Time to remove the "nurse" in APN?

Nurses General Nursing

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More and more, I am seeing posts from people who want to leap straight from taking the NCLEX into an advanced practice role. (Often you see plans of "pre-nursing" students already plotting their CRNA careers, but that's another story.)

Also, an increasing number of schools are designing programs that greatly reduce or eliminate the need/chance for actual nursing experience before acceptance.

It's almost as if the advanced practice role is becoming ever more distant from its origins, i.e. hands on nursing.

On top of that, with questionable programs opening up (which often results in weak practitioners), is it possible that nursing as a whole gets a black eye by association?

Bottom line: is it time for a divorce? Should advanced practice nurses be retitled and called something along the lines of physician's assistants?

This is how I look at it:

1. NP's use medical diagnoses, not nursing diagnoses that take 20 different ways and paragraphs ( ie failure to... or inablity to..) to say the patient is a diabetic.

2. They sign birth and death certificates

3. I have never heard a hospitalist NP or service on-call NP say, wait till I check with a doc- they give medical orders

4. They prescribe medications and perform medical procedures

5. They act independently and open their own practice

6. They can admit patients to hospitals

7. They do doc to doc reports- they don't call to do a nurse to nurse

It all came to me one day when a direct entry NP student was doing some required RN clinical time, she was appreciative but wasn't really interested because- guess, come on, you know what she said: "if I wanted to be a nurse I would have gone to nursing school."

Maybe NP's will end up with their own hospitals like DO's before they were embraced by MD's as equals.

I am wondering if hospitals charge less if they are cared for by an NP than a doc?

So somewhere along the line NP's branched into there own thing, which I believe is much more in common than different with medicine than nursing

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Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.

I am wondering if hospitals charge less if they are cared for by an NP than a doc?

From what I understand, hospitals are reimbursed by CMS guidelines/requirements.

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Thanks shibaowner for an exceptional contribution based on real-world facts.

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In addition, some studies indicate NPs without RN experience have superior clinical skills as evaluated by NPs and MDs. Not one single study has demonstrated that NPs without RN experience have worse patient outcomes.

We all get frustrated with MDs arguing against full practice authority for NPs even though over 100 studies have shown NPs provide the same, or better, quality of patient care.

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I feel it necessary to comment here. I don't get at all frustrated that MD's argue against full practice authority for nurses. I support them. I have read some of the studies that purport to show that NP's deliver the same quality of care as MD's. They did not utilize a high level of evidence, and the patient populations did not include patients with multiple complex chronic illnesses such as those that an internist would see daily in practice, and there were significant limitations in the studies. Also, when you refer to outcomes, which outcomes are you talking about? Morbidity and mortality? I have read at least one study where the outcome measured was patient reported satisfaction with the provider. Other studies I read were qualitative in design.

There is no comparison between the education and training an MD receives versus an NP, even if the NP is a DNP. If you disagree with me, research this for yourself. Research the educational requirements for medical school, the number of years an MD spends in medical school, the number of clinical hours an MD spends in internship, residency, fellowship. Contrast that with the educational requirement for NP school and with the number of hours of education and clinical hours an NP receives. Tell me with a straight face that NP's are as knowledgeable as MD's and deliver care at the same level as MD's when they have a very small fraction of the education and clinical hours that MD's do.

I live in a state that does not permit independent practice for NP's, where the physicians are opposed to independent NP practice. I am glad I do so. This does not mean that I do not value the contribution NP's make as part of the health care team when properly supervised by MD's; I do. NP's are nurses with advanced training and their scope of practice is displayed for anyone to read on the state Board of Registered Nursing web site.

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In addition, some studies indicate NPs without RN experience have superior clinical skills as evaluated by NPs and MDs. Not one single study has demonstrated that NPs without RN experience have worse patient outcomes.

We all get frustrated with MDs arguing against full practice authority for NPs even though over 100 studies have shown NPs provide the same, or better, quality of patient care.

QUOTE

I feel it necessary to comment here. I don't get at all frustrated that MD's argue against full practice authority for nurses. I support them. I have read some of the studies that purport to show that NP's deliver the same quality of care as MD's. They did not utilize a high level of evidence, and the patient populations did not include patients with multiple complex chronic illnesses such as those that an internist would see daily in practice, and there were significant limitations in the studies. Also, when you refer to outcomes, which outcomes are you talking about? Morbidity and mortality? I have read at least one study where the outcome measured was patient reported satisfaction with the provider. Other studies I read were qualitative in design.

