Myths about becoming a nurse practitioner – things to consider about grad school in nursing


If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at


UPDATE:  as of February 3rd, 2015, this entry has 38,633 (thirtyeight thousand, six hundred and thirty three) separate views. It’s the single most popular blog entry I have written. Please feel free to add your feedback and comments. 

UPDATE #2 My book, The Sacrament of the Goddess, was published in April 2014 in USA.  Click here to see reviews on Amazon and order a copy. see the cover on the left, below. People  in USA think of Everest when they think of Nepal. Or maybe the earthquake of April 2015. Right now, the political situation in Nepal is precarious; and one aspect of working in a Low Income Country is the feeling of being out on a limb. My book explores the peculiar terror of being a neutral medical volunteer when everyone else is choosing sides. It’s a fast-paced pageturner! The book has nothing to do with APRNs, but might give you some insight as to why any body would ever want to be a nurse…. why not buy it and become one of the cool people? 

related link about paying for NP education, click here!

Disclaimer: I myself went to grad school fairly early in my career – after just one year as an RN. In those days (the 1970s) the federal government supported nursing education with generous grants and stipends which we knew would not last forever. I did not incur any debt for grad school, whatsoever. sweet!  I continued to work as an RN after grad school, and the MS credential surely came in handy when I finally needed to have it. So – I am in favor of graduate education.

Buzzwords. The Trend Du Jour.

Advanced Practice Nursing is a big buzzword nowadays and we are using the idea of it to attract people to the nursing profession. Throughout the USA there is a proliferation of “three-year’s wonder” programs, the idea being that the student does an entire nursing program the first year, then takes NCLEX, then spend two more years getting their MSN and NP while they work part-time as an RN. It’s particularly attractive during the down economy we are experiencing, because there are plenty of people out there with prior BS degrees who are looking for a fulfilling job. It is oh-so-seductive to think they can gain the RN skill in just one year.

Okay, so it’s a wave – lots of schools and universities are offering these programs. there are plenty of stats to provide a rationale for the career track we are inventing.

The aging of the population

The lack of Medical Doctors to provide primary care

the overall need for RNs to replace the RNs in the baby boom who will be retiring soon.

etc etc etc

I am not disputing those trends, but I am bemoaning some things that seem to be getting lost along the way.

Myth One – no need to learn basic personal care

To begin with, role socialization into nursing goes out the window when the time is compressed. Many of the persons who come from these programs seem to me to be unaware of how nurses work as a team, how nurses work in a hospital, and how to do any kind of personal care for a sick person. In other words, such things as cleaning up “fecal incontinence.”  When this comes up in conversation, they say “oh, well, I am going to be a nurse practitioner and I will be in an independent practice, I don’t need to learn those things.”

Oh Really?

My retort would be: If You are hoping to get a part-time nursing job to put yourself through school while you get the next two years of grad school under your belt, you will be judged according to the standard of the nurses around you, not to the other standard. It is extremely unlikely that you will be getting anything other than a staff nurse job while you work during school. 

also, don’t discount what a staff nurse learns. accountability and integrity are a big piece of the socialization process. A staff nurse in a labor-intensive setting like a hospital, gets daily role modeling from the older nurses. daily mentoring. any new nurse needs to develop trust with those already in the setting, and people will trust you more if you aren’t afraid to get your (gloved) hands dirty.

Think about this: if a patient has been incontinent of feces, no real nurse ever just lets them lay there. Never ever. You may not have to clean them yourself, but you do need to know how. Being clean is a critical element in the dignity of human beings. a very simple precept, really….. and if you as a student disrespect this, you will not gain the trust of the nurses around you.

Myth Two – independent practice

The next myth for Advanced Practice is that “I will be in an independent practice and I am not going to need to learn to work in the kind of subservient hierarchy that a traditional staff nurse needs to navigate through”

If that is truly the case, you will need to borrow money to rent office space, hire a billing agency, advertise to the community, all those things just like you were opening up a furniture store. Ask yourself if you have the business skills to do it, or to get a loan. There are some great resources out there, I particularly recommend one book by Carolyn Buppert; but – is that what you want to do? Most Medical Doctors gave that up twenty years ago, the hassle of “hanging out a shingle” was way too much. We are training you to provide population-based care, which means many of you will be making frequent rounds in a Long Term Care Facility, as part of a group practice. The retired frail elderly population of USA is burgeoning, right? your job will consist of freeing up time for the doc you work with so they can focus more on the technical side.

The small population of ARNPs who will be doing more acute care will be drawn from among those nurses who went the hospital- nursing route and solidified their skills before they enrolled in NP school.

let’s reserve the topic of subservience for some future blog, shall we?

Myth Three

I will be making a lot more money than a staff nurse

In many states the recertification requirement for any ARNP is 40 to 80 hours per year. If you maintain dual-certification, you may have more. This works out to ten working days per year where you are in classes (or being online). When you are in class, you are not seeing patients, and your income is affected. You will also have to pay higher malpractice costs. If you are in a family specialty, you will have many patients who don’t have insurance.  All these things detract from the bottom line.

Myth Four

If it doesn’t work out, I can always fall back on a job as a faculty member somewhere.

Yes, we do have a shortage of nursing faculty. and the minimal requirement to teach is a Master’s Degree. This is one that puzzles me.  For years now there has been such emphasis on going the NP route, that very few nurses enroll in an education track for graduate school. The result? a shortage of faculty, now being filled by recruiting from among those Master’s Prepared nurses who are unsatisfied with an NP job, and who get hired to teach.

There is a problem with this. A converted-over NP with a MS degree does not automatically have the clinical knowledge base to teach in an inpatient clinical setting; and they also don’t have any course work in pedagogy, the science of teaching, how to lecture, how to construct a valid exam, none of the things an educator needs to know in order to be effective.

So far this trend has been under the radar. Any school of nursing where the administration is addressing this, will be ahead of the game.

