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

[Susie2310]

Isn't this a bit hypocritic? If we flipped these words around: if you understood more about advanced practice nursing and had experience yourself as an advanced practice nurse, I think you would appreciate...

Flipping my words to the above would be artificial on your part since I replied to the content of a specific post and my comment was appropriate to the specific post. Please do not take my words out of the context they were written in.

No, given the topic of this thread "Seeking Advice: Direct Entry Blues", and the poster I replied to who said that bedside nursing experience is not relevant to outpatient clinics, my comment is not hypocritical.

My comment was: "If you understood more about acute care nursing and had experience yourself as an acute care RN, I think you would appreciate how much acute care RN experience can inform and benefit a NP's practice and ultimately benefit patients." I am replying as a bedside nurse and I illustrated in my post how relevant acute care nursing experience is to outpatient urgent care clinics, particularly allergy and asthma, which the poster had mentioned in his/her bio is his/her specialty. I provided a statement that was absolutely relevant to the post I replied to and which was not at all hypocritical.

My understanding or lack of understanding/experience of advanced practice nursing is irrelevant in regard to the fact that clearly acute care nursing experience would benefit a NP in an urgent care faced with unstable allergy, asthma/COPD patients and patients in respiratory distress or respiratory failure, which is the point I made in the CONTEXT of the post I replied to.

[BostonFNP, APRN]

Flipping my words to the above would be artificial on your part since I replied to the content of a specific post and my comment was appropriate to the specific post. Please do not take my words out of the context they were written in.

No, given the topic of this thread "Seeking Advice: Direct Entry Blues", and the poster I replied to who said that bedside nursing experience is not relevant to outpatient clinics, my comment is not hypocritical.

My comment was: "If you understood more about acute care nursing and had experience yourself as an acute care RN, I think you would appreciate how much acute care RN experience can inform and benefit a NP's practice and ultimately benefit patients." I am replying as a bedside nurse and I illustrated in my post how relevant acute care nursing experience is to outpatient urgent care clinics, particularly allergy and asthma, which the poster had mentioned in his/her bio is his/her specialty. I provided a statement that was absolutely relevant to the post I replied to and which was not at all hypocritical.

My understanding or lack of understanding/experience of advanced practice nursing is irrelevant in regard to the fact that clearly acute care nursing experience would benefit a NP in an urgent care faced with unstable allergy, asthma/COPD patients and patients in respiratory distress or respiratory failure, which is the point I made in the CONTEXT of the post I replied to.

To be perfectly clear the original post said "often not applicable" which you changed to "not relevant".

I agree that some/much of bedside RN experience is not directly applicable to the daily role of a provider in a clinic. On the other hand I do think that all RN experience (and non-RN experience) in some varying degree is relavent to practice.

So let's do an exercise and take a 40year old patient with a prior history of COPD that comes under your care for acute shortness of breath. What is your responsibility as a bedside RN: given your bedside experience what do you do for this patient? What are the next steps for you?

[Susie2310]

To be perfectly clear the original post said "often not applicable" which you changed to "not relevant".

In the post I replied to the poster used the words "not particularly relevant." I quoted the post. Go back and look at the post I quoted. I quoted part of post #52.

As an aside, relevant is a synonym for applicable and vice versa.

[FiremedicMike, RN, EMT-P]

So for the sake of argument, how far down the rabbit hole can we take this discussion?

For some of you, bedside RN experience is critical to the success of a practicing NP, but how much and what experience? Should FNP students who desire to work in outpatient primary care be forced to show X years of experience as an RN in a primary care office? Should AGACNP students who desire to work in a surgical ICU be forced to show X years of experience as a scrub or ICU RN? Who gets to define on top of ensuring that the experience is relevant to the desired practice setting, who gets to decide how many years should be used to demonstrate competence? Is a nurse with 5 years working on a med-surg floor at a community hospital more or less prepared for NP school than a nurse with 1 year of experience at an ICU for a regional primary trauma center?

