Time to remove the "nurse" in APN?

[Jedrnurse]

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?

[RN-dancer]

Hello All,

Before we go down the road of inexperienced APN, can we acknowledge that there are several highly respectable brick-and-mortor institutions that offer these access to advanced degrees right out of nursing school post-NCLEX. In defense of those accepted into such programs, don't bash the students, bash the schools for allowing this. It really is a cluster.....

[Akay1717]

I believe we should first have a solid foundation of nursing before moving on to advanced degrees.

I worked as an RN for 7 years before becoming a CRNA. The nursing experience is crucial in order to become an "advanced" practice nurse. There is a foundation that must be built upon as an RN that takes at least 2-3 years to acquire if not more. It involves putting yourself in uncomfortable situations, taking your continued learning seriously and working for experience, not just for money.

Becoming an advanced practice nurse to me can only prosper if we as nurses actually work and hone our skills as nurses first. We have such an amazing skill set and are such assets to the health care world.

[RN-dancer]

I totally agree with you. There is this huge misconception that nursing experience can make you a better NP but how does that explain a fully competent NP with no prior bedside experience. Its a totally different way of thinking. I personally think its all relative to the individual and their NP clinical experience exposure.

[RN-dancer]

Advanced nursing degrees have become to easily accessible. We have to raise the standards in nursing education. But nursing education has become a big business....

[subee, MSN, CRNA]

Interesting thread. This topic has been debated vigorously on the APRN and NP forums.

All available evidence indicates that NPs without RN experience are as likely, or more likely, to succeed in MSN programs. 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. In addition, I fail to see how RN experience in an acute care setting helps in the primary care arena. Many primary care and outpatient specialists have told me they have no interest in hiring an NP or PA who only has acute care experience. Finally, ironically, this is similar to the MD vs NP debate. 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. So now we have RNs and NPs arguing that RN experience is necessary to be an NP, but without any supporting evidence.

I do believe we should have NP residency programs for new grads and the AANP, ANNC, and state level NP organizations should lead the way in helping us with policy, legislation, and funding to support this. It would be great if there was funding for residencies in underserved areas and NPs choosing this route could get tax breaks or some student loan forgiveness.

Online programs deliver didactic content online. Clinicals with preceptors are still required. There are many reputable online programs such as Frontier Nursing University.

With regard to online courses – if it is just lecture, then who cares? In fact, the advantage of an online lecture is you can listen to it as many times as you need, whenever you want. The only value to an in-person class is if there is substantial class participation and Q&A. Only a few of my MSN classes had that, and I went to a top school. There are online learning platforms that do provide for real-time student participation and allow the instructor to call on individual students. Online education is the future of education.

References

El-Banna MM, Briggs LA, Leslie MS, Athey EK, Pericak A, Falk NL, & Greene J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5):276-80. doi: 10.3928/01484834-20150417-05.

Rich, E. R. (2005). Does RN experience relate to NP clinical skills? The Nurse Practitioner, 30(12), 53-56.

Rich, E. R., Jorden, M. E., & Taylor, C.J. (2001). Assessing successful entry into nurse practitioner practice: A literature review. Journal of the New York State Nurses Association, 32(2).

Direct entry NP's with no acute care experience should not be let loose in an ER. I know of a post op cholecystectomy sent home from the ER because the inexperienced nurse didn't recognize early sepsis in an otherwise healthy 32 year old. The patient died at home. Nurses who have acute care experience only will survive in office care but the inexperienced nurse won't be able to cut it in a CC area. And class interaction between the student and the instructor? I remember that back in the 80's when I could get answers difficult questions on the spot. I know it's inconvenient but it worked Great! Nor did I have to go looking for my own preceptor while paying full price for tuition. My grad school knew Who these people were and paid them some if my tuition money for their time and intellect. There seems to be an increasingly larger number of graduates who have no idea what academic excellence is because they have no experience of it.

