Seeking Advice: Direct Entry Blues

allnurses Guide · Nov 26, 2017

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.

Believe me, I know that bedside nurses do more than follow orders. Please don't be so quick to assume I have no understanding of the role because I didn't list every responsibility of a RN. Those are merely the main reasons I knew bedside nursing wasn't right for me. Like BostonFNP, I wanted to be the one giving the orders and working autonomously, like I had been doing for years in another medical field. I felt my skills would translate well into the NP role, and they have. I'm not sure I understand where NPs are now representative of leadership in the nursing world. I haven't seen that, and that's not a position I want, to be honest. Don't you think CNLs should be carrying that leadership torch?

I do disagree with paying preceptors. It might improve the number of preceptors, but I doubt it will increase the quality. I use the analogy of blood donation. People who donate do so voluntarily for a number of reasons, but mostly because they feel it is the right thing to do. Paying blood donors would likely increase the number of donors, but would it also bring people who shouldn't donate and may not be forthcoming on their health history? You could use the argument that the testing done on blood will catch those people, but no test is 100% accurate. NPs may pass their boards despite a crappy preceptor, but may not really be prepared for practice due to a lousy clinical experience. I wouldn't want a preceptor who is only willing to do it for money.

WestCoastSunRN, MSN, CNS · Nov 26, 2017

Believe me, I know that bedside nurses do more than follow orders. Please don't be so quick to assume I have no understanding of the role because I didn't list every responsibility of a RN. Those are merely the main reasons I knew bedside nursing wasn't right for me.
I do disagree with paying preceptors. It might improve the number of preceptors, but I doubt it will increase the quality. I use the analogy of blood donation. People who donate do so voluntarily for a number of reasons, but mostly because they feel it is the right thing to do. Paying blood donors would likely increase the number of donors, but would it also bring people who shouldn't donate and may not be forthcoming on their health history? You could use the argument that the testing done on blood will catch those people, but no test is 100% accurate. NPs may pass their boards despite a crappy preceptor, but may not really be prepared for practice due to a lousy clinical experience.

No assumptions here. That's why I was careful to use the word "sometimes" and "you can see how...." -- specifically pointing out the positive intent of your words. I understand what you were saying. But just as I have noted you lamenting RNs frequently misunderstanding/distrusting the DE process, I was simply lamenting how there are also misunderstandings regarding bedside practice. The "following vs giving orders" thing often becomes the focus of differentiation between roles. I think that wording doesn't do justice to either role. No offense intended. Just my .02.

Makes total sense about paid preceptors.

allnurses Guide · Nov 26, 2017

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?

I think it all comes down to money. Practices don't want to pay an RN. I would love to have an RN in my practice to do patient education. MAs are great and do a good job, but I often think how nice it would be to have someone sit down with patients and go over in detail what they need to do, what resources they can avail themselves of, how they can best manage their conditions, etc. We, as providers, do the best we can but are always crunched for time. I have a lot of the educational materials as hard copies and on our practice website, but I think it would be beneficial to have a nurse go over the materials with them. Unfortunately, my practice and many others are not going to take on this expense.

Trauma Columnist · Nov 27, 2017

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.

I'm a CNS (almost 12 years now) and the local hospital-affiliated college of nursing graduates CNSs in a consistent stream. However, our role have never been the 'traditional" change agent, educator, I've always been an APRN with full prescriptive authority, billing, etc., with the same scope of practice as an NP.

I'm not a DE (was an RN for 12 years prior to completing the APRN). We don't have DE's in my local area but that is just because we don't have any local schools producing them.

However, just wanted to clarify the role of many CNSs.

ToFNPandBeyond · Feb 13, 2018

Sorry, you're having a difficult time. I've seen this situation before. Places that expect high productivity without any investment in staff training. It has nothing to do with you being a directly entry NP. Any new grad NP placed in the same situation would have failed.