Myth Five “I can work as an RN after the first year, and use that money to pay for the second and third years, so it’s really not so expensive after all!”  go to my latest blog entry to explore this one. Plan carefully.

Got it off my chest!

So, what you have just read was a “rant” –  the kind of complaining I always dislike. If I were to stand up at a professional meeting,  I am sure there would be  a pregnant pause when I was done. People would look around the room, and then some sweet and wise person would bravely ask And what do you propose that we do about this?

My answer would be:

for the student: realize that you are entering a profession with a long history of service and where you will learn from all those around you in any setting you enter. The more responsibility you are given, the more direct (and sometimes brutal) the feedback will be.

study the idea of role socialization. don’t let it be a hit-or-miss proposition. realize that your thinking style will be changed by becoming a nurse. oh yes it will…..

don’t disrespect the basic skills of personal care. paradoxically, the more likely you are to work in critical care, the more you will need the kind of  teamwork and excellent personal care skills you learn at a basic level.

don’t disrespect the work done by staff nurses, whether it is in a hospital, long-term care facility, or other setting. not ever.

for the schools: be realistic when advertising what a fast-track program can provide and how it fits into a clinical track. When a MEPN student is disrespecting the work of staff nurses, call them out.

emphasize the whole role socialization piece. Insist that the skills portion of undergrad curriculum is rigorous and incorporates socialization, not simply mechanical performance.

insist that converted over NPs who take on a faculty role be given the maximum in mentorship

reclaim the nursing focus of advanced practice nursing. I think it is too easy to slip in to a purely medical model…..

I am fully aware that I will get feedback on this one……. I don’t pretend that this is the end-all and be all of the discussion – But, as oif you have another idea, 2016 this comment section is closed.



Filed under APRN education, nursing education, nursing faculty jobs in Hawaii, Nursing in Hawaii, Obamacare

56 responses to “Myths about becoming a nurse practitioner – things to consider about grad school in nursing

  1. jpacklin

    I just wanted to comment about the first part — about schools offering these accelerated programs. Schools are a money-making business like anything else. And like most everything else, supply and demand is what dominates. Except that for schools, the supply is “education” and the demand is people saying “I want to go into nursing cause I hear about the great $$ and there’s such a huge nursing shortage.” The problem is the equation ends there.

    Schools don’t seem to care that they are churning out armies of nurses who can’t find work. They just care about enrolling more, about expanding their curriculum to accomodate their consumers. We’ve seen that trend go rampant here on the island in recent years, with the local schools churning out hundreds more nurses than are needed. I’d like to see the schools taking a more active role in helping to find work for grads. I don’t care about NCLEX pass rates, which is about as far as stats-tracking seems to go for any given school — I care about how many of the grads find work within 1 month, 3 months, 12 months. But it’s not in the schools’ interests to collect that info because it will drive away the demand.

    That’s my rant.

    • Tsk tsk!

      The demographics have not changed – us old nurses are bound to retire and or die off – as soon as the economy straightens out and the 401’s come up, you will see the involuntary exodus.

      So despite my whining, don’t totally give up. We are at a point where we reinvent the nursing profession and I worry that we are not passing along quite the attention to skilled practice that we should; also that the psychosocial piece is getting short shrift. Nurses are NOt “junior doctors” nor should we try to be.

    • science educated parent of nursing wannabe

      That’s a true statement about every degree granting program in every discipline. Workplaces are hiring advanced degrees because it doesn’t cost them much more. Schools are pushing their economy as the only solution… “we have entered a knowledge based economy” ring a bell? It is what every university president says in an interview. Meanwhile, the degree escalation hurts students because it is increasingly difficult to get hired without an advanced degree. Nursing saw LPN/RNs. Now it is RN/BSN. How long till it drives to BSN/MN-MSN is anyone’s guess but that is going to be the long term trend, if what has happened in every other degree granting field holds here.

  2. Future Nurse

    I was one of those who applied for the fast track program…. Fortunately I did not get accepted… While I won’t name any schools in particular, the program was very expensive, especially for those out of state, and somehow, many out of state candidates were accepted from a phone interview over the many qualified students in state. Anyhow back to the blog issue at hand…

    I quickly realized that there was NO WAY that I could obtain the tools, knowledge or experience needed to become a proficient nurse in one year. Sure I could pass the NCLEX in a year of study, but clinical know-how is a whole other story. I eventually would like to become a FNP, however, I believe that clinical experience will make me a better NP, or a better any other position for that matter. For nurses that want to work in administration, or teaching… yes, please have hands on clinical experience so that you can relate and understand the goings on of a staff nurses day, or know what to teach students that the NEED TO KNOW.

    Eventually, I hope, there will be more facilitation of FNPs to provide primary care, without all the red tape, for the sake of the people who it will benefit.

  3. Lauren F

    So i have been perusing your blog and have noted posts about grad school relating to the MNP program positive and negative as well as heading directly into grad school after undergrad but they did not cover all i want to know. :)

    Would you please blog about the changes in health care related to nursing education (how the masters in nursing degree will become a doctoral degree.. or willl it- with a potential supreme court ruling?) and how that influences the decision of when to go to school or if to go?

    I know you touched on it a bit but would you elaborate more? please :)

    The question behind this is the closer I get to graduation the more I think about what happens after. Is it beneficial to go to grad school soon (as it is simpler to do it as a single younger person while I work as an RN) or will I be at a disadvantage to go for a masters in the next few years to only have the system and requirements changed on me so I should wait a little bit, really get the experience and then go? or ever? what are the benefits of an advanced degree? does it depend on the area? will the cost of school really balance out with the benefits in patient care and salary?

    Thanks Joe!!