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[shibaowner, MSN, RN, NP]

Direct entry NP's with no acute care experience should not be let loose in an ER. I know of a post op cholecystectomy sent home from the ER because the inexperienced nurse didn't recognize early sepsis in an otherwise healthy 32 year old. The patient died at home. Nurses who have acute care experience only will survive in office care but the inexperienced nurse won't be able to cut it in a CC area. And class interaction between the student and the instructor? I remember that back in the 80's when I could get answers difficult questions on the spot. I know it's inconvenient but it worked Great! Nor did I have to go looking for my own preceptor while paying full price for tuition. My grad school knew Who these people were and paid them some if my tuition money for their time and intellect. There seems to be an increasingly larger number of graduates who have no idea what academic excellence is because they have no experience of it.

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I'm not sure what your response to me is saying.

1. I stated RN experience is not beneficial to a primary care NP and the studies bear this out. Do you have evidence to the contrary specific to PRIMARY care?

2. I indicated RN experience is probably helpful to an ACUTE care NP. Most reputable NP schools require RN experience for ACUTE care NPs.

3. Anecdotes are not evidence. I have a lot of anecdotes about RNs that appear incompetent and so forth.

4. There is absolutely no need for a live in person class unless the instructor is going to interact with the students. If the instructor is just going to lecture, then I can watch a recorded video of that. I can then email or call the professor with specific questions. In addition, with modern technology, a live class can be conducted via Adobe Connect so that the students see and hear the professor in real time, and they can ask questions real time via the online education platform.

[operations]

I'm not sure what your response to me is saying.

1. I stated RN experience is not beneficial to a primary care NP and the studies bear this out. Do you have evidence to the contrary specific to PRIMARY care?

2. I indicated RN experience is probably helpful to an ACUTE care NP. Most reputable NP schools require RN experience for ACUTE care NPs.

3. Anecdotes are not evidence. I have a lot of anecdotes about RNs that appear incompetent and so forth.

4. There is absolutely no need for a live in person class unless the instructor is going to interact with the students. If the instructor is just going to lecture, then I can watch a recorded video of that. I can then email or call the professor with specific questions. In addition, with modern technology, a live class can be conducted via Adobe Connect so that the students see and hear the professor in real time, and they can ask questions real time via the online education platform.

The other thing I can say in your defense is that things like the illustration of the NP missing a critical sign is something that happens all the time with new doctors... Yet no one has said "Hey, maybe phsycians should have some real experience before being let loose in the ER". You could argue that a resident is technically monitored by the attending and staff, but these things still happen. In fact, we all have heard stories of or been involved in countless numbers of events in which an RN has saved a pt from a baby doc error. Let's face it, attendings use their residents as grunts, and provide little to none of the guidance that you'd expect. I wonder why medicine is so untouchable of this criticism but the NP who has at least had plenty of clinicals is hit so hard. It's not great that specific NPs don't get the experience that they probably should have had, but before we go after our own let's look at this huge problem that's been going on forever in medicine and no one has batted an eye.

Also, I don't know why the "online class" comments are being used as reasons to argue NP's don't have quality education. Please, this is 2017. I can tell you about how much I have learned from lecture classes over online, and that is absolutely nothing. There is literally no measurable benefit to learning anything that is not a manual skill in a classroom, other than some people need that for their learning style for whatever reason. In fact, if you are very successful with online learning, it often means you can handle doing a lot of academic research on your own for information, rather than be spoonfed by an instructor. A sign of a very competent and resourceful individual.

[Susie2310]

[quote=Susie2310;9551697

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?

At the bottom of your post your bio says you are from "California." The NP Scope of Practice in CA says that if you are practicing as a NP there you will be working under standardized procedures if you are diagnosing/treating patients (RN's work under standardized procedures too), and the standardized procedures that you work under require physician supervision.

If you read the John Hopkins study that suggests medical errors are the third leading cause of death in the US, you will learn that patients deaths due to medical errors are not recorded on a patient's death certificate, and there is no national database where patients deaths due to medical errors are recorded. So it is futile for you to say that there should be evidence if it is a bad idea to allow NP's to practice independently.

