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

[BostonFNP, APRN]

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

But not all RNs are bedside RNs. Does an ICU RN share the same "individual history of practice" as an RN working in a school or with the VNA or in a pediatric clinic or public health? The commonality of all nurses is the education and practice model that all of our practice was based on.

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.

I think this is a relatively common "belief" of many bedside RNs when they consider NPs. The way it is described/thought-of is much more like the role of the Clinical Nurse Specialist; of course, recently that line has been blurred by the decrease of CNS and increase of NP market share.

I think the problem lies in that even if a bedside RN is working at the top of their license there is still a large gap between that role and the provider role; working as a bedside RN takes a great degree of knowledge and skill but that knowledge and skill if often different from the knowledge and skill that a provider needs.

I am not sure why people always think of this single line of evolution: student RN -> novice RN -> expert RN -> student NP -> novice NP -> expert NP. Really these lines evolve separately: student RN -> novice RN then splits to separate lines of expert RN practice and student NP -> novice NP -> expert NP.

No matter what your RN expertise is, you have to start back at the same spot, and everyone will start as a novice in the new role.

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)

I hear this all the time and I never have understood it: why is the statement "I never intended to work at the bedside" offensive to anyone? If you have devoted your career to the bedside why is this offensive? Are you offended by case management RNs? Physicians? Plumbers? Real estate agents? They didn't intend to work at the bedside either, would it be offensive if they said it? I wouldn't be offended if an RN said "I never intend to become an NP".

Again, what it the "reason to" that bedside RNs have for questioning the DE process? Most have never experienced it, never researched it, never shadowed a APN, etc.

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?

Have you ever met an RN that was ready to practice on day 1? I haven't. Do you think there are some poor quality RN programs out there with low standards that remain accredited? For profits? Poor clinical experiences? This is not a problem unique to NP school but I rarely see bedside RNs making judgements about that even though they have the relevant expertise to judge that topic.

At the end of the day, just like at the RN level, there is a basic competency board examination that limits entrance to practice to those who would be a safety hazard/lack the core competency of a novice.

I don't disagreed at all that there are some poor quality NP programs out there, and I absolutely think something should be done about it. It's current NPs that need to take on that charge. I have been very active on this at both the state and national level. There is a great deal of ongoing work on this.

[WestCoastSunRN, MSN, CNS]

But not all RNs are bedside RNs. Does an ICU RN share the same "individual history of practice" as an RN working in a school or with the VNA or in a pediatric clinic or public health? The commonality of all nurses is the education and practice model that all of our practice was based on.

.

I hear you but an ICU RN -- or most acute care RNs, by necessity, must have a deeper working knowledge of the three Ps. This is why that particular experience is relevant to future NP practice. But I absolutely agree with you that the roles of bedside RN and NP are very different. I do not equate the two, but I do think one can build upon the other. But do I think a school nurse or clinic nurse is less a nurse than the ICU nurse? I do not (was that what you were getting at?). I think you may be saying the connectedness many nurses see between a bedside nurse and NP simply isn't there. But since I am that ICU nurse who works collegiately with providers day in and day out -- I DO see the connectedness. I can see that and yet never confuse my role with that of a provider.

Sorry -- I'm on my phone so quote function is difficult. But I want to say I think you hit a HUGE nail on the head regarding the decrease in CNS and influx of NPs. In my humble opinion I think our profession is in desperate need of CNSes. Thank goodness they do still exist and I am hoping they will make a comeback in terms of nursing benefiting from the full scope of their utility within the profession. I see what you're saying about the linear pathway not being necessary for NP the way it is for CNS. But with CNS decline, nurses are looking for NPs to be able to represent in similar ways. And I don't think this is what a lot of NPs signed on for. So perhaps misplaced blame in the face of such great need in terms of nursing needing the kind of leadership CNSes give.

And about being offended by people not wanting to do bedside nursing? Lots of bedside nurses don't want to do bedside nursing. That role takes a hit from every direction. It really does. An NP saying it just adds insult to injury. That's a whole other thread, really.

And RNs absolutely criticize subpar undergrad programs. Most of them don't even know about subpar grad programs. Bad programs ARE everywhere. You are right. I'm glad and thankful for nurses like you who are willing to give of your time and effort to combat these. At some point, when I don't have quite so many plates spinning, I will join you in that.

