Should You Be an Advanced Practice Nurse Without “Practice?” The Great Debate.

There was so much discussion regarding experience prior to NP programs on yesterday’s post I wanted to summarize some thoughts. To preface, I do not want nurses to feel judged by what I am going to say, but some are not going to like my opinion. I also realize there are exceptions to every rule, and experience may be dependent on the type of NP and the area of practice. However, it’s important to realize that this is in reference to educating the masses and there should be an element of standardization.

Prior to beginning NP school, I worked as a full time bedside nurse for three years, picking up loads of over time, in high acuity ICUs. Through NP school I worked mostly full-time until the very end, making my bedside experience about 7 years total. My BSN and DNP were all campus based and my clinicals were all directly supervised by experienced NPs and physicians. While I do not believe everyone needs the same experiences I had, I’m just setting the stage for the rest of the post.

I am a firm believer in experience prior to becoming an NP, not only for clinical expertise, but for learning to navigate social and cultural situations within the hospital. In the simplest terms, you should not be an “advanced practice” nurse without any “practice.” The NP education was initially designed for nurses with experience and if the “experience” portion for admittance is going to be dropped then the clinical hours required should be increased or a residency should be required in the area of practice for which the NP decides to work.

We are trained as generalists in a certain age group, but when we are hired, we are expected to be specialists – this creates an immense amount of stress.  In addition, it increases the importance of the experience of the NPs training us in our new jobs. An NP with one year of experience as an NP and 6 months experience as a bedside nurse should not be training a new NP, and the same goes for bedside nursing.

By not having a standardized amount of experience prior to NP school, not only does it negatively impact the NP personally, it negatively impacts the system. Many NPs schools across the country convince new grad RNs to directly admit themselves to NP programs right out of the gate. Of course, this is for money. It creates the sense of urgency that the RN needs to continue directly into NP school and the opportunity will not be there if she or he does not accept it immediately. It also gives the RN an excuse to subconsciously not be fully invested in the work of a bedside nurse further watering down the profession of bedside nursing and advanced practice nursing.

I stand by my previous statements that the work of a bedside nurse is the most important job in the hospital. Experienced nurses need to be training new nurses and that is not what is happening. The administrative shift of pushing RNs to become advanced practice nurses prior to them even knowing what an RN does, has given hospitals an excuse to not value the RN and the position of bedside nursing. While there is bullying of nurses wanting to go back to school in the profession of nursing and that is wrong, the reasons for this bullying are clearly stated above; lack of caring, lack of trying, lack of valuing, and the issue is perpetuated by the institution, not necessarily the individual nurse. Experienced bedside nurses are invaluable as mentors, trainers, and clinicians and the position should be more valued than it is. With all of that being said, there is no excuse for bullying, ever. Many new nurses are victims of a broken system and experienced nurses should be cognizant of that.

Nursing is HARD. Healthcare is HARD. I started as a nursing tech over 10 years ago and the nature of healthcare has only become harder over those 10 years. In the recent two to three years, I have become disheartened in many ways regarding the direction nursing is headed. Much of that not the fault of nursing necessarily, but the fault of healthcare being nothing but a business. When it comes down to it, the American healthcare system is about the bottom line making our profession and education about the bottom line more than anything else.

So if you’re a nurse born into this system, what do you do? You be the best you can be. Don’t rush. Enjoy the journey. Be selective when choosing your educational program and be certain of the direction you want to go. There are many schools who will urge you forward before even getting your feet wet. I assure you, they’ll be there in two years and ten years and they will take your money at any time.

Be prepared to differentiate yourself when you graduate. I am lucky to have the job I have. I work with multiple very experienced NPs that guide me and no one on my team was hired without a bare minimum of three years of bedside experience and most had over five years of experience. I know so many NPs and PAs who are having difficulty finding jobs right now because the need is not there. So, you need to be excellent, your clinical experience need to be excellent, and your social skills need to be excellent.

The system will not change overnight and at this point, I’m not sure how it will change at all. When you graduate as an NP, there will be some physicians who do not like you and will never believe you to be adequate. Becoming an NP blurs the line between nursing and medicine and many physicians will not accept your lesser education and clinical time. Your profession can be perceived to overlap and threaten theirs and after the minimum 12 years of education they have had (typically even more), some physicians will not accept you as an entity. So, you need to be competent and confident because you will spend many hours proving yourself.

With that being said, many physicians will accept you. Many will find the value in you being there. They will invest the time in training you and when you are trained, they will recognize your importance and competence in care. The longer you work as an adequately trained NP, the less you will need guidance from a physician. However, you will not know close to everything when you graduate and it is more damaging to lead you to believe that you will.

This is another reason why you need to be gritty and competent, why you need experience, because becoming an NP will not make life any easier for you. You need to be prepared to stand up for your skill set and usefulness within healthcare. You need to be prepared to fight for a fair wage when you are experienced enough to care for 85–100% of your patients independently.

Nursing is a profession of ambiguity. It’s a beautiful and infuriating thing. Nurses have more titles and certifications than any other area of healthcare. Wrong or right, there is a method of education to fit every lifestyle and I do find significance in that. Nursing is a female dominated profession which means it includes many working and/or single mothers and can give them a means to provide and support themselves. By default, a profession that is born from ambiguity will have an educational system that is somewhat obscure.

Nurses can wear countless hats and I swear to you if you want anything done, call a nurse and they will get it done even in less than desirable circumstances. Nurses naturally care and have an ability to connect with patients that I think is rarely paralleled by other professions in healthcare. And while that connection is difficult to measure or prove and is often taken advantage of, it is what separates nurses from other sects of healthcare.

While I don’t want to be a physician, sometimes I envy the profession of medicine and the standardized training of physicians and PAs. It’s simply easier to understand to the public and the participant. Medicine is a profession that garners confidence and self-worth in many ways and I can count the number of times I felt empowered by my profession during my education on one hand—and that makes me really sad.

Because if our education system can’t translate empowerment – then nursing empowerment will not happen the right way in healthcare. I know, in my heart, and I have seen countless examples of it over the last 10 years in healthcare, that nurses and nurse practitioners are of great and irreplaceable value. But our educational system needs to breed and reflect that and that requires experience. While our system does meet various requirements for coursework and clinical hours, I believe setting further standardization would benefit our profession much more than hindering it. If solid bedside nursing experience is not required for admittance to an NP program, and by solid I mean full-time employment in acute care for no less than 2 years and 3900 proven hours, then the clinical hours required in an NP program should be increased not only for clinical competence, but competence in navigating the system and its idiosyncrasies.