  4. I would love to have written uour eloquent and down to earth entry. I taught at UH/Manoa for over 12 years as well as practicing in Honolulu. (I had completed my B.S.N. at UH/M.) Then I taught at a Mainland university “college” of nursing for 12 years. The latter is nationally ranked — which means, of course, that the PhD program is nationally ranked, not the B.S.N. program. I found the UH/M B.S.N.curriculum BOTH more professional & stronger in theory as well. My M.S.N. was from Boston University, where I did a double major in Rehab nursing & Nursing education. When I joined the UH/M faculty I was nurtured by older “local” faculty, whom I remember with much admiration & affection. I also took a remarkable course (in a summer) in test writing & course evaluation. I have always felt that nursing faculty need to keep a hand in nursing practice — so I moonlighted on weekends, first in Rehab Hospital of the Pacific (in Honolulu) then in psych (in the hospital affiliated with the Mainland university nursing program.) The new Dean at the latter put in place one of those (much too short) “fast track, second degree” 13 month B.S.N. programs. She also instructed faculty to recruit graduates of both generic & fast track programs directly into the college’s graduate programs, without first working clinically. She put building the graduate program way ahead of preparing good bedside R.N.s. I thought that was a BIG mistake! I still think so. (It was no surprise to learn that Dean had no clinical practice experience, by the way.) I also found that faculty knew nothing about either nursing education in Hawaii or about clinical practice, and were invincible in their ignorance — they were not interested in learning about the Islands. They do have a reputation for being inbred, and it is accurate. I would like to add one more thing about nursing education in Hawaii. We benefit from a strong core of Masters and PhD prepared R.N.s from the Islands (“local” folks), combined with additional faculty – many of whom are military spouses – from the Mainland. They often stay for 4-5 years, enrich our experience and knowledge and we teach them a lot, too. Also, we benefit from associating with the stable faculty in the various A.D.N. programs, with whom the UH faculty gather at various educational & HNA meetings. (Or that was the case when I taught at Manoa, I hope it is so still.) TEAMWORK is absolutely a major principle in nursing education & practice in Hawaii. Aloha nui loa to all.
    Pat McKnight, R.N., M.S.N., M.P.H.

    • Justin

      I am highly suspect of these “fast track programs” to begin with. How can a person with a BS degree in finance truly become a Master’s-level nurse in a year? It took me 5 years to get my BSN, and it will take me another 2 for a Master’s. And I wouldn’t even think about trying to get an MSN without having some clinical experience (unless I can’t get a job and am forced back to school). Yet the schools are happy to take a VERY large sum of money, and after a year of intense work on an basically completely untrained and unprepared person and give them an MSN. I suspect these programs will really dilute what a “traditional” MSN has worked so hard for.
      Now, an accelerated BSN program actually does make sense. That’s the basic entry into practice, and those 5 years could definitely be accelerated if a person were capable of it. But there, too, as you mentioned, schools are trying to just build and expand money maker programs by exchanging proper education and clinical experience for lower quality nurses. But like I mentioned in my previous comment and someone else touched on, these schools are businesses. The service they sell is a nursing degree. The public is demanding them, so the schools come up with more ways to expand programs, charge a person more, rotate them through very quick, rinse and repeat.

      I have yet to work clinically (just passed my NCLEX two days ago) so I can’t comment on the strength of UH/M’s BSN program, but I will say I am very glad I got the “traditional” version of it. They’ve completely reworked the curriculum from the ground up; it’s vastly different than what you taught and what I learned. It looks horrifying to be honest, and time will tell if it’s an improvement on what they were doing. My understanding is what they were doing was just fine, and if it ain’t broke don’t fix it, but I am not a teacher or administrator so maybe there are details I don’t know about.

      • Justin

        I just wanted to add — if a person with no nursing education can go from zero to MSN in a year, why can’t I go from BSN to MSN in 6 months? Are MEPN programs reserved for those without nursing degrees, and those with must do the 2 year version of an MSN? If so again what does that say about the quality of the degree?

        • RN

          Just to clarify, a MEPN program does not grant a masters degree in one year, at least I have not come across any programs that do that. My MEPN program requires 995 clinical hours in addition to completing all the required courses. All this has to be done in one year in order to be eligible to take the NCLEX. Most of the 995 hours are spent in a hospital setting providing patients with the care they need and that most definitely includes cleaning feces, urine, vomit, and working with experienced nurses as part of a team. Two additional years of successful theory coursework and clinical practice grant the student a Masters Degree.

          • thanks> many of these points are covere din previous comments. be advised, your description makes me think you “get it” and your program does. But, when i ade the original list of myths, it was based on stuff I actually heard people say or saw them do.

            thank you for your insight….

          • Lyn

            I would like to respond solely to the comment “… includes cleaning feces, urine, vomit, and working with experienced nurses as part of a team”. It’s not just “cleaning”: it’s assessing the feces / vomit / urine – what color, consistency, smell; it’s monitoring feces / vomit / urine – when does it occur, how often, what symptoms come with it, does it hurt / burn when it comes out; is perianal skin intact, irritated, is the patient neutropenic? Please don’t minimize that task by calling it “cleaning”. Because it’s so much more than that. It’s part of the assessment in clinical practice. Thank you.

            • exactly. precisely. couldn’t have stated it better myself. Wish i had written it this way!

              This section has gotten a lot of comments. I included it because the original comment (“I won’t have to do that…”) was something a stduent actually said to me. There is more to nursing practice than dealing with stool. But when the time comes, you need to know how and you need to know the reason why.

              again thanks!


              • laurie

                That’s fine but I think that poster ‘RN’ was responding to the OP about how ‘these MSN fast track candidates don’t want or think they will need to clean feces’ [ie, implying that these students think they are ‘too good for it’]. So you comment that RN called it ‘cleaning’ is descriptive and instructive, but we don’t know if RN’s comment meant ‘only’ cleaning and it was a response to the post itself re: lack of clinical hours and ‘doing the dirty work’ on the part of fast track MSN’s.

                One comment that would be useful is how to best prepare career transition to nursing. Because surely there is a good path to career transition. People change careers mid way or even after just a few years, all the time and increasingly so. So, should it be another 3 years? How much schooling does an RN do? Or should it be a gap between the fast track to RN, with clinical time in between that and the MSN program first [minimum of certain number of years?]