There is no comparison between the education and training an MD receives versus an NP, even if the NP is a DNP. If you disagree with me, research this for yourself. Research the educational requirements for medical school, the number of years an MD spends in medical school, the number of clinical hours an MD spends in internship, residency, fellowship. Contrast that with the educational requirement for NP school and with the number of hours of education and clinical hours an NP receives. Tell me with a straight face that NP's are as knowledgeable as MD's and deliver care at the same level as MD's when they have a very small fraction of the education and clinical hours that MD's do.

I live in a state that does not permit independent practice for NP's, where the physicians are opposed to independent NP practice. I am glad I do so. This does not mean that I do not value the contribution NP's make as part of the health care team when properly supervised by MD's; I do. NP's are nurses with advanced training and their scope of practice is displayed for anyone to read on the state Board of Registered Nursing web site.

1. There are over 100 studies demonstrating NPs provide good quality care, comparable to MDs.

2. I agree MDs have much more education that includes more clinical hours, plus they have an internship and residency. However, the US is the only country that requires MDs to have a 4 year college degree and a 4 year med school. Please show me evidence that foreign MDs in countries like England, Germany and so forth are inferior to U.S. MDs.

3. Our country faces a severe shortage of PRIMARY CARE providers MDs, PAs, NPs. Our question should be how do we produce PCPs in a quick and effective manner? Currently, it appears the NP model is working in this regard. Given that a number of states have allowed NPs to practice independently for years now, there should be evidence if this is a bad idea. Where is it?

4. US med schools are now experimenting with a 3 year program for primary care docs.

5. Finally, you produce no evidence to support your points, but make a feeble attack on the studies you disagree with. Don't you think the AMA has had ample time to come up with a contradictory study? It must be that these 100+ studies are indeed correct! Did you read and critique all 100 of these studies? If so, please share something other than talking points from the AMA.

6. This ship has sailed and people need to get over it. 23 states and the VA provide full practice authority for NPs. That number is only going to grow.

I am an activist advocate for NP full practice authority. This will decrease costs and improve access for many patients.

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Direct entry NP with no previous experience. True online programs that only require a 2 week campus visit. They all meet the NP requirements. I work with one RN graduating from NP school and she has a 22 y/o in her class that had no previous experience who will be out in the world this semester. I got an email the other day- some site must have sold my address, not sayin nothin- online only ADN to NP without having to stop @ BSN and collect $200. I honestly don't know why anyone would go to RN school anymore. There are Associate Degree PA schools in FL (it was located in my "medical campus" was how I know)- when I tell PA's that they tell me I'm full of crap and must be MA or some-other eieio alphabet medical profession. We go to the website and they are shocked they spent so much time and money when 2 years is all you need to be a PA. The problem with PA's is there is no national standard- EMS addressed that problem by National Registry, if you want to be NR you have to do approved course and CEH hours to renew. Its always up to the state you live in to license you but more and more states and employers are deferring to NR. NR also makes it soooo much easier to receive reciprocity if you move.

There are Associates, Bachelors, and Masters level PAs, but their curricula are very similar.

PA programs may be direct entry (no experience) or they may have admission requirements of healthcare experience (these requirements vary from shadowing/volunteering a few hundred hours to being a paid healthcare provider with 2 years experience).

PA was originally created for the very experienced provider (Vietnam medics with years of experience were the prototypical PA student). No longer the case...

A few things.

The AS programs are ending. All are moving to Masters. The AS programs are some of the longest standing programs and have great reputations. These were born out of the old Certification Programs that started the profession.....remember, NP started the same, a few years after the first PA programs started.

The requirements to get into the AS programs are similar to all PA programs. You have to have the core sciences (about 2 years worth) before you can apply. Also, these programs usually have the highest amount of required health care experience.

There was mention in another post about lack of standardization in PA programs? The standard curriculum and single governing body (ARC-PA) is the reason I became a PA and not an NP. The ARC-PA is no joke. If a program is not holding up to standards, they are shut down. Schools with good reps end up on probation every year.