[MurseJJ]

I hear you but an ICU RN -- or most acute care RNs, by necessity, must have a deeper working knowledge of the three Ps. This is why that particular experience is relevant to future NP practice. But I absolutely agree with you that the roles of bedside RN and NP are very different. I do not equate the two, but I do think one can build upon the other. But do I think a school nurse or clinic nurse is less a nurse than the ICU nurse? I do not (was that what you were getting at?). I think you may be saying the connectedness many nurses see between a bedside nurse and NP simply isn't there. But since I am that ICU nurse who works collegiately with providers day in and day out -- I DO see the connectedness. I can see that and yet never confuse my role with that of a provider.

I agree. While the roles of bedside RN and NP are different (just like the roles of bedside RN and physician are different), there is also some overlap, and I agree that there is a connectedness between the two roles. For example, as a clinical RN, one is hopefully:

-performing physical assessments and correlating findings with normal and abnormal findings related to disease states

-interpreting laboratory test data and correlating with presentation, disease states, and interventions

-understanding indications, contraindications, etc related to pharmacological interventions

-understanding common indications and contraindications for radiologic and other diagnostic studies and their relevance to your area

The NP of course will add a deeper understanding of pathophysiology and pharmacology, as well as the diagnostic perspective of being a provider to all of that and more, however it is clear that the clinical RN, functioning at the "top of his/her license" should be more than a task-manager/order-fulfiller (as we are often perceived as being).

[BostonFNP, APRN]

Obviously these are just my thoughts, I am sure others have their own experience.

I hear you but an ICU RN -- or most acute care RNs, by necessity, must have a deeper working knowledge of the three Ps. This is why that particular experience is relevant to future NP practice.

Having taught (both clinically and didactically) student NPs with the full spectrum of prior RN experience, I just don't see that at the graduate level.

It has been my experience that RNs with more extensive experience are more likely to anticipate and act but often are not able to describe why they are doing what they are doing and they tend to pigeonhole assesments and plans; in contrast, student NPs that are 0-5 years out of school tend to have a much better working knowledge of patho and pharm but tend not to anticipate. I hate to say it but many bedside nurses I've seen (and not just nurses, frankly everyone in patient care) don't do a tremendously good physical exam.

I think the benefit of prior RN experience is really in intangibles not in patho/pharm/pe knowledge or skill.

And about being offended by people not wanting to do bedside nursing? Lots of bedside nurses don't want to do bedside nursing. That role takes a hit from every direction. It really does. An NP saying it just adds insult to injury.

I think there is a difference between devoting your career to the bedside and being at the bedside when you don't want to be "just because". I can absolute understand why the latter is offended by it, but I would hope we all agree that's really not the fault of the person who simply acknowledges they don't want to do that.

[BCgradnurse, MSN, RN, NP]

I never really wanted to do bedside nursing. I don't have the temperament for it, and I'm not great at following other people's orders or dealing with bureaucracy. I don't look at bedside nursing as beneath me, and I don't know any DE NPs who do. I have nothing but admiration and respect for those who do stay at the bedside, but it's not for me. A Direct Entry program was the clear path for me to reach my goal, and enabled me to use my strengths and experiences to be a successful NP. Going this route is not a slap in the face to bedside nurses. We are not looking to take shortcuts or the easy way out. A good DE program is not easy in any sense of the word. They are rigorous and only admit the most qualified students. I think we are viewed as not having paid our dues because we didn't take the familiar and traditional path. MDs looked down on DOs for years because they went through a different educational process. The negativity is more about perceptions and feelings, rather than facts and evidence, in my opinion.

I agree with much of what WestCoastSun said about NP education, be it traditional or DE. You shouldn't be able to pay your way into a program with few to no barriers to entry, in any profession. I think for profit education lessens quality. The preceptor issue is a huge problem. I don't understand how a program can leave students twisting in the wind to find their own preceptors. I don't care so much about getting paid to precept. I do it because I enjoy it, and because people did it for me. Getting paid would be a nice bonus, though.