While there is a shortage of primary care providers, it is important to safeguard the standard of care. Many physicians (and others) object to dilution of the standard of care.

Money is the dominant factor, and there is much money to be made. Who lobbies for independent NP practice?

[operations]

If you read the John Hopkins study that suggests medical errors are the third leading cause of death in the US, you will learn that patients deaths due to medical errors are not recorded on a patient's death certificate, and there is no national database where patients deaths due to medical errors are recorded. So it is futile for you to say that there should be evidence if it is a bad idea to allow NP's to practice independently.

While there is a shortage of primary care providers, it is important to safeguard the standard of care. Many physicians (and others) object to dilution of the standard of care.

In order to "safegaurd" the standard of care, you have to establish data on breaches in standard of care.

You're assuming that doctors live up to the standard of care and that nurse practitioners are not, and this is the problem I have with this whole thread

If doctors are the living up to the "standard", how are they measured? How are the Nps measured? How then can the doctors be compared to Nps?

You mentioned the John's Hopkins mortality study. The findings were that 1/3 deaths were caused by medical errors. But, there is no information regarding these errors because MEDICINE will not record the data of these patient deaths. Medicine is at fault for that arrangement, likely as well as most of those deaths caused since doctors are the majority who practice medicine.

Why do you jump to attacking Nps on something for which their is no data? That makes for an incredibly poor argument.

I'm not sure why there is so much blame on Nps for patient deaths when there just is no evidence of it. I think we need to support our Nps more than this. And if medicine wants to whine and blame Nps for everything then they can develop ways to measure both doctors and Nps for this issue and prove it.

Doctors are more interested in the dilution of their paychecks than this ambiguous deaths resulting from this alleged "poor standard of care" for which they refuse to collect data on.

[EJN, RN, BSN]

Excellent point of view, Operations! I appreciate your insightful look into the disparity in complaints against certain NPs by other nurses that, somehow, have made it their life mission to put down and smear the reputations of NPs that advanced in ways they do not expressly approve. Having said that, no amount of evidence or reasonning is likely to keep them from bashing NPs they dissaprove of.

[Ruby Vee, BSN]

I just copied this from another posting....

Hello all, I was hoping someone had some good suggestions for EKG resources??? I will be starting my first NP job in a few months, which is a Cardiology clinic position. My program did not require me to learn how to read EKG. I have a few mo months so I am wanting to prepare. I have ACLS and i have taken an arrhythmia course in the past, so I have basic understanding of some things; however, i want to be more prepared than what i feel now, Thanks!

I think I met this NP. She worked in my unit for a short time.

When my patient went into atrial fib, "Betsey" didn't believe me. I had the telemetry strip in my hand, and showed it to her. She wasn't convinced that you could determine atrial fib with just a rhythm strip, so I went over it with her and explained how it was "irregularly irregular," etc. (I teach ACLS). She said she needed a 12 lead, because she thought I might have reversed the leads or something. (OK, but is it still an abnormal rhythm that needs to be looked into? She wasn't sure.) I double checked my leads, even doublechecked with another nurse. Then ran her a twelve lead. She still couldn't be sure it was A fib from the 12 lead, and had to have it looked at by an MD. In the mean time, the patient is beginning to decompensate. I had the code cart in the room when she showed up with the MD, and we cardioverted immediately.

Betsey was one of those straight from BSN into NP program without stopping to work at the bedside at all. She didn't recognize A fib, so she didn't think I could. My hospital doesn't hire NPs without bedside experience any more.

[operations]

Still taking isolated incidents and slamming and entire group of professionals with that label. No one has explained the difference to me between Np without bedside experience, and a resident. Technically the Np is a full hospital employee, but still associates with the MD in the same as a resident does. And you even illustrated that with your scenario. It's almost the exact same thing. It's really pretty absurd. I think ya'll just salty. If you want to sit here and bad mouth Nps by personal bias and isolated incidents (I. E. Sharing subjective narratives with can't be verified) over data involving entire profession (I. E. number of nps who've had a malpractice case immediately after hire), then you are just gossiping and I'm done here.