Experience requirements have gone down in the last decade, this is true. That said, it is very difficult to get in any program without experience. One in five qualified applicants will get into PA. Having experience gives folks the edge.

I have noticed that nurses like to reduce PA training to only 2 years. The actual length of most PA programs is 27 months. Average credit hours crammed in those 27 months is approx 100 credit hours (think about that for a sec). Then you have to consider the approx 2 years of upper level sciences just to apply. Be careful when you are generalizing the folks who most of you work with side by side. Remember, for the most part, we do the exact same job.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.
I currently teach advanced practice nursing courses (classroom and clinic with online components). Some of my students are in a direct entry program and some are experienced career nurses, so I've seen examples of everything you're talking about in this post first-hand from an instructor's perspective. Honestly, helping seasoned RN's make the transition to advanced practice (FNP) has been one of my biggest challenges as an instructor, because many experienced RNs find it difficult to get into the mindset of thinking like a provider” as opposed to doing what they've always done so well for their whole careers, which has been fulfilling physicians' orders. I'm constantly reminding my students that they are the ones giving the orders now. The NP role really does involve a different way of thinking from the RN role.

As I was reading this thread, a few things came up for me as important points to keep in mind: 1) hospital bedside nursing is not the only type of nursing; 2) nurses are trained under a fundamentally different philosophy and paradigm from physicians (physicians are trained to fix problems and nurses are trained to assess how well those fixes are working for the patient); 3) the concept of advanced practice” is more about advancing the nurse's scope of practice through academic preparedness than logging hours of experience; 4) there is no substitute for experience, and where the individual's journey begins for obtaining that experience should not matter; 5) not all experience transfers well into all work environments or job descriptions (which brings me back to point number 1).

As healthcare in general moves farther and farther away from valuing the human touch (less time allotted for medical encounters, algorithm-driven treatment protocols, tele-medicine, robotic and AI assisted assessments and procedures), I believe there will be more and more demand for well-trained nurses because nurses are trained to emphasize the human connection. Ultimately, that's what people want--better health and wellness--and you can't have that without quality human interaction. Having said all that, there is absolutely no excuse for bad nursing education programs, and weak practitioners will either get stronger with experience or find more suitable work for themselves. This is definitely an interesting topic.

Thanks for your perspective from the instructor's point of view. I found it very thought provoking, so I will share some of that, but it isn't intended as criticism at all.

I'm not going to weigh in on the competence issue, just the question of whether or not the NP role has completely divorced itself from it's historic roots, aka "taking the nurse out of APN"

I think that once the first wave of NPs retires, you'll be correct to say the nurse is out of advanced practice nursing, by which I mean:

The word "nurse" meant "experienced nurse" because it was simply assumed to be there, and "advanced practice" presupposed a basic level of practice has been successfully achieved. Therefore "thinking like a nurse" was an enhancement, which is admittedly difficult to describe in neat paragraphs, but not assumed to be of no value.

The one factor that created the divide I think is the mushrooming number of online programs, not a lack of relevance. There isn't any reason direct-entry APN programs were not proliferating at any point in recent decades. The "why" I will speculate is the experience factor.

Somehow, before there were all the online programs, seasoned RNs learned to think like a provider, so maybe there is more than meets the eye when the role is summarized as "doing what they've always done so well for their whole careers, which is fulfilling physician's orders."

I honestly don't believe any prospective NP who is an RN with years of experience would summarize their role that way.

Here are a couple of quotes that demonstrate further a disconnect in the modern academic nursing concept of today, and what is the norm in related disciplines, such as medical school.

...the concept of advanced practice” is more about advancing the nurse's scope of practice through academic preparedness than logging hours of experience

It appears there is a subtle difference in attitude displayed by calling doing what you're learning is logging hours of experience rather than the traditional view of both being learning, one reinforcing the other.

I've seen many posts here complaining about how pointless it is to log the hours of experience as a nurse when that experience is thought to be an obstacle rather than a foundation.

...there is no substitute for experience, and where the individual's journey begins for obtaining that experience should not matter

This is another departure from traditional thought, as it seems to restate the idea there is nothing to be gained with 10 years of experience vs any number below that starting with zero.

