What's the least saturated specialty in APRN?

[soljhs]

What's the least saturated specialty in APRN?

[adventure_rn, MSN, NP]

10 hours ago, ghillbert said:

Yes I understand all that, and by no means intend to minimize the super-specialty-ness (?!) of NICU and neonates.

I wasn't comparing a trained adult NP's competence in a NICU to a trained NNP. I was saying for admission to an NNP program, I would think an adult critical care NP would be at least as well-prepared as an RN with NICU experience.

(Still thinking about this topic several hours after my last response...)

This is perhaps more controversial, but I actually think that having an adult critical care NP background could be a detriment in certain ways.

There are a lot of 'fundamental' concepts and protocols in adult ICU (and PICU) that are exactly the opposite of what you do in neonatal care. Just look at the difference in resuscitation approaches in NRP vs. ACLS/PALS.

An adult acute care NP would have to unlearn a lot of the 'fundamentals' that they learned in adult care. So little of the management actually translates across patient populations. I honestly think that adult-acute-care-NPs-turned-NNP-students might struggle with changing their whole frame of reference (since they're used to managing similar situations in such a different way). It would be kind of like telling someone "you need to forget everything you've ever learned about patient management, because if you do what you're used to doing it, there's a 95% chance it's going to be wrong."

Granted, I also think it would be tremendously inappropriate for an NNP with a background exclusively in NICU to complete an adult acute care NP program with the expectation of working in an adult ICU.

On 12/26/2019 at 11:00 PM, babyNP. said:

I agree that there is a culture in the NICU of being hyper-alert and anal about care that doesn't really matter (who cares if the duckies are facing the wrong way? lol).

Sidebar, I once worked with a guy (total smart *ss) who would go around behind the admit nurse and flip all of the bunny blankets in her empty bed spaces upside down just because he knew how much it would piss her off. It was pretty amusing to watch.

[myoglobin, ASN, BSN, MSN]

And yet as an FNP (which I am not) I could manage that same infant when they went home and as an ARNP I could manage a critically ill adult in the ICU? I was a 4.0 student in nursing school and have 12 years experience in the ICU and yet have met many first year nurses far more equipped both intellectually and emotionally than I will ever be. Medical schools don’t require specifically defined experience and neither should ARNP schools. Doing so artifically restricts the range and talent entering the profession.

[adventure_rn, MSN, NP]

2 hours ago, myoglobin said:

Medical schools don’t require specifically defined experience and neither should ARNP schools. Doing so artifically restricts the range and talent entering the profession.

The major difference being that med schools (and PA schools for that matter) have *way* more clinical hours than NP programs. Residents literally spend years learning to do what NPs learn in a couple of semesters, hence the benefit of staring the program with years of experience already under your belt.

Also, those super chronic former preemies are arguably better served being managed by a PNP.

[myoglobin, ASN, BSN, MSN]

33 minutes ago, adventure_rn said:

The major difference being that med schools (and PA schools for that matter) have *way* more clinical hours than NP programs. Residents literally spend years learning to do what NPs learn in a couple of semesters, hence the benefit of staring the program with years of experience already under your belt.

Also, those super chronic former preemies are arguably better served being managed by a PNP.