                I mean, RN with a BSN had 4 years of schooling-but how much was actual nursing clinical experience and coursework? RN’s typically have 2 years and clinical is included. The experience bemoaned in this article is not something they graduated with. Everyone needs to start somewhere.

                BSN, RN and fast track MSN are all doing pre reqs, typically, as well. It sounds like the fast track first year is the part experienced nurses have a problem with. So, would you propose a 2 year fast track? A clinical requirement after fast track [gap year before MSN type of thing?]

                There’s definitely an entrenched mindset in nursing-just as there is among MD’s and many other fields, as well. When changes threaten this status quo, a certain legitimate reason/aspect for these changes can get lost when feathers get ruffled. Not to belittle the important factors and issues with the fast track programs, of course. Just sayin’, all of the ‘when I started in this field’, OR, “i’ve been a nurse for 25 years’. How many people get their personal power, identity/authority from their title, experience and subsequent feeling that this is ‘their domain’ and woe be anyone who tramples on it? Nobody, in any profession, likes the feeling that their territory or sphere of influence is being compromised or threatened, in my experience.

                Your comment that it took 90 years to gain acceptance/recognition is important, but also telling b/c that’s the mindset that often prevents changes in professions or society. Perhaps someone thought things ‘were broken’ enough to initiate changes??? I don’t think this trend was *only* the result some hair brain scheme for schools to make money ‘hey, let’s hire a bunch of non nurses and make lots of money training them’. I don’t think I’m jaded enough to believe it was that deliberate. Also, 90 years in the digital age is about 500 years, I think. lol. We can all expect continued and rapid change in all areas of our lives, all institutions and structures. Anything institutionalized is fair game for massive overhaul with the advent of technology, social media, global culture, etc.

                How many of these programs, for example, are attracting foreign students? These students may well need this training and use it to serve their local communities quite well. I’ve noticed several programs emphasize rural, global and public health. We now have a global economy and a greater focus on global health and providing medical care in under served and developing communities/countries.

                Your comments re: Hawaii specifically are relative to a larger socio-political discussion about how clueless mainlanders are about hawaii, its history and it relative status as a ‘US state’. People think it’s a state and they can just pop over and enjoy the beauty. It’s ignorance and people who have visited on vacation or never been to HI at all will never understand. And will get schooled in very quickly if they decide to move to the islands-whether to be a nurse or for any other field of work or lifestyle goal, right? So I don’t think the HI part is necessarily related to the training and fast track programs, per se. Of course the two factors impact one another, but your discussion really touches on two different points-that of cultural ignorance [nursing culture in hawaii is quite different than that on the mainland anwyay] and that of inadequate training and appropriate social mindset for entering the nursing profession.

                Thanks for the helpful article.

                • Laurie, it’s clear that people are looking for just the very thing you suggest – most of the hits on this blog entry come from search engines in which the person was seeking out info about a career switch. YOU ARE INVITED to write a guest blog from the perspective you describe.

                  I agree that Hawaii is a special place. I love the people there.

                  I don’t pretend to be the best phraseologist of these blogs, however, I am secure enough to think that people will catch the general gist. So – don’t waste time responding to highly-detailed critiques of word choice. Gotcha!

            • Lyn

              And one more thing, in response to the comment: “Most of the 995 hours are spent in a hospital setting…” 995 hours / 12 hour shift = 82.9 = 83 days on the job. Just saying….

              • B

                I agree Lyn, I am a nurse of 25 years. I’m in my last 6 months of my 36 month MSN/FNP program. The minimum number of clinical hours we are expected to complete is around 800 hours. And these are hours by nurses who have been practicing a minimum of 2 years. We already get what it means to be a nurse. What separates Nurse Practitioners from PA’s and docs is that we are nurses first. That can not be over emphasized. My frustration is the programs that allow an RN to immediately enter a masters program without at least 2 years of experience. It removes the essence and finesse of nursing and allows for those practitioners to just follow the medical model. As Joe stated – we are not mini-docs.

            • laurie

              This person wasn’t minimizing it by calling it ‘cleaning’. This person was, in my understanding from reading it, responding to Joe’s post about how these fast track students don’t want or expect to have to clean feces.’Clean’ is the term discussed in the original post. If the orginal article talked specifically about how fast trackers also don’t think it’s important or necessary [or even know how to identify] the color, smell, frequency, etc, then you could argue that point. Otherwise, you are assuming and projecting that this commenter is minimizing a task.

              Your comment sounds as though you, as a nurse, do not like your medical knowledge minimized or undervalued/ignored. I respect that. I also think that MSN and DNP could well mitigate that from happening in the future. Educational status can have the ability impact image among and between professions. But something common to nurses that I’ve met is this sort of cognitive dissonance or contradiction: On one hand, wanting to be taken seriously as a medical professional. On the other, stating that ‘nursing is about focus on care and should stay that way. We are not doctors (true, but other types of medical providers do exist)’. It’s a bit of a mixed message. I think nurses can both be seen for their medical knowledge and for their psycho social mindet and ability to extend care and comfort.

  5. Pingback: Nurses and OCD (Obsessive Compulsive Disorder) – is it good or bad? | Nursing in Hawaii

  6. Lyn Pyle, RN

    I have an ADN from Kapiolani Community College and 5 years of RN experience working with med-surg / hematology / oncology (including Bone Marrow Transplant) patients. In 2007 I was enrolled at UHM’s RN to BSN program but ended up dropping out after 1 semester because of the difficulty of having to convince each instructor to accommodate my work schedule and because of advice I received from the RN advisor, who recommended I quit my nursing job to go to school because the program was only going to get harder. I am a little annoyed that there isn’t an accelerated program to get employed ADNs to MSNs but there is an accelerated program for people who have no prior nursing experience to get an master’s degree in nursing. How can people trust the clinical judgment of an NP or a teacher who doesn’t have the knowledge base earned by working years in a hospital or any other nursing job?

