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 https://goo.gl/PGTW30

 

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.

Should a new nurse go to graduate school right away if they can’t get a staff nurse job?

Funny you should ask… I will answer in a minute, but before you read on, please take a look at my book about hospital care in a Low Income Country. My book won’t help you get a nursing job, but it will remind you of the value of nursing.  And why not go the right of the screen, and click oon the little box that says “sign me up” ?????

It’s a tight economy for nurses

The job market has changed from just two or three years ago. This past month, three different new graduates told me they were worried about their prospects of getting  a staff nurse job. Each of the three asked me the same question.

“If I can’t get a nursing job right away, should I go to graduate school?”

And

“What track should I take? Is it better to be a nurse practitioner or a nursing administrator?”

The pros:

You will have more credentials.

You will be doing something productive.

In the long run, you can get it over with before you have other responsibilities.

The cons:

Running up more debt in student loans.

Not having enough experience to draw upon.

Still having job search trouble after graduating.

As always, the answer that fits you depends on your circumstance. If you are young and your parents will still foot the bill this is different from being say, thirty and with two kids.

My story

For me personally, I went to grad school after being an RN for a year, worked in ICU while in school, and then took a management job for ten years after grad school. I knew I wanted to teach eventually, and the MS degree was always in the back pocket, just in case. By the time I made the move, I had two kids and a house and a mortgage; I was living in rural Maine far from the nearest graduate program. Having the credential allowed me to make a career change within the nursing profession that would have eluded me if I needed to go back to school right then. So, the timing was auspicious.

I did my grad school in a “Clinical Specialist” track, what would now be lumped in with other ARNPs. There was a window of opportunity in the nineties, when the ARNP standards were revised during which I could have become an NP with nine more post-Master’s credits, but I decided not to at the time. The classes would have been 65 miles away; it would have cost $2500; I would have needed to do a clinical placement in an MD office practice. Finding the MD sponsor would not have been a problem, but I always did ICU and the thought of looking at otitis all day or dealing with management of HPTN, was not appealing. Those things are important but in my heart of hearts I wanted to be doing hospital-based acute care.

Call me a traditionalist.

How many NPs do we need?

For awhile there, the federal government was subsidizing the expansion of NP programs around the USA. There are statistics to say we need these primary care providers, but I wonder. When layoffs and restructurings happen in the health care industry, reductions in clinic staff always seem to involve the NPs before the doctors. I just don’t think the underlying reimbursement structure is well-established enough. And if you are a family NP? There are fewer kids nowadays and family care includes a lot of clients who lack insurance. This has been true for decades. Even in the 1980s, both of the two pediatricians in town had less take home pay than I did as ICU manager of the local hospital (they had office overhead, employees, etc).

What does an ARNP do all day?

A friend of mine in Maine is a women’s health APRN. She spends her whole work day doing contraceptive counseling, pelvic exams, and fitting diaphragms, IUDs and depo-provera inserts. She loves what she does. Simply gushes with enthusiasm. I don’t want to deny the importance of women’s health – it is critical. But would I want to do that? No way.

There is significant Continuing Education required to be an ARNP – to maintain certification takes 80 hours per year (varies from state to state).  this is a sizeable investment of time and money. Yes, we need to stay current in our field. But this is time spent away from patient care activities.

How to fix the nursing job market

In My Humble Opinion, we need to fix the gridlock in Washington DC before the health care situation will be improved. We have a series of paradoxes: lots of patients; lots of need; a huge cohort of older nurses preparing to retire in the next few years; and a larger supply of newer ( younger) nurses waiting in the wings. But jobs in health care are being held hostage by Congress. We need to get some grownups in charge back in the Capitol Building.

student nurse job description – the unwritten rules for success

This one of a series of blog entries on the interface between nursing school and work. Every new grad needs to make the big leap. Past blogs have addressed issues of resumes, cover letters, etc.  Future blogs will address issues of how to make the transition to critical care. You are invited to subscribe. click on the button at the right!

Worked at McDonald’s, ever?

Nursing school admission is competitive these days, and you need to have a good GPA in order to get a seat in the class.  There is a difference between the nursing students from ten years ago, and the ones nowadays.  When studying is the main goal to the exclusion of everything else, it’s less likely that the student has had a part-time job outside of school in the past, not even at a McDonald’s. 