I will grant you that more clinical hours in all specialties would be optimal. I will also agree that having neonatal experience would/should be a strong consideration in favor of an applicant to a neonatal program. However, my position is that it should not be mandatory. I graduated in the mid 2000's from a Midwest nursing school and the two men in the program were told that we couldn't even apply for our "intensive internship" (the last two months in the program) to be in NICU or OB because "men just were not hired" into those positions. Stated differently if being female (or extensively OCD as were most of the nurses that I had the opportunity to work with during a different, previous NICU rotation in nursing school) is a prerequisite to work in the NICU (and working in the NICU is a mandatory prerequisite for being a neonatal NP). Then, I would submit that the ultimate product of that arrangement is to significantly impact the diversity of that workforce downstream. Also, while the "OCD" detail oriented personality certainly has many benefits (such as perhaps catching early sepsis) it may also correlate with certain weaknesses (failure to see or focus on systemic issues such as having separate pediatric pharmacies to help for example prevent heparin concentration errors which have on several occasions (including at IU Health where I had the opportunity to rotate) killed infants. Even as a student I remember asking the nurses at the time on that unit something to the effect of "shouldn't this unit already have bar code scanning in place" and them looking at me like I was on LSD or something. Everyone was so (understandably) for lack of a better term " task focused" that there was less "higher order discourse" occurring. I have seen this same dynamic occur over the years in the ICU (and especially CVICU), but it seemed to be an order of magnitude greater in the NICU. That is to say great emphasis on the "what"/tasks that we are doing with little discussion of "why" and whether or not the doctor's orders are congruent with best practice(s).

[ghillbert, MSN, NP]

On 1/22/2020 at 8:36 AM, adventure_rn said:

(Still thinking about this topic several hours after my last response...)

This is perhaps more controversial, but I actually think that having an adult critical care NP background could be a detriment in certain ways.

There are a lot of 'fundamental' concepts and protocols in adult ICU (and PICU) that are exactly the opposite of what you do in neonatal care. Just look at the difference in resuscitation approaches in NRP vs. ACLS/PALS.

An adult acute care NP would have to unlearn a lot of the 'fundamentals' that they learned in adult care. So little of the management actually translates across patient populations. I honestly think that adult-acute-care-NPs-turned-NNP-students might struggle with changing their whole frame of reference (since they're used to managing similar situations in such a different way). It would be kind of like telling someone "you need to forget everything you've ever learned about patient management, because if you do what you're used to doing it, there's a 95% chance it's going to be wrong."

Granted, I also think it would be tremendously inappropriate for an NNP with a background exclusively in NICU to complete an adult acute care NP program with the expectation of working in an adult ICU.

Sidebar, I once worked with a guy (total smart *ss) who would go around behind the admit nurse and flip all of the bunny blankets in her empty bed spaces upside down just because he knew how much it would piss her off. It was pretty amusing to watch.

Are you a neonatal NP?

[myoglobin, ASN, BSN, MSN]

My point is that there are gifted people from a plethora of backgrounds who would make good NNP's. To limit the opportunity to only those with NNP specific experience is to lose many, if not most of these people and to create a less diverse workforce. Maybe things have changed (since I graduated in 2008), but at that time I wasn't aware of a single male working in NICU at Methodist or anywhere in IU Health. Also, I was specifically told that I need not apply (by my nursing school) since males simple were not hired into this specialty (or OB). Now in my case this is no longer relevant (I am a Psych NP). I would like to believe that men and women who have good nursing backgrounds would at least have the opportunity to apply into these programs.

[adventure_rn, MSN, NP]

2 hours ago, myoglobin said:

My point is that there are gifted people from a plethora of backgrounds who would make good NNP's. To limit the opportunity to only those with NNP specific experience is to lose many, if not most of these people and to create a less diverse workforce.

I think what you're saying is a non-sequitur. People who become NNPs choose to work pretty much their entire careers in NICUs (since that's just about the only practice setting where NNPs can work). I don't see how you'd 'lose a group of talented people' who are expecting work in NICU their entire careers by asking them to work in a NICU for two years.

It's hard for me to imagine a person is who so put-off by the bedside NICU nursing requirement (and role's anal retentiveness) who would want to be an NNP. If there's a pool of untapped potential there, it's pretty shallow. IMO, the remote possibility of recruiting these people isn’t a good enough reason to forgo the 2 year NICU experience requirement.

And to your last point, every NICU job I've ever had has included some phenomenal male nurses, and I've worked with some amazing male NNPs. It's untrue (at least in this decade) to say that men can't get NICU jobs, and it doesn't have any bearing on this discussion.

Out of curiosity, do you feel this strongly that CRNA schools shouldn't require two years of ICU experience?