    I learned a lot in nursing school and I am proud of my academic record, but when I started working in the hospital, I can honestly say I did not feel prepared. I think being a staff RN should be a prerequisite for getting a masters degree. I’m ok with a program for those with degrees in other fields to get BSNs or ADNs but not MSNs.

    • Justin Acklin, BSN, RN

      This is something that has always bothered me as well. I understand the MEPN program is VERY accelerated, but still… How is it that someone with a BS in Anthopology can take that to an MSN in one year and really gain the clinical experience needed to provide quality NP level health care? Yet I went to school for 3 (5 when you count pre-reqs) for a Bachelor’s, still feel totally unprepared for work environment (still haven’t found a job of course), and would have to go 2 more for my MSN. Can I just do a MEPN so I can get a MSN in 1 year now too? I’d be better prepared than that English Lit student sitting next to me. If they can accelerate it for a Women’s Studies major, why can’t they accelerate it for *actual nurses*. Why can’t you do an RN-MSN in one year? That would make way more sense. Sorry, but the existence of MEPN programs rubs me the wrong way and I can’t believe that, no matter how intense it is, a quality NP can pop out the other end in just 1 year. I think the existence of such programs is a money grab by nursing schools and I suspect it dilutes the professional image of NPs.

      Now, as you mentioned, taking another BS and having a “BEPN” makes sense to me. Sure, I can see how 3 years of education and clinicals can be compressed into 1. But compressing 5+ years of theiry and clinical experience into 1? Really?

      • To clarify: the student in these programs typically gets the MS degree only after a three-year course. the first year is taken up with the RN reuqirements, for which there is a certificate ( not a BSN, not any actual “degree”) – so , it is not a one-year MSN program by any means.

  7. Lin – thank you for this perspective. They say that if one person actually wrote something it’s likely that five hundred others also had the same response but were too shy to write.

    First, UH has evolved and you may find that they are more open to the student’s scheduling concern – don’t sell them short :-)

    secondly, you describe the issue of trust. I agree wholeheartedly. A new nurse or a new NP needs to focus on how to establish this, because nobody will ever give them responsibility for anything important without it. It goes to such things as whether the person exhibits elementary work behaviors such as showing up on time, having done their homework, and participating in the somewhat menial tasks that make things go.

    If the staff nurses don’t trust a person, whether it’s a student, new nurse, or an intern or resident doctor, the life of that person will be difficult. In a small hospital in rural Maine we once brought in a new obstretrician. The L & D nurses decided he was not good, and created the word of mouth that prevented him from getting any pateints; he left within six months. Maybe he wa sperfectly competent, I don’t know – but – he was gone.

    Role Socialization can take some strange turns. On the one hand, the faculty want to help the new student develop some confidence, and some adopt a strategy of never stressing the student out. I call that “phoning in the faculty job.” I believe that students will rise to the occasion when challenged and that confidence comes not from “my mother loves me” but from actually achieving something.

    call me Old School.

    • Lyn Pyle

      Joe, I appreciate your response but I am not sure you really address my question: “How can people trust the _clinical judgment_ of an NP or a teacher who doesn’t have the knowledge base earned by working years in a hospital or any other nursing job?” A masters degree to me means Mastery of the subject. Mastery of the subject includes theory and book learning and actual meaningful experience in the field. If the clinical experience in the MEPN program is 24 to 36 hours a week, every week, in a hospital / clinic for the length of the program, which would be 3 years, then that’s acceptable experience. Anything less, I’m afraid, would be questionable.

      • Lin, thank you so much for shining Nightingale’s lamp of knowledge into this dark spot. The people who have studied role socialization would tell you that even an experienced person in a new role will be a neophyte nonetheless. I do not have the space or time to give your question the truly deep analysis it deserves.

        One guiding point would be, an entry-level professional program is always designed to produce competence, not excellence. You are asking whether a person can be excellent after an NP program; that is an entirely laudable goal, but unrealistic. Otherwise, we should only graduate people who have a GPA of 4.0 (or better!)

        There needs to be a link to lifelong learning. Don’t get me wrong – I am in favor of excellence! But from the educational viewpoint, hoping for simple competence is often challenging enough.

        • Lyn Pyle

          Hi Joe,
          I would say that excellence following the completion of a MEPN program is great, but I’m not asking for excellence. I’m asking for competence. The more experience a person has, the more competent he or she is. I understand that an experienced person in a new role is a neophyte nonetheless, but I’d really prefer a neophyte NP or faculty member with a lot of assessing/teaching experience rather than a neophyte NP or faculty member with the bare minimum. And I’ll leave it at that as to why I am not a particular fan of the MEPN program. This was a very interesting discussion. Thank you so much.

          • Lin – I have to admit, I did not expect the amount of interest in this particular post when I wrote it – at this point it has been viewed by hundreds and hundreds of people. Anyway, I do agree with you about the need for competence. that was the original point.

  8. Janet

    Hi Joe, I found your blog through one of my google searches as I consider going back to school to become credentialed as an advanced nurse practitioner- question- what kind of advice would you give someone like me, a 54 year old woman who has a Bachelor’s Degree in Business, an “Associate Nurse Degreed” RN, a Master’s Degree in Organizational Development – with health care work experience- acute, chronic, palliative and much more experience in the business of healthcare- worksite health promotion, sales/management, owning my own health coaching company, etc. My desire is to have more direct impact one:one with people – to help them with chronic disease and/or avoiding chronic disease- a holistic and “self empowerment” approach through education, attention and care – helping them find the answer within themselves. Thoughts?

    • Hi. Janet –

      Thank you for this. This touches on a constellation of issues such as ageism in nursing, future needs for NPs, and lifestyle issues.

      In short, my advice for you is probably not to do it.

      First, there is the simple cost-benefit ratio analysis.

      Cost: three years of your life, disruption in personal relationships, and tuition which will be a bedrock minimum of twenty to thirty thousand dollars, though most programs charge more. Would you need to take out loans for this?