Again, I'm not talking about outcome studies, and I know direct-entry APNs I would trust to take care of my family without hesitation, and some who post here frequently.

My final point is that with our voracious profit-driven system, the idea that providers with nursing education necessarily have more time to make a personal connection. It seems there are more NPs talking about how swamped and unsupported they feel.

Nurse-driven innovations don't fare so well in the world of strict profit and loss.

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Specializes in CVICU, MICU, Burn ICU.
Thanks for your perspective from the instructor's point of view. I found it very thought provoking, so I will share some of that, but it isn't intended as criticism at all.

I'm not going to weigh in on the competence issue, just the question of whether or not the NP role has completely divorced itself from it's historic roots, aka "taking the nurse out of APN"

I think that once the first wave of NPs retires, you'll be correct to say the nurse is out of advanced practice nursing, by which I mean:

The word "nurse" meant "experienced nurse" because it was simply assumed to be there, and "advanced practice" presupposed a basic level of practice has been successfully achieved. Therefore "thinking like a nurse" was an enhancement, which is admittedly difficult to describe in neat paragraphs, but not assumed to be of no value.

The one factor that created the divide I think is the mushrooming number of online programs, not a lack of relevance. There isn't any reason direct-entry APN programs were not proliferating at any point in recent decades. The "why" I will speculate is the experience factor.

Somehow, before there were all the online programs, seasoned RNs learned to think like a provider, so maybe there is more than meets the eye when the role is summarized as "doing what they've always done so well for their whole careers, which is fulfilling physician's orders."

I honestly don't believe any prospective NP who is an RN with years of experience would summarize their role that way.

Here are a couple of quotes that demonstrate further a disconnect in the modern academic nursing concept of today, and what is the norm in related disciplines, such as medical school.

It appears there is a subtle difference in attitude displayed by calling doing what you're learning is logging hours of experience rather than the traditional view of both being learning, one reinforcing the other.

I've seen many posts here complaining about how pointless it is to log the hours of experience as a nurse when that experience is thought to be an obstacle rather than a foundation.

This is another departure from traditional thought, as it seems to restate the idea there is nothing to be gained with 10 years of experience vs any number below that starting with zero.

Again, I'm not talking about outcome studies, and I know direct-entry APNs I would trust to take care of my family without hesitation, and some who post here frequently.

My final point is that with our voracious profit-driven system, the idea that providers with nursing education necessarily have more time to make a personal connection. It seems there are more NPs talking about how swamped and unsupported they feel.

Nurse-driven innovations don't fare so well in the world of strict profit and loss.

This. This. This. And that is the real question the OP posed, does it make sense to refer to APNs as nurses anymore when by direct-entry they are divorced from the role of nurse as we've historically understood it?

And also..... you are so right. As a bedside nurse I don't think I'm at my best and fulfilling my professional duties by "following physician orders". That is not how I define what I do. And while I am sure the intent was not meant to condescend, that particular comment seems strange coming from a nurse educator.

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Many of the concerns in this thread are from people who seem to be conflating "direct entry" NP programs with "online" NP programs. It'd be nice to know where the concern really lies - in providers who have no bedside nursing experience, or in nursing credentialing bodies approving programs that might produce sub-par providers, or in something else together (this is not necessarily my opinion, just what I've gleaned from this thread!). I know of direct-entry MSN programs that have higher admission standards than any ASN/BSN program, and I know of online programs that only take students who have bedside nursing experience. Lumping a variety of concerns into one "problem" is leading to confusion, at least on my part, as to what the "real" problem is.

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Below quoted from another post on this site. I believe the concern is a race to the easiest and fastest, but title of this thread is: should nurse be removed from NP. If there are NP's that don't need nursing experience, don't do what nurses do, and some provided evidence based information that actually experienced RN's are sub-par to non-experienced when it comes to NP then maybe its time. In my book to be a duck you have to look like a duck, sound like a duck and act like a duck, if you don't you're a bird of a different feather. Take an MD or DO license- everyone knows exactly what it takes to get those- there is standardization. I have yet to see an online medical school, if its good enough for NP's it should be good enough for doc's, yes? I've been at work with people using notes, books, asking the doc, and the internet to take NP exams at online schools. What I do know about life is all will be judged by the weakest link of the chain. NP's from all-online schools will be held equal to those of Ivy league schools- right, wrong, or indifferent

This is a story about how I got accepted to a big name online for-profit:

A phone number kept calling me incessantly for weeks... I finally answered, prepared for my usual, "I'm on the no-call list so please remove me from your call list." It was a rep from some school I hadn't heard of, but apparently I'd filled out some webform.