[myoglobin, ASN, BSN, MSN]

46 minutes ago, adventure_rn said:

I think what you're saying is a non-sequitur. People who become NNPs choose to work pretty much their entire careers in NICUs (since that's just about the only practice setting where NNPs can work). I don't see how you'd 'lose a group of talented people' who are expecting work in NICU their entire careers by asking them to work in a NICU for two years.

It's hard for me to imagine a person is who so put-off by the bedside NICU nursing requirement (and role's anal retentiveness) who would want to be an NNP. If there's a pool of untapped potential there, it's pretty shallow. IMO, the remote possibility of recruiting these people isn’t a good enough reason to forgo the 2 year NICU experience requirement.

And to your last point, every NICU job I've ever had has included some phenomenal male nurses, and I've worked with some amazing male NNPs. It's untrue (at least in this decade) to say that men can't get NICU jobs, and it doesn't have any bearing on this discussion.

Out of curiosity, do you feel this strongly that CRNA schools shouldn't require two years of ICU experience?

The difference is that in my (limited, but still somewhat long) experience is that there is an opportunity for a variety of personalities, and sexes to work in the ICU (I don't believe that CRNA school's should only take or even prefer CVICU which I've been told many do). I actually don't believe now that I think about it that CRNA schools should necessarily require ICU experience (again it should certainly be a strong factor in favor of admission). I know that at my hospital a 600 bed facility the NICU doesn't have any males. I also know that Methodist (in 2008) in Indianapolis (the largest NICU in Indianapolis at the time) didn't have any males. And I know that I was told specifically by my instructors that males were simple not hired into NICU's so I could forget about an internship there (again we did these over the last six to eights weeks of our program in the areas where we had the most interest) Perhaps that has changed and perhaps it is somewhat regionally based. Still, one does not need Psych experience to apply into a psych NP program, nor does one need "primary care" experience to apply into an FNP program, and at many schools one does not need critical care experience to apply into a ARNP program. also at many schools one does not need geriatric experience to apply into that specialty.

[babyNP., APRN]

Wow, this blew up for awhile before I noticed! I'll see if I can put together a cohesive reply- many interesting points members have brought up...

I think adventure_rn had some great points. Other things to consider...

You actually don't need any NICU experience to take the board exam for NNPs. It's the schools that require it and there are 2/37 schools that do not require NICU experience- although they do require PICU or PCICU experience and tbh I don't know how that is actually viable in terms of job employability.

I am sorry to hear that myoglobin was told that he couldn't work in a NICU during nursing school and knew of no males in the NICU at the large medical systems in the mid-west. That is sexist and 100% wrong and not the case nationwide. In fact I think you would have a strong case for gender discrimination- there is a thread over in the OB forum here about an experienced male OB nurse (who also coincidentally had special care nursery experience) who was told that by a recruiter and all h*** broke loose once he called the hospital on it. I don't know if that is a midwest thing but it's idiotic. From my own anecdotal evidence, I have been in neonatology since 2008 and have worked in large academic NICUs and community NICUs in the north east, mid-Atlantic, southwest, and northwest regions and have always worked with male NICU co-workers. It's definitely not 50/50 gender split, but I've known a couple dozen male NICU nurses & NNPs. There used to be a prominent member here on allnurses who posted frequently on the NICU forum- SteveNNP21 (or something like that) about 5-10 years ago. He worked in the north east I believe.

Coming back to the idea of AGACNP that works in adult ICU doing a post-masters, that is more feasible than comparing a NNP new grad vs an experienced AGACNP. But in order to practice effectively you would need an actual fellowship with didactics and clinical for a full year, similar to a neonatal PA fellowship. I suppose a PA would be on part with AGACNP, although not a new grad AGACNP- it would need to be someone who is experienced as a medical provider (earlier in tis thread someone mentioned that you don't need RN experience to be AGACNP). A new grad PA vs a new grad AGACNP with no RN experience should be no comparison, I would think.