[WestCoastSunRN, MSN, CNS]

Having taught (both clinically and didactically) student NPs with the full spectrum of prior RN experience, I just don't see that at the graduate level.

It has been my experience that RNs with more extensive experience are more likely to anticipate and act but often are not able to describe why they are doing what they are doing and they tend to pigeonhole assesments and plans; in contrast, student NPs that are 0-5 years out of school tend to have a much better working knowledge of patho and pharm but tend not to anticipate. I hate to say it but many bedside nurses I've seen (and not just nurses, frankly everyone in patient care) don't do a tremendously good physical exam.

I think the benefit of prior RN experience is really in intangibles not in patho/pharm/pe knowledge or skill.

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Everyone will have a learning curve. I suspect there may be appreciable differences not only in various areas of the country but also among different specialties -- such as acute care NP vs primary care NP.

Boston, you have a unique perspective as an educator. It seems as though you've been a provider for a number of years. Have you ever practiced at the bedside?

[BostonFNP, APRN]

Everyone will have a learning curve. I suspect there may be appreciable differences not only in various areas of the country but also among different specialties -- such as acute care NP vs primary care NP.

Boston, you have a unique perspective as an educator. It seems as though you've been a provider for a number of years. Have you ever practiced at the bedside?

I have worked at the bedside, though I was far from an expert bedside RN, and I found the practice itself rather frustrating.

I will say that one thing bedside nursing helped me with was being able to confidently navigate a hospital: when I started rounding as an NP I felt comfortable going onto any floor and asking for what I needed, knowing who to talk to get X done, etc.

[WestCoastSunRN, MSN, CNS]

I never really wanted to do bedside nursing. I don't have the temperament for it, and I'm not great at following other people's orders or dealing with bureaucracy. I don't look at bedside nursing as beneath me, and I don't know any DE NPs who do. I have nothing but admiration and respect for those who do stay at the bedside, but it's not for me. A Direct Entry program was the clear path for me to reach my goal, and enabled me to use my strengths and experiences to be a successful NP. Going this route is not a slap in the face to bedside nurses. We are not looking to take shortcuts or the easy way out. A good DE program is not easy in any sense of the word. They are rigorous and only admit the most qualified students. I think we are viewed as not having paid our dues because we didn't take the familiar and traditional path. MDs looked down on DOs for years because they went through a different educational process. The negativity is more about perceptions and feelings, rather than facts and evidence, in my opinion.

I agree with much of what WestCoastSun said about NP education, be it traditional or DE. You shouldn't be able to pay your way into a program with few to no barriers to entry, in any profession. I think for profit education lessens quality. The preceptor issue is a huge problem. I don't understand how a program can leave students twisting in the wind to find their own preceptors. I don't care so much about getting paid to precept. I do it because I enjoy it, and because people did it for me. Getting paid would be a nice bonus, though.

Fortunately, bedside nursing involves far more than "following other people's orders and dealing with bureaucracy". The rest of your post makes it clear you harbor no disrespect to bedside nurses, so I don't assign any negative intent to your words. That said -- it is phrases like the one I quoted which sometimes reveal a person's misunderstanding of the actual work that takes place at the bedside. And you can see how a nurse might wonder how a DE NP could ever really understand bedside work. As I said before -- NPs are becoming frontline, representative leaders in Nursing -- in many cases for ALL of nursing -- not just advanced practice. If DE is going to become the new black, then that's a gap worth bridging, somehow.

Yes, the preceptor thing is crazy, IMO. I have spoken with preceptors like yourself, who are happy to give back to NP education, but it just seems like monetary compensation could go a long way in not only securing more preceptors, but ensuring the quality of those preceptors as well.

[BostonFNP, APRN]

Fortunately, bedside nursing involves far more than "following other people's orders and dealing with bureaucracy". The rest of your post makes it clear you harbor no disrespect to bedside nurses, so I don't assign any negative intent to your words. That said -- it is phrases like the one I quoted which sometimes reveal a person's misunderstanding of the actual work that takes place at the bedside. And you can see how a nurse might wonder how a DE NP could ever really understand bedside work. As I said before -- NPs are becoming frontline, representative leaders in Nursing -- in many cases for ALL of nursing -- not just advanced practice. If DE is going to become the new black, then that's a gap worth bridging, somehow.