Had I? OK... "are you good to go in my state? Well, I'm not interested but... OK I'll look at your application." I'd filled out the whole application in about 10 minutes while on the phone with the rep with 6 questions:

"Where do I submit my references information?"

"Where do I submit my CV?"

"Transcripts?"

"What are the application essay guidelines?"

"What is the interview like?"

"Is there an application fee?"

The answers were: "we don't need references, no CV, only transcripts for your BSN (not the other 5 schools), no essay, no interview, no fees."

I almost asked if they were a real school or if this was some kind of joke, but I played along because I was thoroughly amused. I sent one transcript, worth $5 for my amusement. Then I hit the internet to learn about this school.

I learned the school is a for-profit. Oh..... now it makes sense! I learned Walden doesn't have a physical campus, only office buildings that house the servers, executives, and recruiters (aka admissions advisors). Perusing threads on this forum only darkened the reputation. Yet, they are accredited by HLC and CCNE.

36 hours later I received my acceptance email. I declined. The admissions advisor started leaving me voicemails implying I must have clicked on the wrong button... I could still change my mind. I wrote him an email politely informing him I'd declined. He left me another voicemail that was distinctly aggravated.

I'm not opposed to the idea of online programs, but there have to be standards because a profession is perceived and regulated by its lowest common denominator. This selection process for lowest common denominator in NP education is a joke. No entry standards lets in good students too, but don't filter the subpar. It implies the standards once in the program won't be high either. The bar for admission should be higher than a RN license, a pulse, and the ability to sign off on student loans. This is a story about how I got accepted to a big name online for-profit:

A phone number kept calling me incessantly for weeks... I finally answered, prepared for my usual, "I'm on the no-call list so please remove me from your call list." It was a rep from some school I hadn't heard of, but apparently I'd filled out some webform.

Had I? OK... "are you good to go in my state? Well, I'm not interested but... OK I'll look at your application." I'd filled out the whole application in about 10 minutes while on the phone with the rep with 6 questions:

"Where do I submit my references information?"

"Where do I submit my CV?"

"Transcripts?"

"What are the application essay guidelines?"

"What is the interview like?"

"Is there an application fee?"

The answers were: "we don't need references, no CV, only transcripts for your BSN (not the other 5 schools), no essay, no interview, no fees."

I almost asked if they were a real school or if this was some kind of joke, but I played along because I was thoroughly amused. I sent one transcript, worth $5 for my amusement. Then I hit the internet to learn about this school.

I learned the school is a for-profit. Oh..... now it makes sense! I learned Walden doesn't have a physical campus, only office buildings that house the servers, executives, and recruiters (aka admissions advisors). Perusing threads on this forum only darkened the reputation. Yet, they are accredited by HLC and CCNE.

36 hours later I received my acceptance email. I declined. The admissions advisor started leaving me voicemails implying I must have clicked on the wrong button... I could still change my mind. I wrote him an email politely informing him I'd declined. He left me another voicemail that was distinctly aggravated.

I'm not opposed to the idea of online programs, but there have to be standards because a profession is perceived and regulated by its lowest common denominator. This selection process for lowest common denominator in NP education is a joke. No entry standards lets in good students too, but don't filter the subpar. It implies the standards once in the program won't be high either. The bar for admission should be higher than a RN license, a pulse, and the ability to sign off on student loans.

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I think nursing schools should conduct screening for people who want to ignore nursing and just do medicine as advanced practice nurse. That attitude is terrible for nursing, and still bad if the person decided to go to med school. It's advanced practice, not elevated/privileged practice, and it's core is nursing. My best friend is in Np school and the dogma of nursing is very much there and I'm glad it is. I don't have personal experience with Np but as someone who happily switch from wanting to go to med school to now in nursing school I am going to give you my perspective on that.