So even though the AGACNP would be doing a 1 year post-masters program in neonatology, there are only a minimum of 600 clinical hours, which is not enough if you don't have any NICU clinical background (RN).

One of the academic centers I worked at tried to hire a PA and gave them a long 6 month orientation with no formal fellowship but they flamed out because of the difficulty in the differences of care of adult vs infant. This is anecdotal, for sure, but I've now worked with almost a dozen PAs that have gone through a formal year long fellowship for NICU (post-PA school) and they are excellent providers. But a new grad PA has many more clinical hours than does a new grad AGACNP, which is why I would argue that you would at the very least need to be an experienced NP.

That being said...there is no way to police an AGACNP doing a post-masters NNP to require a year long fellowship afterwards to gain the appropriate clinical exposure...and running the fellowship is costly to hospitals that are usually full of their own orientations for NNP students & traditional new grad NNPs. There is a severe shortage of clinical sites in many areas of the United States simply because you can only orient in a NICU and there is usually only room for 1-2 orientees each day in each NICU. This is different than adult medicine where there are multiple med-surg floors & types of ICUs for adults.

There is a shortage of neonatal providers, but keep in mind that we are also still small potatoes in the grand scheme of things. There are just over 5,000 board certified NPs out of 270,000 in the United States, making us 0.02% of the NP population (wow, lol, I didn't realize I was that small a minority!). If we added even 500 providers I suspect we would be overstaffed. So the scope of the problem of having AGACNPs join our profession is pretty small.

Finally- in a timely article published last month by the American Academy of Pediatrics, they posted a technical report regarding the different types of neonatal providers (neonatologists, NNPs, PNPs, neonatal hospitalists, and physician assistants) and how their roles intersect with providing care in the NICU. Interesting read if you are so inclined...

https://pediatrics.aappublications.org/content/144/6/e20193147

[babyNP., APRN]

edit to the above, we are actually 2% of the NP population, not 0.02%- math % fail.

[NPvampire, MSN, RN, APRN]

Ah, don't go into psychiatry for the money. It won't last. And in my state--which has NO autonomy at all-- it's taken me seven YEARS to get to my piddly salary that barely grazes 100. To put it in another perspective, a teacher with the same number of years experience and the same degree makes just as much per hour here. The cost of living isn't cheap either. Where are y'all making 170?!!!!

[myoglobin, ASN, BSN, MSN]

21 minutes ago, NPvampire said:

Ah, don't go into psychiatry for the money. It won't last. And in my state--which has NO autonomy at all-- it's taken me seven YEARS to get to my piddly salary that barely grazes 100. To put it in another perspective, a teacher with the same number of years experience and the same degree makes just as much per hour here. The cost of living isn't cheap either. Where are y'all making 170?!!!!

I would argue that if you practice in a state with true IP practice (Washington, Oregon, Arizona, Colorado, New Mexico) for example and develop your own clinic and clientele be it in primary medicine as an FNP or mental health as a PMHNP and provide excellent service, and hours to your clients that you can make a good living (200K plus after expenses) going forward. Of course as demand and saturation changes you may have to "move" over time. However, people tend to appreciate high quality service and will often remain loyal to providers who demonstrate it over the course of time. Also, to some extent I've done every job I've ever done "for the money". From my first job as a life guard to nursing as an RN. Were I very wealthy I would be starting orphanages in Africa, or trekking Nepal in search of the Yeti or developing a low cost healthy Ramen noodle to feed the world. As it is I'm a lowly PMHNP struggling to pay student loan and credit card debt, and a son in college, but blessed with the opportunity to possibly serve others and at the same time support my family. Heck, if it were not "for he money" I would probably sit in my lazy boy, grow to over 300lbs, stop bathing, develop stage three sacral ulcers, sit in my own feces and wash myself with a rag on a stick as Netflix endlessly played streaming marathons and my Sony Playstation overheated from excessive gaming.