This means that when we teach beginner nursing students, we  also need to teach them about work behaviors. Oh, I believe in focusing on the illness the patient is experiencing, but the faculty would be missing something important unless we spent time saying what it means to have a job and be part of a team. Nursing is labor intensive and twenty-four hours a day seven days a week.

Unwritten rules for any job

The odd thing is that there is always a set of unwritten rules, things that are so common-sensical that a person who has been in the workforce takes them for granted. But when I have a kid who is just twenty years old and not had a time-clock type of job,  I go over “The Rules.”

Nursing is eclectic, and draws from a wide variety of sources for inspiration.  Don’t disrespect McDonald’s – it’s the entry-level job for many a sixteen-year-old around the USA – they teach people how to have a job.

 The Few, The Proud, the Brave

You may laugh, but there is another large organization in USA which has been around a long time, and which has gained a lot of experience giving responsibility to young people. They hire a lot of eighteen- to twenty-year olds every year, and teach them how to behave at their first job.  And so, I have borrowed the minimal job description from them. It’s – The United States Marines. Every Marine is required to memorize a set of Rules during boot camp.

Here is the Job Description for a sentry in the Marines:

“The Rules”

• 1. Take charge of this post and all government property in view.
• 2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.
• 3. Report all violations of orders I am instructed to enforce.
•  4. To repeat all calls [from posts] more distant from the guardhouse than my own.
• 5. Quit my post only when properly relieved.
• 6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.
• 7. Talk to no one except in the line of duty.
• 8. Give the alarm in case of fire or disorder.
• 9. To call the Corporal of the Guard in any case not covered by instructions.
• 10. Salute all officers and all colors and standards not cased.
• 11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

Let’s break them down one by one and comment on what they mean when they are applied to a nursing unit.

1. Take charge of this post and all government property in view.

Be on time, and be very specific about which patients are yours and which tasks you will or will not do.  Introduce yourself to all other persons present and communicate.

2. Walk my post in a military manner, keeping always on the alert and observing everything that takes place within sight or hearing.

Don’t sit down on the job, make frequent rounds and check on things regularly. Don’t lose sight of the Big Picture.

3. Report all violations of orders I am instructed to enforce.

Learn what the orders are in the first place, and have a plan for every “order” whether you understand it or not. Know who to call when you need help.

 4. To repeat all calls [from posts] more distant from the guardhouse than my own.

Help the people around you as much as you can.

5. Quit my post only when properly relieved.

Don’t ever leave the floor without telling anybody. Don’t go to the rest room without telling anybody.  Don’t hand off a pateint without giving a report as to how your day went. Always share information.

6. To receive, obey, and pass on to the sentry who relieves me, all orders from the Commanding Officer, Officer of the Day, Officers, and Non-Commissioned Officers of the guard only.

see report, above. check in with your nurse frequently in case the “orders” change.

7. Talk to no one except in the line of duty.

don’t use FaceBook on the job. Turn off the mobile phone. Keep frivolous talk to a minimum.

8. Give the alarm in case of fire or disorder.

have a CPR card, get help when you need it.

9. To call the Corporal of the Guard in any case not covered by instructions.

This is about teamwork and communication. Ask questions when you don’t understand something.

10. Salute all officers and all colors and standards not cased.

Your faculty member, the staff, the housekeepers, every one else who works there – deserves your respect.  If somebody tells you anything, write it down and try to follow it. Yes, there is a pecking order, but that does not mean you should disrespect those who might be further down on the hierarchy. You can not do your job unless the housekeeping staff does theirs!

11. Be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority

pay attention to the activities of the patient even if they do not involve you directly. who is seeing your patient and what are they contributing.

Read them, Learn them, live them

Sometimes I am met with incredulity when I talk about these rules with beginner students. They ask “how can this be? aren’t nurses independent professionals?”  They are surprised to learn that there may be any regimentation in nursing. The answer is, we need to have structure and a plan in order to accomnplish anything great.  An experienced nurses makes all his or her activities look like they just unfold naturally and there is a sense of  flow; but there is an underlying structure, always.

I suppose that discipline gets a bad rap when the indoctrination is mixed up with intimidation, such as the stereotype of a Marine Corps Drill Sargeant would present.  Nursing education is conducted with a lot more finesse than a USMC boot camp.

The fact is, we all need to work together as a team, and nobody will give you more responsibility unless you have shown that you can deal with the simple responsibilities. As Atul Gawande and others have described, sometimes excellence is a question of diligently working on the same thing every day and having good habits.