Yes, the preceptor thing is crazy, IMO. I have spoken with preceptors like yourself, who are happy to give back to NP education, but it just seems like monetary compensation could go a long way in not only securing more preceptors, but ensuring the quality of those preceptors as well.

I didn't do great with "orders"either because I wanted to be the one writing them. That doesn't imply any disrespect it demonstrates a desire for the role (which IMHO is the only reason to persue APN). I think providers need that motivation.

DEs don't need to understand the bedside role. That's an unreasonable assumption. Most providers don't truly understand the bedside role (MD/DO, PA, DPM, etc). They should respect it.

I don't ever see NPs speaking for bedside RNs. Can you show us some examples?

Paying preceptors is the absolute wrong response. Crappy programs pay preceptors.

[WestCoastSunRN, MSN, CNS]

I didn't do great with "orders"either because I wanted to be the one writing them. That doesn't imply any disrespect it demonstrates a desire for the role (which IMHO is the only reason to persue APN). I think providers need that motivation.

DEs don't need to understand the bedside role. That's an unreasonable assumption. Most providers don't truly understand the bedside role (MD/DO, PA, DPM, etc). They should respect it.

I don't ever see NPs speaking for bedside RNs. Can you show us some examples?

Paying preceptors is the absolute wrong response. Crappy programs pay preceptors.

I agree, DEs don't need to understand bedside nursing to do their job as providers. However, as mentioned earlier here, with the decline of CNSes, NPs are often disseminating clinical information to nurses via professional organizations/journals and the like. Tailoring that info towards bedside clinicians would be a challenge for someone who has no skin in the game at the bedside. So is this unfair to expect that kind of leadership from NPs? Probably. Which is why we absolutely need the CNS role.

Mind you, we still have CNSes but I am noticing more and more clinical contributors to nursing coming from Provider roles (and there will always be value in Provider contributions to nursing but it needs to be balanced with constant awareness of the utilitarian realities present at the bedside). So "represent" may have been faulty language on my part. I'm not sure this is something you would experience in primary family care as nursing outside of advanced practice does not typically present or necessary at that level of care.

As for paid preceptors -- honestly you would know far better than I. That's your wheelhouse.

[BostonFNP, APRN]

I agree, DEs don't need to understand bedside nursing to do their job as providers. However, as mentioned earlier here, with the decline of CNSes, NPs are often disseminating clinical information to nurses via professional organizations/journals and the like. Tailoring that info towards bedside clinicians would be a challenge for someone who has no skin in the game at the bedside. So is this unfair to expect that kind of leadership from NPs? Probably. Which is why we absolutely need the CNS role.

Mind you, we still have CNSes but I am noticing more and more clinical contributors to nursing coming from Provider roles (and there will always be value in Provider contributions to nursing but it needs to be balanced with constant awareness of the utilitarian realities present at the bedside). So "represent" may have been faulty language on my part. I'm not sure this is something you would experience in primary family care as nursing outside of advanced practice does not typically present or necessary at that level of care.

As for paid preceptors -- honestly you would know far better than I. That's your wheelhouse.

CNS have a role I agree especially in acute care. I do disagree that just because a NP doesn't have experience in a provider role that can't help beside RNs with patho or pharm or exam or critical evaluation of literature. I also don't agree that nursing isn't necessary at the primary care level; nurses can make the biggest impact here.

[WestCoastSunRN, MSN, CNS]

CNS have a role I agree especially in acute care. I do disagree that just because a NP doesn't have experience in a provider role that can't help beside RNs with patho or pharm or exam or critical evaluation of literature. I also don't agree that nursing isn't necessary at the primary care level; nurses can make the biggest impact here.

Actually we agree on that first point, as I also said Provider (NP) contributions are important but that nursing ALSO needs contributors with more practical knowledge regarding the work of the average RN in whatever specialty is the subject matter of said contribution.

On the second point, I think it would be great to have more RNs at the primary care level-- but that's not what we typically see happening is it? In my experience it is the rare primary care setting that is employing RNs over MAs or LPNs. I do see RNs present more in pediatrics or some specialty clinics, but not usually family practice. Are they used more in your area?