and they know her) and all that time she was doing NURSING job, then there can be reasonable expectations that she would be more or less comfortable there as an NP.

Otherwise, there gonna be a big, terryfying, lonely terra incognita anywhere she goes and a very long, very steep learning curve before she feels comfortable.

The OP needs to go either to NP residency program, or find a practice which has established orientation routine with several months side-by-side work, preferably with one provider, whether MD or NP. The latter is probably easier to find in private practice. ER would be one of the worst enviroinments imaginable, either as RN or NP.

Finding bedside nursing job as an NP can be very difficult, as in many states there are clauses in Scope of Practice for Nurses which put such individual in a legal "gray zone", making him or her potentially liable for not prevening or recognizing negative events. Such bedside RN presents too much of a liability to put up with for most hospitals.

[Jules A, MSN]

What about emergency room nursing as an RN? That can be very applicable to what's seen in a clinic and office.

That is exactly what I believe and being able to triage like an ED RN is valuable in any specialty, imo.

My psychiatric RN experience was absolutely invaluable. I spent years seeing the diagnoses, medication doses, reactions, adverse reactions. It is probably why I was able to start as a new grad after only 2 flimsy pharmacology classes and handle a full patient load. I'm not saying I wasn't terrified and there wasn't a learning curve but I utilized my RN experience constantly and actually still think back to some of the unusual presentations I have seen over the years when hit with an especially challenging case.