Someone recently within this thread mentioned previous exposure to COPD or asthma exacerbations would be beneficial to their future NP practice model, but lets be honest, how many times does one really need to see a COPD patient decompensate before you know what it looks and feels like? Isn't it reasonable to assume that direct entry programs will expose their students to these pathologies during their training?

For full disclosure, I am not a nurse or an NP. As my handle suggests, I'm a fire-based paramedic who's planning on entering a local, respected, direct entry NP program within the next year or two, at which point I'll have nearly 20 years of experience in EMS.

[BostonFNP, APRN]

In the post I replied to the poster used the words "not particularly relevant." I quoted the post. Go back and look at the post I quoted. I quoted part of post #52.

As an aside, relevant is a synonym for applicable and vice versa.

I was going by her original post not her followup that you quoted, so I'll concede that point.

Lets move on to the demonstration of how prior acute care bedside RN experience is vital to being an NP in clinic. You are in the clinic and presented with a 40yoM with prior history of COPD that arrives with a CC of acute shortness of breath. What are your next steps based on your prior RN experience?

[BostonFNP, APRN]

For some of you, bedside RN experience is critical to the success of a practicing NP, but how much and what experience?

This is a big part of the issue. Add to that the student NPs that are trying to work full or part time in their first two years of RN practice while also trying to go to grad school and do APN clinicals. Are they really getting a good learning experience in any of those roles (RN, student, or NP preceptee)?

If we want to make RN experience a pre-requisite then shouldn't, logically, FNP or AGPCNP or PPCNP programs require X amount of RN experience in a clinic setting?

The honest truth of this issue is that the only real reason it is an issue is that RNs that have put in years of experience just "don't like" the idea that individuals with less experience with them being in a position to give them "orders". And honestly, I can understand that.

[BCgradnurse, MSN, RN, NP]

So for the sake of argument, how far down the rabbit hole can we take this discussion?

For some of you, bedside RN experience is critical to the success of a practicing NP, but how much and what experience? Should FNP students who desire to work in outpatient primary care be forced to show X years of experience as an RN in a primary care office? Should AGACNP students who desire to work in a surgical ICU be forced to show X years of experience as a scrub or ICU RN? Who gets to define on top of ensuring that the experience is relevant to the desired practice setting, who gets to decide how many years should be used to demonstrate competence? Is a nurse with 5 years working on a med-surg floor at a community hospital more or less prepared for NP school than a nurse with 1 year of experience at an ICU for a regional primary trauma center?

Someone recently within this thread mentioned previous exposure to COPD or asthma exacerbations would be beneficial to their future NP practice model, but lets be honest, how many times does one really need to see a COPD patient decompensate before you know what it looks and feels like? Isn't it reasonable to assume that direct entry programs will expose their students to these pathologies during their training?

For full disclosure, I am not a nurse or an NP. As my handle suggests, I'm a fire-based paramedic who's planning on entering a local, respected, direct entry NP program within the next year or two, at which point I'll have nearly 20 years of experience in EMS.

Good for you, Mike! I wish you well and hope you love it.

[mmak]

I would hiiiiiiighly recommend getting an RN job to help get your feet wet.

[myelin]

I am a direct entry NP grad. I did get some RN experience before graduating, but it was per diem. I would describe myself as quite successful. I literally have only had good feedback from the physicians and other providers I work with. I was very careful and cautious (especially when I first started) and now 2+ years into practice am really settling into the groove of my field. I also do a lot of reading, which has helped. Was my RN experience helpful? Sure. But it has been completely eclipsed by my first few years of practice as an NP and the support I've had from my provider colleagues. The reality is that what matters (IMO) to be successful as an NP is having a supportive, high quality NP position as a new grad. You want to see a variety of pathology in a supportive environment with reading on the side - this is what makes a great provider. It sounds like OP did not have that in her job and was set up to fail.