To me, the "skip rn" Np is no different than a wanna be MD that thinks they they are above doing "nursing" roles. Instead of what you said about doing away with Advanced Practice, I think that medicine should adopt the Advanced Practiced care, empathy, and patient centered core values instead of this very stupid method of requiring people to be lab dwellers for years and then plunge them into a care centered role.

In fact, as someone who loves biology and hard sciences I was originally working toward medicine at first, taking my calc, physics, bios etc while preparing for mcat daily a year before I was to take it. These classes were enjoyable, but as tools to prepare an inexperienced person for a career as being a PHYSCIAN in medicine, I feel they are, in fact, absolutely worthless (unbeknownst to my starry-eyed, blissfully inexperienced premed cohort) . Yes, you need to know detailed biochem and understand some physics but students need to be exposed to something close to the role of doctor first, instead of training as a lab scientist for 4 years. Nursing elements need to become a part of medicine because it already is part of medicine and will always be so long as doctors have to interact with patients. Things like bedside manners and empathy and caring are what patients need, not this indifferent attitude medicine wants to hold on to so badly. People in my classes often had no social skills and personality traits that would have been disastrous for a patient oriented career. The Advanced Practiced Nurse model is so much smarter and better for the medicine and the world. I think medicine should borrow from the advanced practice nurse model for training doctors because starting with just the hard sciences is so stupid. That's how you get unhappy doctors and unhappy patients

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Honestly, helping seasoned RN's make the transition to advanced practice (FNP) has been one of my biggest challenges as an instructor, because many experienced RNs find it difficult to get into the mindset of thinking like a provider” as opposed to doing what they've always done so well for their whole careers, which has been fulfilling physicians' orders. I'm constantly reminding my students that they are the ones giving the orders now. The NP role really does involve a different way of thinking from the RN role.

...

As healthcare in general moves farther and farther away from valuing the human touch (less time allotted for medical encounters, algorithm-driven treatment protocols, tele-medicine, robotic and AI assisted assessments and procedures), I believe there will be more and more demand for well-trained nurses because nurses are trained to emphasize the human connection. Ultimately, that's what people want--better health and wellness--and you can't have that without quality human interaction.

Absolutely love love love what you said here. This is exactly it. Some of these girls in my nursing class have leadership, order giving qualities so I can see why they want to go quickly into the program. Some of them, however are struggling even when being given tasks in school and that's scary. And I wonder if this is evidence that the experience required to go to Np school is very variable. You must be "ready" for taking that role, and I believe some people would be without a long time in a bedside role. They have a well developed confidence in themselves and advance quickly, why should they be forced to stay in a role that's not challenging for them. On the other hand, some probably graduate rn school and can't imagine giving the orders. Then, after several years they feel like that's the exact place they need to be. I hope that people look at it from this perspective. Some people are truly leaders, and some are followers and no amount of experience will change that. This core aspect is probably the most important determining factor in readiness for Np school. As far as the quality of the cirriculum and validity of the direct entry programs, I am skeptical that they are as irreputable as some of you claim they are.

I wonder if I will have problems with order receiving to some degree when I graduate, since I was originally wanting to go to med school because I liked being responsible and leading. But I am happy with choosing to do nursing because I believe the philosophy is better for me than medicine.

I wondered if I want to do adv practice. I did throw it around as an end goal before I was in nursing school but at this point I'm too busy worrying about how not to fail as a nurse than fantasize about giving orders on tasks I barely know how to do. And then when I'm done I'll be in the same place, worrying about if I can remember the stuff I need to do now without the supervision.

I think there is a happy place when you have at least a little experience in patient centered roles before going into giving "medical" orders such as medicine and np. I still think med students need to touch patients and understand the role of their main subordinates. That's a big failing of medicine. At least Nps go through the rn program so they have to have to do nursing (as well as see cases, provide care for practical experience ) , where as medicine gets to wash their hands of all things associated towards empathy or even seeing what it's like to be in a patient centered career somewhere in your years of education.

One more thing: I think we should remember that one of the reasons that doctors are not happy with NPs, and probably a bigger one, is that it means their job market becomes slimmer, and that their work has less value because someone can do it for less pay, so theoretically it reduces the value of their labor because they must compete. It sucks that med schooling is so ridiculous in time and expense in this country but there is no entitlement to anything based on time and cost of education, only quality. Any doc I talk to about this eventually brings this up.

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