Exactly! I disagree with those who are stating that one should have RN experience in order to be a good NP. The issue here is lack of on-the-job orientation/training, not RN experience. Specifically, RN experience is irrelevant when referring to primary care, which I believe the OP is referring to. I attend a direct-entry nursing program, and my school is adamant about negotiating adequate onboarding/orientation training. They even provide a list of NP residencies that we may choose to take part of. Many of my friends who have graduated the program are in some of those residencies suggested by our program.

Like others have mentioned, I would look into either specialty, or consider a residency program. All is not lost! Good luck.

Guest123456788, MSN, RN · Feb 13, 2018

That's an obscene amount of money!
How do you plan on being able to repay that amount and still afford rent/mortgage, gas, utilities, food, insurance, etc?

I never got a notification that there were replies on this, but the average psych NP salary in the area I want to work in is $142k. I lived in that same area easily on $30k working out of undergrad, so live like I did then for a few years and put the bulk of my income into loans. No one who has graduated from my program has taken more than 7-8 years to pay their loans off so far.

Guest123456788, MSN, RN · Feb 13, 2018

Or save up for school then work while getting your degrees? As someone who worked the entire time from my LPN to MS and post masters I seriously can't fathom justifying that amount of money for a nursing degree especially with the anticipated numbers who will be graduating and competing for jobs in upcoming years.

I have a bachelors degree in psychology with a small amount of loans from undergrad (and that was after working three jobs the entire time I did my bachelors). I worked one of the highest paying jobs available to me in the area with that degree and was only able to save a little , in the length of time it would have taken me to save up for a nursing program and all of the living costs during that program I would have wasted many years that I could have been earning an NP salary. So yes, I am taking out loans for now and they will be paid off within 5-6 years after I graduate, which is a much faster path than saving and going through several degree programs.

Oldmahubbard · Feb 13, 2018

I am curious regarding the OP's apparent inability to succeed on their first job, ie, if any specifics were mentioned. Too slow? issues with differential diagnosis?

Skippingtowork · Feb 14, 2018

It is quite possible that pediatrics is not for the OP. In that field you really have to be productive as it tends to be less profitable per patient. You also have to deal well with the family. Essentially, you have 2-3 patients per visit (mom, dad and child). Not everyone is warm and fuzzy or enjoys children. If OP was an FNP grad versus a PNP grad, the transition may be harder. Clearly her invitation to move along could not have been related to safety or competence. If possible, OP may like adults or specialty. Also, some NPs don't find pediatric primary care interesting. They prefer excitement. I would love to hear what OP decided.

mk989 · Mar 4, 2018

Just wanted to update, especially for those who found themselves in a similar situation...don't give up. As Kelly Clarkson's song goes, "what doesn't kill you makes you stronger." When everything first came up I was quite sad but then decided to react in a different way, I grew real fast and kicked my rear into gear in many ways. I was offered to stay and received a raise.

Strangely enough I do plan on venturing into a specialty though, I'm still fairly young and want to try out different things.

Thank you for all of your advice and support.

caliotter3 · Mar 4, 2018

Well, looks like my question was answered! Congratulations on your success and best wishes going forward.

Riburn3, BSN, MSN, APRN, NP · Mar 7, 2018

Just wanted to update, especially for those who found themselves in a similar situation...don't give up. As Kelly Clarkson's song goes, "what doesn't kill you makes you stronger." When everything first came up I was quite sad but then decided to react in a different way, I grew real fast and kicked my rear into gear in many ways. I was offered to stay and received a raise.
Strangely enough I do plan on venturing into a specialty though, I'm still fairly young and want to try out different things.
Thank you for all of your advice and support.

Sometimes it takes a little fire under your bum to get you moving and motivated. I'm happy for you!

When I first started working as a baby RN in critical care, my preceptor told me I didn't seem motivated and she didn't like that I constantly had to be told what to do like I was still in nursing school. That moment dropped me into full gear, encouraged me to be more confident in what I was doing, and really led me down a path that turned into a great leadership career as a critical care RN, and now a dual certified NP, earning in the top 1% of NP's.

Those moments are about seizing the day. You can either let them get you down and wreck you, or you can use them as motivation to make yourself better. I'm glad you did the latter.