Also, I can't help but find it frustrating to hear non-NPs comment on NP practice. The fact that they are so highly focused on RN experience indicates to me that they don't really know a lot about what it's like to be an NP and develop your way of practicing. RN experience in minuscule in comparison to working as an NP - seeing patients, working through diagnoses and tests, coming up with treatment plans, and getting guidance from more experienced providers - this is what matters. Truly every single person from my program is a successful NP or RN. Some chose to not go on to become NPs but to stay RNs. Those of us (the majority) who opted to continue on to become NPs after the accelerated RN training are practicing in this role without any issues at all.

My biggest concern is online NP programs with low barriers to entry. These are what will damage our field. I know two terrible psych nurses. Both are attending some BS part-time online PMHNP program. One is such a terrible psych nurse that he was recently remediated and is having to go through training again. He has no business whatsoever becoming an NP. Of course his online program is happy to take his money.

[WestCoastSunRN, MSN, CNS]

I am a direct entry NP grad. I did get some RN experience before graduating, but it was per diem. I would describe myself as quite successful. I literally have only had good feedback from the physicians and other providers I work with. I was very careful and cautious (especially when I first started) and now 2+ years into practice am really settling into the groove of my field. I also do a lot of reading, which has helped. Was my RN experience helpful? Sure. But it has been completely eclipsed by my first few years of practice as an NP and the support I've had from my provider colleagues. The reality is that what matters (IMO) to be successful as an NP is having a supportive, high quality NP position as a new grad. You want to see a variety of pathology in a supportive environment with reading on the side - this is what makes a great provider. It sounds like OP did not have that in her job and was set up to fail.

Also, I can't help but find it frustrating to hear non-NPs comment on NP practice. The fact that they are so highly focused on RN experience indicates to me that they don't really know a lot about what it's like to be an NP and develop your way of practicing. RN experience in minuscule in comparison to working as an NP - seeing patients, working through diagnoses and tests, coming up with treatment plans, and getting guidance from more experienced providers - this is what matters. Truly every single person from my program is a successful NP or RN. Some chose to not go on to become NPs but to stay RNs. Those of us (the majority) who opted to continue on to become NPs after the accelerated RN training are practicing in this role without any issues at all.

My biggest concern is online NP programs with low barriers to entry. These are what will damage our field. I know two terrible psych nurses. Both are attending some BS part-time online PMHNP program. One is such a terrible psych nurse that he was recently remediated and is having to go through training again. He has no business whatsoever becoming an NP. Of course his online program is happy to take his money.

Some really good thoughts here. As a non-NP nurse who has watched my profession change and morph over the last couple of decades, I'll be honest and say one of my concerns with DE is the *idea* of producing advanced-practice-nurses-who-are-not-really-nurses. And this is not a jab at DE APNs -- and I am not saying I think you are not really nurses -- but I'm trying to put into words what I think could be at the heart of the DE APN "controversy" -- if that's what you want to call it. It feels like a dilution of our profession to me when our highest clinical practitioners (who are often in a position to speak for and represent nursing) are unable to relate to nursing in it's most basic forms.

It has been suggested here (maybe not this very thread) that bedside nurses just don't like being directed by APNs who haven't "paid their dues". For me this could not be more inaccurate. It insinuates a lot of negativity toward the bedside, for one, and secondly assumes most nurses are juvenile.

But I think there is something to nurses wanting their APN colleagues to share commonality not only in undergrad education but in practice with them. I agree that such commonality will not make or break an individual APN's practice. But I don't agree that it may not be an important element to consider when looking at nursing practice across the continuum and what it means when we speak of being more collective and organized as a profession.

This is no hill I will ever want to die on. I could argue the benefits of DE programs from another perspective (such as how they will not bleed nurses from the bedside). I'm just sharing my personal, limited perspective on the matter.

I also agree -- better standards for all APN education are needed, yes. I feel like nursing is all over the place when it comes to standards and scopes and so forth. Because of that, it is extremely vulnerable to money making schemes infiltrating higher education.