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Use FaceBook to JUMP START your nursing career!

This is part two of my blog about social media and how it impacts your search for a nursing job.

We don’t need Sherlock Holmes to investigate you.

Yesterday I wrote to alert you that your potential employers were conducting internet research on  you before they even decided to interview you. It’s true, and I got a comment on the blog from somebody to whom that happened. Keep reading to find out what happened in that case…..

Have you ever looked at somebody’s profile?

The whole premise of FaceBook is that people are nosy.

More young nurses are internet savvy. When they join the workforce, they are just as clever at doing a websearch as you are, and they are transforming how the web is used to supplement the hiring process. Yes, maybe the manager of the nursing floor is older, but it’s common practice to allow current staff to participate in the interview process, and if they decide to include some young nurses on the committee, I guarantee that every candidate will be Googled and checked out on FaceBook. We have HIPAA to protect the patients, thank God, but there is no HIPAA to protect you – FaceBook is free speech, sort of……

How will you do?

There are two sides to this, and they are every bit as important as writing a good resume and cover letter.

The first is the negative side.

Many college students are naïve about the downside of FaceBook. The negative side shows up  when the potential employer sees mainly pictures of you drinking or partying, gets the list of books you read, movies you like, and music you listen to – and disapproves. Sees your friends dressed in Heavy Metal outfits and reads status updates that sound like you were angry and sarcastic all the time or perhaps notices that you do a lot of “drunk-texting” at three in the morning.

Fix those things. For a list of ideas as to how to fix those things, go to yesterday’s blog.

“420 Friendly”

I only know what “420-friendly” is, because my students told me, and I have bookmarked Urban Dictionary.  If your profile is public and your tastes run toward a lot of heavy metal, goth, “420,” or substance abuse, don’t be surprised if the person Googling you goes on to the next job applicant’s profile. Yup. It’s true. If you put it there, it’s public and it’s fair game.

Now the positive side.

Which is this: it can work in your favor, all you need to do is to think of ways to make it happen. Think of your internet presence as if it were your portfolio. Yes, nowadays its trendy in nursing education to gather your best academic work to create a file on your progress through nursing school. The theory of gathering a portfolio is that this will help you to present yourself as a new professional. The downside of a ‘portfolio’ is that it’s hard copy and even if it’s wonderful you probably only have one copy. You can’t share it freely without making sure it’s returned to you. Portfolios don’t photocopy well. Nobody sees it unless they ask for it. Wish it were otherwise, but hey – that’s how it works.

For all intents and purposes, this idea has morphed into something else altogether now that electronic media has taken off like a rocket. The paper portfolio has been left behind.

You already have a portfolio, whether you think so or not.

It consists of:

FaceBook;

Flickr;

Twitter;

YouTube;

Any blog you have ever done; and

Every time your name has appeared in the paper or on a website.

The next step for you is to actually take charge of your Internet image, just as if you were a politician or celebrity.

GOOGLE YOUR OWN NAME!

Accentuate the positive

Eliminate the negative

latch on to the affirmative

(Don’t mess with the in-between, as the next line of the old Arlen and Mercer song says).

Do a total makeover on your profile.

Take control of it, and use it to sell yourself. Find ways to post photos or videos of the positive activities you engage in. Take an inventory of the nice things about yourself that you want people to know. If you don’t have something in your informal internet portfolio, go out of your way to put it there.

Here is the update from yesterday’s blog comment. A subscriber who read yesterday’s blog emailed to say he’d put his resume on LinkedIn a few months ago. Only yesterday, a  nurse manager from a teaching hospital on the mainland called and offered him a job (!) And in the course of the phone call, it turns out that the manager on the other end of the phone had Googled the subscriber, viewed the entire YouTube clip of the subscriber’s wedding including the reception, and taken  special notice of the groom’s chemfree behavior in a social setting. The manager also checked out the web sites of previous employers and other LinkedIn connections.

LinkedIn is sort of like “The FaceBook for Grown-Ups”

Why should your employer pay for a background check when they can find so much free info that you put there yourself?

They need your permission to get a written reference from your past employer; they don’t need permission to Google you.

Ten years ago this may have been spooky. Nowadays it’s becoming normal. In this case it had a warm fuzzy nice outcome.

What would the outcome be if it was your internet portfolio that was being Googled?

Please share this with every new graduate nurse you know, and consider subscribing to this blog.

Peace out