      Benefit: having the credential, after which you still have to get the job.

      You have about ten years of work life ahead of you, and you would presumably get the ARNP degree at the age of 57. to me this is similar to my own decision as to whether to enroll in a doctoral program. For that specific career path, the payoff doesn\’t come until you get tenure (and the process is longer). For me, I decided that any \”extra money\” I had would be better spent by simply giving it to my kids, as opposed to tuition; and also, that I could achieve my goals without needing one more credential. For a nurse who was say, twenty five, I might advise getting the PhD now, but for me? No.

      I do think the NP role has been co opted by the prescriptive authority aspect. When the NP acts like a \”junior doctor\” they are under a lot of pressure to crank out patient visits, etc – I\’m not it reconciles with the vision you describe.

      Having said all that, I highly applaud your description of how you want to relate to patients – you want to address the psychosocial piece. We spend most of nursing school trying to teach people that\’s it\’s not just about high tech hospitalization and biomedical equipment – so, you \”get it\” – excellent!

      That is also a mark of maturity, for which I also applaud. To me, your description sounds a lot like doing Case Management. My advice would to explore that area first. Haven\’t given it much thought lately, but it sounds like you would be a fit.

  9. This is a great blog post. I, too, have many concerns about the teaching pedagogy displayed by faculty in higher education. I worked in secondary education as a teacher for a few years before entering nursing, and I was a very much taken aback when I saw the classroom practices of some teachers. I applaud any teacher that can still make notes on a whiteboard and not resort to death by Powerpoint.

    That said, I became a nurse through an ABSN program, and I thought the preparation was phenomenal. The amount of clinical hours performed was comparable to traditional programs.

    Currently, I am pursuing my MSN (FNP) in a program that really caters to its “fast track” MSN students. I have my reservations about such programs, but every APRN that I know who came out of this particular program is very solid and has excellent clinical skills. I personally loved the experience and skills I got from my RN experience prior to pursuing my MSN, but I can’t say that it’s a definite must-have before continuing on to graduate work (especially if you have the money).

    I fear that the cost of non-traditional nursing programs is overall too high, and the ADN preparation at the community college level is way too impacted, leaving prospective students waiting in lottery systems that they might never get out of. On the West Coast, there simply aren’t enough state schools that offer a traditional BSN program.

    If the trend towards requiring the DNP for APRNs continues, I feel that the role will just be educated out of existence, as the barrier to entry becomes too high. All evidence points to APRNs doing a great job without the extra credential, so it would be sad if yet another barrier were created, which I think would decrease the access to healthcare that has been made possible by APRNs.

  10. Jay Dickson

    Hi Joe.

    I am a practicing Chiropractor for over 27 years. three years ago I achieved my BSN but have been unable to find a job as a nurse. No experience! In retrospect I am thankful I didn’t get a job as a nurse as it really isn’t a good fit for me. I am just to used to being my own boss. I am now considering gaining my FNP degree as I could continue with my Chiropractic practice and incorporate a more medical treatment side to my patients. In truth I believe I would probably seek employment as a FNP in a private medical office rather than in a hospital setting as this is what I know best.
    I am torn, however as to weather this is a path I should follow. I would welcome your input as to weather I should take on a 2 year masters program with a $40,000 cost for this 57 year old Chiropractor.

    • see the above comments for what I wrote to a person who asked this same question.

      you can make two columns, pro and con.

      be sure to cost out each option.

      If you are 57 now, and the program is $40,000, and takes a minimum of two years? you will be 59 at least, when you finish it. you may still have a lead-in time for the first NP job. you will still need to take direction, I think it’s a misconception that NPs are somehow independent. will you be paying off the loan when you are 70 years old? wouldn’t you rather be retired by then?

      if it were me, I would say no. I personally was faced with the idea of getting a PhD back along, and decided that it was not worth it. I wanted to spend the time with my kids, and I don’t regret it. in that case, it would have been a quest that took five years for the PhD then years of struggling for tenure.

      I don’t know enough about your personal situation – why not read my other post about having a personal board of directors, then convene your ten advisors and ask them?


  11. free

    What would you say to someone who has a B.S. in Science and wants to pursue a a fast track NP degree? I am in my late 20’s. Would the lack in clinical (on the floor) experience in many of the programs be a hindrance for me? I feel like as long as I work in a hospital floor during my program or after I should be ok.

  12. concerned

    Hi Joe,
    I’ve been searching the web to read people’s feedback on the MSN accelerated program. I, too, want to pursue an accelerated MSN in administration with a BS in Mathematics background. I completed a CNA program and gained respect for all the title’s in the nursing field. I wanted to gain knowledge before I even pursued the nursing field. In doing so, I loved what it meant to perform personal care. However, I do have a passion for administrative studies because I want to be able to influence that in a positive way both educational and politically.

    I am 24 now. Would you say I still do not have what it takes to perform an accelerated program for a msn?

    • Hi – i invite you to read all my other blog entries on carrer advice, esp the one that describes the virtues of having a “personal board fo directors” that includes some working nurses.

      I simply do not knwo enough about your back ground to personally advise you. I know that several previous posters asked me for specific guidance, but I think their questions were related to age. you are 24 – the future is ahead of you. you will be in the workforce long after I am dead!

      the best thing I can tell you is to go to a school of nursing and ask to speak to a career counselor, and ask as many people as you possibly can, what they think – people who know you. there’s justr so many factors that go into it that you need to consider. this blog posting is for those wo have already been admitted into a program.

      best wishes.

      “there is always room for one more good one”

  13. mae


    I am a second career nurse-to-be in an ADN program, and expect to graduate and take NCLEX in May. I have a BA in another field, but chose this route because I want to have great basic skills and learn from the ground up. I was a computer programmer for many years, and while these skills help me navigate the chances in healthcare IT, they don’t inform the myriad of skills I use in my clinical rotations.