[BostonFNP, APRN]

Great post thanks for sharing your thoughts. A few follow-up questions:

I'll be honest and say one of my concerns with DE is the *idea* of producing advanced-practice-nurses-who-are-not-really-nurses. It feels like a dilution of our profession to me when our highest clinical practitioners (who are often in a position to speak for and represent nursing) are unable to relate to nursing in it's most basic forms.

But I think there is something to nurses wanting their APN colleagues to share commonality not only in undergrad education but in practice with them.

I do think your thoughts mirror the thoughts of many other bedside RNs regarding APNs: they seem to have a general distate/distrust for DE grads but when it comes down to it, don't have a really good "idea" why other than they are "APN-who-are-not-really-RNs" (which you can imagine reads a lot like "because you haven't paid your dues" to the other side).

APNs and RNs have do share a commonality (and always will). All APNs are RNs and have been through the same programs, the same fundamental clinical training at the RN level, and the same competency exam (at the RN level) regardless of their experience (or lack of) as a RN. Does a RN who has been in the ICU for 30 years have more or less in common with a RN who has worked in homecare or as a school nurse for the same amount of time compared to a novice NP?

I find it hard to argue that it is a dilution: it is clearly an expansion! Regardless of RN experience, all APNs share the same foundation which (in theory) should make them far better teammates for bedside RNs.

I agree that such commonality will not make or break an individual APN's practice.

It is a fairly easy argument to make that commonality doesn't make-or-break providers, MD/DOs have been doing it for the history of medicine. It could help though!

I also agree -- better standards for all APN education are needed, yes.

Devils advocate, but based on what?

[WestCoastSunRN, MSN, CNS]

APNs and RNs have do share a commonality (and always will). All APNs are RNs and have been through the same programs, the same fundamental clinical training at the RN level, and the same competency exam (at the RN level) regardless of their experience (or lack of) as a RN. Does a RN who has been in the ICU for 30 years have more or less in common with a RN who has worked in homecare or as a school nurse for the same amount of time compared to a novice NP?

I find it hard to argue that it is a dilution: it is clearly an expansion! Regardless of RN experience, all APNs share the same foundation which (in theory) should make them far better teammates for bedside RNs.

Yes, APNs are RNs by every legal definition and, as I stated also, share the same undergrad education with bedside RNs. When I point out the issue of DE APNs not sharing a common, individual history of practice with bedside RNs -- I do think it is relevant as the hope and expectation is that the bedside RN is practicing at the top of his licensure and that same RN who hones his clinical knowledge and skill through actual practice of that knowledge and skill, at the bedside, will then be building upon a foundation of nursing practice. As an APN this RN will advance from what we would hope would be an already expert level --- proficient at the very least. This was, in my understanding, the original intent and focus of advanced nursing practice.

As to DE APNs not diluting but rather being a clear expansion for advanced practice? In a perfect world, where non-NP RNs didn't question the DE process (and didn't have reason to), and where DE APN grads didn't go around talking about how they never intended to care for people at the bedside (true as it may be, it doesn't come across well to people who have devoted their career to the bedside) -- and all sorts of other comments which could be taken as disdain for bedside nursing, and where everyone and their brother wasn't looking for the fastest, cheapest way to become a provider..... well then, yes, I can see where we could see it as an expansion. And, in fact, I hope for the day when we can all heartily agree that it is an expansion. And I mean that sincerely as someone invested in nursing and cares about the future of our profession.

Regarding standards for APN education: For profits, 550 hours of clinical, unpaid, unvetted preceptors, low GPA, no GRE, and I've never met an NP who said he/she was ready to practice -- and my gut tells me this goes beyond the normal, healthy and expected anxiety that any new provider would face. There are very good schools (high standards) and there are poor schools(low standards) but they are all accredited.

Seems like something should be done about that.

Do you disagree?