    I thought I might enroll in an RN to BSN program immediately after graduation, and work during further schooling. I eventually want to work in critical care, and I know I need 2+ years of experience in ICU nursing before I can take the CCRN exam. I also know I will need years of experience in general acute care before I can work in an ICU. I see my slow progression from “novice to expert” (as they say) as something that can’t be jumped over. However, no one in my graduating class seems to agree with me. 90% of my fellow students are going direct to MSN right out of the ADN program. Some have experience as medical assistants and CNAs, but none have experience as actual nurses (yet). Is my reasoning faulty? My classmates seem to think they are *much* smarter than I am, and I’m starting to wonder if they are right…


    • Hi – see my previous comments about specific advice. I have heard, anecdotally, that in New York State, the hospitals are in a mad rush to go for Magnet ( a good thing) and consequently are preferentially hiring BSN nurses ( a bad thing if you are an AND grad). I don’t know your location or the market where you are.

      If that is happening, though, then your friends may be exploiting a good opportunity.

      As above, I simply don’t know enough about your situation to comment. Find a local “Board of Directors” and get as much input as you can.

      Best wishes,


      • Amy


        I am a 13 year RN (BSN) nurse in NYS.I am expected to graduate in May 2012 with my FNP with a minor in education. The hospital I work in (St. Joseph’s Hospital Health Center in Syracuse NY) is making their new A.A.S. graduates sign paperwork stating they will obtain their BSN within 5 years of employment. If not they lose their job. I am not a fan of this approach since I stared nursing from a A.A.S. program and have worked in the trenches with exceptionally skilled A.A.S. nurses. I did not return to school for my BSN until 7 years from my initial nursing degree.

        Currently, I work in labor & delivery in a Level III hospital and teach clinical adjunct. I have past expereince as critical care nurse in their surgical ICU (mostly open heart surgery, neuro, and vasular). My husband and I are considering a move to Hawaii after my graduation. I am fearful as a “mainlander” I will not be welcomed. In your opinion which island would you recommend for a mainlander FNP? In addition, I would like to work in private practice and teach. I LOVED YOUR post and feel like it is something I would write here! In my current master’s classes I sit with brand new nurses who have NO clinical experience but KNOW IT ALL. I am only 40 but cringe at how a APN is truly no longer advanced……….to me in order to be advanced don’t you have to be a practicing nurse first?

        Any advise would be greatly appreciated!



  14. Jeff

    This blog is excellent, and extremely timely. I am one of those mid 40s career changers going into an advanced degree for an AGNP, will come out the other side in 3 years with 80k (private school) in debt and no nursing experience. I love the personal interaction, the psychosocial aspect of healing, the trust and hard work and all that goes into sifting through the life (and the poop and the puke) of a stranger to heal them and teach them to heal themselves… BUT I am absolutely terrified of abandoning my current career and then not finding work. That enormous debt load will rob my children of college assistance and time with their father. I’ve made checklists and spreadsheets and quantified the unquantifiable, but cannot answer the question of employment. Much of my confusion stems from this very dispute – can a 3 year wonder be taken seriously. Will a physician look at a 49 year old new NP grad as someone who is wishy washy about their career choices, or as a person with life experience that new patients might relate to. I have to believe if we learn the technical details in those 3 years, and have spent a couple decades working hard and working well, and have compassion for our patients and are not afraid to get our hands dirty, then everything will be fine. The hard part is getting that foot in the door.

    • Hi Jeff – go through my other blog entries. most of them are addressed to the young person who is 22 and entering the field, but many still apply to you. get a personal “Board of Directors” if you don’t already have one, and get their opinion. I am ten years older than you, and I look back and am really happy with having been able to be with my kids when I needed to, and to pay for college.

      I frankly think that 80,000 in debt would scare me off, personally. as I wrote in the blog, when I did grad school, the federal government was giving money away to find people to go to grad school. sometimes I worry about whether it is a scam. I would be lying if I said otherwise.

      bottom line: I can’t predict the future. best wishes!

  15. Lyn, RN

    This blog address the question of whether or not someone should pursue a MEPN. Here’s my question: what’s waiting after a MEPN graduation? Does a MEPN qualify for a job as an NP for Cardiology patients? Does a MEPN qualify for an NP position to place neglected / injured children into foster care? For an NP working to meet the needs of Spinal Cord Injury patients? These are open positions in Hawaii right now. The one with children requires 2 years previous experience in peds. The Cardiology job requires experience with post open heart pts and acute MI. The SCI job requires prescriptive authority. Sounds like a good candidate would have past experience working as an RN in a hospital. Where I am employed, the aides are all new RNs hoping to have a foot in the door for a plain old hospital staff RN job. Some have been waiting for 2 – 3 years. So what kinds of positions can a fast-track MEPN expect to get? Especially wondering since job outlook on Oahu isn’t great right now.

    • Lyn, RN

      An FYI re my prior comment – the positions I cited above I found by using “simply”, which is public information available to anyone.

  16. Trevor

    “Nurses certainly aren’t “junior doctors”. They would need to go to school much longer to earn that title.”

    -made my day

  17. Pingback: It’s Official – Hawaii has an “oversaturated” market for nurses | Nursing in Hawaii

  18. Kim

    I am a little surprised at your replies to the over 50 posters who are considering getting their advanced practice credentials. Age should not be a determinant in this decision. Sure it takes time and money. But, time is going to go by whether you’re studying for a degree or fly fishing in a mill pond. And, money is just money. You only get one life. Who can say exactly what we’ll be doing five, 10, and 20 years from now, whether we’re 20 or 50ish? If you want to go to school, go. If you want to be an NP, be one. If you’re still paying off student loans when you die, who cares? You won’t. You’ll be dead. And, if your kids begrudge you $20,000 or $30,000 less in their inheritance because you followed your dreams in the one and only life you’ll ever have, just leave the a note with the will and tell them to get a job. It’s really not that complicated. I know one thing for myself, I’ll be able to work many more years as an NP than I will a bedside nurse. And when I do die, or stroke out, or whatever calamity awaits me, I’ll know I did my best while I could and I had fun while I was doing it.

    • Kim –

      surely you jest.

      In today’s job market I see people who are going to NP school with no idea as to what they are getting into. In this era of 7% unemployment due to GOP austerity measures, they see it as a lucrative job. (it’s not) they figure they will get rich doing this. (they won’t) they finish school with $80,000 in loans, and the payments start coming due within six months. (yes they sure do) the monthly loan payment can approach $1,000.

      the situation is made more difficult when admissions personnel say “oh, you can start actually working as an RN after the first year of this compressed master’s entry program, therefore it pays for itself.” – that is the biggest miscalculation. it is not a sure thing to fund it that way. read up on the Dunning-Krueger hypothesis.

      and they can’t get a job. can’t get their foot in the door. But they moan and ask for sympathy for the situation they are in. the stress of having this debt hanging over their head drives them crazy and exacts a toll on their personal life. they cease being fun to be around.

      nursing is not for everyone. and whether you are a nurse or not, you need to run your life as if it’s a business. because it is.

      • Kim

        No, I don’t jest. I’m not saying you go into something with pie in the sky ideas and no preparation. What I am saying is age should not be a limit to your dreams. Surely, a 50 year old who’s never danced before will likely never become a prima ballerina, but if you’re physically and mentally capable of doing something, the fact you might not be 20 or 30 or five years from now should not be the only reason you don’t do it. That’s a ridiculous premise. There are many paths an NP can follow. They can create their own jobs. It’s not just about racking up debt and begging somebody to hire them. If it were, nobody would ever get a degree in anything. Life’s not just a business, it’s a gamble. Your best laid plans could be scuttled by a drunk driver as you’re taking your nightly stroll down a lonely road. You can sit home and think of all the reasons you shouldn’t do something, how you shouldn’t follow your dreams, or you can get out of your scared box and make something happen. Time passes. That’s the only certainty in life. It passes and it passes. You do with it what you will. Then you die. I can say with a lot iof certainty, nobody on their death bed laments following their dreams. Nobody.

    • jpacklin

      Love your point of view!

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  21. As some one in an accelerated RN-MSN program I found this blog interesting! I have worked as a nursing assistant for 1 year, patient care technician for 3 years (both jobs in hospitals) while working on my bachelors degree in Business. Upon graduation, I could not bring myself to leave healthcare. I decided to apply to a variey of programs and was accepted into the fast track RN-MSN. the program is 4 quarters of RN classwork (traditionally done in 6 quarters) and a normal length MSN program right after that.
    I’m so thankful for my healthcare experience, even though it is not as an RN. Some of my classmates are so anxiouse during clinicals, and focus much more or their GPA. Grades are certainly important, but being comfortable doing patient care is paramount. I’ve also heard comments like “I don’t really need to know these skills because I’ll be an NP, not an RN.” and “I just need to know enough to pass the NCLEX.” At first I couldn’t put a finger on why these comments seemed wrong, but now I realize that these comments make us seem seperate from nursing. I love nursing! I don’t want to just pass the NCLEX; I want to be a nurse. It doesn’t matter that I’ll eventually have an advance practice degree, everything that I’m learning is important and I plan to work as an RN at the hospital I currently work for until I find a NP job.
    Experience cannot be replaced, and the NP that come out this program with no other health care expieriance will have a lot to learn still about teamwork, nursing culture etc. They might benefit from NP residency programs that are popping up in the area where I live (Seattle). Experience is a must for any healthcare professional. The other day me and an RN were helping a patient clean up after a loose BM, and a med student came in (without knocking), and blushed and left. He came back later and admitted that he didn’t know much about C. Diff and asked us if we were familiar with the smell of C. Diff, because the patient has been having loose stools. We both replied that we have lots of familiarity with the smell of C. Diff and we didn’t think this patient has it. The med student order a stool sample sent to the lab for testing just in case, and it was indeed not C. Diff. I respected that this med student didn’t have experience in this particular situation and it built trust with us that he admitted to it and asked for advice. I think this can be applied to anyone who is brand new in healthcare. After some time, they will have expereince. As long as they remain humble and ask a lot of questions of their peers and remember that they are still learning, they have a chance.

  22. lisa bolton


    as a 3-year wonder: could not agree more with your assessment of the current np puppymill situation

    (driven in part by insurance suits who like the less-expensive malleability of the so-called midlevel provider —
    now more than ever: doctors and nurses need to team up as we are very much on the same side, aka the prioritization of patients over profits!)

    i’m a midlife 2nd career nurse:
    felt the call 40ish for work w purpose
    corporate writing job eating soul
    began w 3 years of nursing prereqs
    while volunteering friday nights ER
    1 yr to RN
    worked PRN LTC while getting MSN
    elderly, atypical, polypharm, endoflife
    learned skin/pericare rounding w CNTs
    dug in
    learned FNP in chaotic clinic harsh MD
    nights/wknds as he couldnt keep 2 NPs
    chose sink/swim over easier gig: swam
    now at small urban safety net hospital
    outpt clinics: int med, coag, uro/sg
    i go where they need me
    yes: role soc — i became a nurse
    and think/ see world differently
    love parse’s human becoming theory
    changed foley this wk in uro
    performed excellent skin/peri care
    as it was needed
    i use my nursing skills daily as FNP
    and feel RNs should ban “only”
    and “just” from their descriptions of their professional role as NURSE
    glad to have studied in classroom
    and clinicals vs online
    in 20/20 hindsight would have gotten RN then worked in hosp, then NP
    im well suited to outpatient care
    and again: use my nursing skills daily
    nsg school like childbirth:
    a transformative experience
    i wouldn’t wish to repeat
    but treasure having had
    you sound like excellent teacher
    & preceptor: your students=blessed!
    lisa bolton RN FNP

  23. Pingback: “Friday Night at the ER” is also Simulation and – your school needs it! | Nursing in Hawaii

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